Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study

BACKGROUND

The impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on postoperative recovery needs to be understood to inform clinical decision making during and after the COVID-19 pandemic. This study reports 30-day mortality and pulmonary complication rates in patients with perioperative SARS-CoV-2 infection.

METHODS

This international, multicentre, cohort study at 235 hospitals in 24 countries included all patients undergoing surgery who had SARS-CoV-2 infection confirmed within 7 days before or 30 days after surgery. The primary outcome measure was 30-day postoperative mortality and was assessed in all enrolled patients. The main secondary outcome measure was pulmonary complications, defined as pneumonia, acute respiratory distress syndrome, or unexpected postoperative ventilation.

FINDINGS

This analysis includes 1128 patients who had surgery between Jan 1 and March 31, 2020, of whom 835 (74·0%) had emergency surgery and 280 (24·8%) had elective surgery. SARS-CoV-2 infection was confirmed preoperatively in 294 (26·1%) patients. 30-day mortality was 23·8% (268 of 1128). Pulmonary complications occurred in 577 (51·2%) of 1128 patients; 30-day mortality in these patients was 38·0% (219 of 577), accounting for 81·7% (219 of 268) of all deaths. In adjusted analyses, 30-day mortality was associated with male sex (odds ratio 1·75 [95% CI 1·28-2·40], p<0·0001), age 70 years or older versus younger than 70 years (2·30 [1·65-3·22], p<0·0001), American Society of Anesthesiologists grades 3-5 versus grades 1-2 (2·35 [1·57-3·53], p<0·0001), malignant versus benign or obstetric diagnosis (1·55 [1·01-2·39], p=0·046), emergency versus elective surgery (1·67 [1·06-2·63], p=0·026), and major versus minor surgery (1·52 [1·01-2·31], p=0·047).

INTERPRETATION

Postoperative pulmonary complications occur in half of patients with perioperative SARS-CoV-2 infection and are associated with high mortality. Thresholds for surgery during the COVID-19 pandemic should be higher than during normal practice, particularly in men aged 70 years and older. Consideration should be given for postponing non-urgent procedures and promoting non-operative treatment to delay or avoid the need for surgery.

FUNDING

National Institute for Health Research (NIHR), Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, European Society of Coloproctology, NIHR Academy, Sarcoma UK, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research.

Intraoperative angiography with indocyanine green to assess anastomosis perfusion in patients undergoing laparoscopic colorectal resection: results of a multicenter randomized controlled trial

BACKGROUND

Insufficient vascular supply is one of the main causes of anastomotic leak in colorectal surgery. Intraoperative indocyanine-green (ICG) angiography has been shown to provide information on tissue perfusion, identifying a well-perfused location for colonic and rectal transections, and thus possibly reducing the leak rate. Aim of this study was to evaluate the usefulness of intraoperative assessment of anastomotic perfusion using ICG angiography in patients undergoing left-sided colon or rectal resection with colorectal anastomosis.

METHODS

This randomized trial involved 252 patients undergoing laparoscopic left-sided colon and rectal resection randomized 1:1 to intraoperative ICG or to subjective visual evaluation of the bowel perfusion without ICG. The primary aim was to assess whether ICG angiography could lead to a reduction in anastomotic leak rate. Secondary outcomes were possible changes in the surgical strategy and postoperative morbidity.

RESULTS

After randomization, 12 patients were excluded. Accordingly, 240 patients were included in the analysis; 118 were in the study group, and 122 in the control group. ICG angiography showed insufficient perfusion of the colic stump, which led to extended bowel resection in 13 cases (11%). An anastomotic leak developed in 11 patients (9%) in the control group and in 6 patients (5%) in the study group (p = n.s.).

CONCLUSIONS

Intraoperative ICG fluorescent angiography can effectively assess vascularization of the colic stump and anastomosis in patients undergoing colorectal resection. This method led to further proximal bowel resection in 13 cases, however, there was no statistically significant reduction of anastomotic leak rate in the ICG arm.

CLINICAL TRIAL

ClinicalTrials.gov NCT02662946.

Elective Cancer Surgery in COVID-19-Free Surgical Pathways During the SARS-CoV-2 Pandemic: An International, Multicenter, Comparative Cohort Study

PURPOSE

As cancer surgery restarts after the first COVID-19 wave, health care providers urgently require data to determine where elective surgery is best performed. This study aimed to determine whether COVID-19-free surgical pathways were associated with lower postoperative pulmonary complication rates compared with hospitals with no defined pathway.

PATIENTS AND METHODS

This international, multicenter cohort study included patients who underwent elective surgery for 10 solid cancer types without preoperative suspicion of SARS-CoV-2. Participating hospitals included patients from local emergence of SARS-CoV-2 until April 19, 2020. At the time of surgery, hospitals were defined as having a COVID-19-free surgical pathway (complete segregation of the operating theater, critical care, and inpatient ward areas) or no defined pathway (incomplete or no segregation, areas shared with patients with COVID-19). The primary outcome was 30-day postoperative pulmonary complications (pneumonia, acute respiratory distress syndrome, unexpected ventilation).

RESULTS

Of 9,171 patients from 447 hospitals in 55 countries, 2,481 were operated on in COVID-19-free surgical pathways. Patients who underwent surgery within COVID-19-free surgical pathways were younger with fewer comorbidities than those in hospitals with no defined pathway but with similar proportions of major surgery. After adjustment, pulmonary complication rates were lower with COVID-19-free surgical pathways (2.2% v 4.9%; adjusted odds ratio [aOR], 0.62; 95% CI, 0.44 to 0.86). This was consistent in sensitivity analyses for low-risk patients (American Society of Anesthesiologists grade 1/2), propensity score-matched models, and patients with negative SARS-CoV-2 preoperative tests. The postoperative SARS-CoV-2 infection rate was also lower in COVID-19-free surgical pathways (2.1% v 3.6%; aOR, 0.53; 95% CI, 0.36 to 0.76).

