Background Pneumoperitoneum for laparoscopic surgery is associated with a rise of driving pressure. The authors aimed to assess the effects of positive end-expiratory pressure (PEEP) on driving pressure at varying intraabdominal pressure levels. It was hypothesized that PEEP attenuates pneumoperitoneum-related rises in driving pressure. Methods Open-label, nonrandomized, crossover, clinical trial in patients undergoing laparoscopic cholecystectomy. “Targeted PEEP” (2 cm H2O above intraabdominal pressure) was compared with “standard PEEP” (5 cm H2O), with respect to the transpulmonary and respiratory system driving pressure at three predefined intraabdominal pressure levels, and each patient was ventilated with two levels of PEEP at the three intraabdominal pressure levels in the same sequence. The primary outcome was the difference in transpulmonary driving pressure between targeted PEEP and standard PEEP at the three levels of intraabdominal pressure. Results Thirty patients were included and analyzed. Targeted PEEP was 10, 14, and 17 cm H2O at intraabdominal pressure of 8, 12, and 15 mmHg, respectively. Compared to standard PEEP, targeted PEEP resulted in lower median transpulmonary driving pressure at intraabdominal pressure of 8 mmHg (7 [5 to 8] vs. 9 [7 to 11] cm H2O; P = 0.010; difference 2 [95% CI 0.5 to 4 cm H2O]); 12 mmHg (7 [4 to 9] vs.10 [7 to 12] cm H2O; P = 0.002; difference 3 [1 to 5] cm H2O); and 15 mmHg (7 [6 to 9] vs.12 [8 to 15] cm H2O; P < 0.001; difference 4 [2 to 6] cm H2O). The effects of targeted PEEP compared to standard PEEP on respiratory system driving pressure were comparable to the effects on transpulmonary driving pressure, though respiratory system driving pressure was higher than transpulmonary driving pressure at all intraabdominal pressure levels. Conclusions Transpulmonary driving pressure rises with an increase in intraabdominal pressure, an effect that can be counterbalanced by targeted PEEP. Future studies have to elucidate which combination of PEEP and intraabdominal pressure is best in term of clinical outcomes. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

Aim The purpose of the present study was to evaluate the accuracy of computed tomography colonography (CTC) in the preoperative localization and TN staging of colon cancer. CTC can be an effective technique for preoperative evaluation of colon cancer and could facilitate the selection of high‐risk patients who may benefit from neoadjuvant chemotherapy. Method This was a prospective observational study conducted at a single tertiary‐care centre. It involved 217 patients (225 tumours) who had colon cancer and underwent preoperative CTC and elective colectomy. The radiologist determined the TNM stage using postprocessing software with multiplanar images and virtual colonoscopy. The following criteria were analysed for every colon tumour: location, size and signs of direct colon wall invasion. The histopathological findings of the surgical colectomy specimens served as the reference standard for local staging. Results CTC detected all tumours and achieved an exact location in 208 cases (92.4%). CTC findings changed the surgical plan in 31 patients (14.3%) following colonoscopy. The accuracy in differentiating T3/T4 vs T1/T2 tumours was 87.1%, with a sensitivity and specificity of 88.5% and 84.1%, respectively (kappa = 0.71). For high‐risk tumours (T3 ≥ 5 mm and T4), CTC showed an accuracy, sensitivity and specificity of 82.7%, 86% and 80%, respectively (kappa = 0.65). The accuracy of N‐stage evaluation was 69.3%, the sensitivity 74% and the specificity 67.1% (kappa = 0.37). Conclusion CTC provides accurate information for the assessment of tumour localization and T staging, allowing better surgical planning and also allows the selection of locally advanced tumours that may benefit from new treatments such as neoadjuvant chemotherapy.

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Background Iatrogenic bile duct injury (IBDI) is a challenging surgical complication. IBDI management can be guided by artificial intelligence models. Our study identified the factors associated with successful initial repair of IBDI and predicted the success of definitive repair based on patient risk levels. Methods This is a retrospective multi-institution cohort of patients with IBDI after cholecystectomy conducted between 1990 and 2020. We implemented a decision tree analysis to determine the factors that contribute to successful initial repair and developed a risk-scoring model based on the Comprehensive Complication Index. Results We analyzed 748 patients across 22 hospitals. Our decision tree model was 82.8% accurate in predicting the success of the initial repair. Non-type E (p < 0.01), treatment in specialized centers (p < 0.01), and surgical repair (p < 0.001) were associated with better prognosis. The risk-scoring model was 82.3% (79.0–85.3%, 95% confidence interval [CI]) and 71.7% (63.8–78.7%, 95% CI) accurate in predicting success in the development and validation cohorts, respectively. Surgical repair, successful initial repair, and repair between 2 and 6 weeks were associated with better outcomes. Discussion Machine learning algorithms for IBDI are a novel tool may help to improve the decision-making process and guide management of these patients.

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Introduction: Metabolic syndrome (MS) and cardiovascular risk factors are commonin liver transplant (LT) candidates and recipients. Cardiovascular events and de novo tumours are increasingly common causes of mortality in liver transplant recipients. The aim of this study is (i) to assess the prevalence of MS in LT recipients and its growth over the years and (ii) if the presence of MS pre-LT is associated with a higher risk of post-LT cardiovascular events (CVE), de novo tumours or early and late survival. Patients and methods:Retrospective study that included LT recipients from January 2012 to December 2017. Baseline features (MS before LT and at 1year post-LT) and outcomes (CVE, de novo tumours and survival) were recorded.Results: 483 recipients were included, MS was present pre-LT in 20% with an increasing prevalence over time, from16% in 2012 to 34% in 2017 (p=0.025). One-year post-LT, an additional 12% had developed de novo MS .At a median of 56-months follow-up, 13% developed a CVE and 9% a de novo tumour. One and 5-yr survival rates were91% and 83 % in those with pre-LT MS and 93% and 85 % in those without (p=0.94).The presence of MS before LT was independently associated with a higher risk of post-LT CVE (HR: 2.66 IC (95%): 1.6-4.4 p< 0.001), but not with de novo tumors (p=0.94) nor early and late survival (p=0.58 and p=0.87). Conclusion:Pre-LT MS is increasing among LT candidates and is associated with a higher risk of post-LT morbidity CVE yet without affecting mortality.

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