CONCLUSION

Within available resources, dedicated COVID-19-free surgical pathways should be established to provide safe elective cancer surgery during current and before future SARS-CoV-2 outbreaks.

Evaluation of appendicitis risk prediction models in adults with suspected appendicitis

BACKGROUND

Appendicitis is the most common general surgical emergency worldwide, but its diagnosis remains challenging. The aim of this study was to determine whether existing risk prediction models can reliably identify patients presenting to hospital in the UK with acute right iliac fossa (RIF) pain who are at low risk of appendicitis.

METHODS

A systematic search was completed to identify all existing appendicitis risk prediction models. Models were validated using UK data from an international prospective cohort study that captured consecutive patients aged 16-45 years presenting to hospital with acute RIF in March to June 2017. The main outcome was best achievable model specificity (proportion of patients who did not have appendicitis correctly classified as low risk) whilst maintaining a failure rate below 5 per cent (proportion of patients identified as low risk who actually had appendicitis).

RESULTS

Some 5345 patients across 154 UK hospitals were identified, of which two-thirds (3613 of 5345, 67·6 per cent) were women. Women were more than twice as likely to undergo surgery with removal of a histologically normal appendix (272 of 964, 28·2 per cent) than men (120 of 993, 12·1 per cent) (relative risk 2·33, 95 per cent c.i. 1·92 to 2·84; P < 0·001). Of 15 validated risk prediction models, the Adult Appendicitis Score performed best (cut-off score 8 or less, specificity 63·1 per cent, failure rate 3·7 per cent). The Appendicitis Inflammatory Response Score performed best for men (cut-off score 2 or less, specificity 24·7 per cent, failure rate 2·4 per cent).

CONCLUSION

Women in the UK had a disproportionate risk of admission without surgical intervention and had high rates of normal appendicectomy. Risk prediction models to support shared decision-making by identifying adults in the UK at low risk of appendicitis were identified.

2015 European Society of Coloproctology collaborating group. The relationship between method of anastomosis and anastomotic failure after right hemicolectomy and ileo-caecal resection: an international snapshot audit

BACKGROUND

Anastomosis technique following right sided colonic resection is widely variable and may affect patient outcomes. This study aimed to assess the association between leak and anastomosis technique (stapled versus handsewn) METHODS: This was a prospective, multicentre, international audit including patients undergoing elective or emergency right hemicolectomy or ileo-caecal resection operations over a two-month period in early 2015. The primary outcome measure was the presence of anastomotic leak within 30 days of surgery, using a pre-specified definition. Mixed effects logistic regression models were used to assess the association between leak and anastomosis method, adjusting for patient, disease and operative cofactors, with centre included as a random effect variable.

RESULTS

This study included 3208 patients, of whom 78.4% (n=2515) underwent surgery for malignancy and 11.7% (n=375) for Crohn's disease. An anastomosis was performed in 94.8% (n=3041) of patients, which was handsewn in 38.9% (n=1183) and stapled in 61.1% (n=1858) cases. Patients undergoing handsewn anastomosis were more likely to be emergency admissions (20.5% handsewn versus 12.9% stapled) and to undergo open surgery (54.7% versus 36.6%). The overall anastomotic leak rate was 8.1% (245/3041), which was similar following handsewn (7.4%) and stapled (8.5%) techniques (p=0.3). After adjustment for cofactors, the odds of a leak were higher for stapled anastomosis (adjusted odds ratio 1.43, 95% confidence interval 1.04-1.95, p=0.03).

DISCUSSION

Despite being used in lower risk patients, stapled anastomosis was associated with an increased anastomotic leak rate in this observational study. Further research is needed to define patient groups in whom a stapled anastomosis is safe. This article is protected by copyright. All rights reserved.

Predictors for Anastomotic Leak, Postoperative Complications, and Mortality After Right Colectomy for Cancer: Results From an International Snapshot Audit

BACKGROUND

A right hemicolectomy is among the most commonly performed operations for colon cancer, but modern high-quality, multination data addressing the morbidity and mortality rates are lacking.

OBJECTIVE

This study reports the morbidity and mortality rates for right-sided colon cancer and identifies predictors for unfavorable short-term outcome after right hemicolectomy.

DESIGN

This was a snapshot observational prospective study.

SETTING

The study was conducted as a multicenter international study.

PATIENTS

The 2015 European Society of Coloproctology snapshot study was a prospective multicenter international series that included all patients undergoing elective or emergency right hemicolectomy or ileocecal resection over a 2-month period in early 2015. This is a subanalysis of the colon cancer cohort of patients.

MAIN OUTCOME MEASURES

Predictors for anastomotic leak and 30-day postoperative morbidity and mortality were assessed using multivariable mixed-effect logistic regression models after variables selection with the Lasso method.

RESULTS

Of the 2515 included patients, an anastomosis was performed in 97.2% (n = 2444), handsewn in 38.5% (n = 940) and stapled in 61.5% (n = 1504) cases. The overall anastomotic leak rate was 7.4% (180/2444), 30-day morbidity was 38.0% (n = 956), and mortality was 2.6% (n = 66). Patients with anastomotic leak had a significantly increased mortality rate (10.6% vs 1.6% no-leak patients; p > 0.001). At multivariable analysis the following variables were associated with anastomotic leak: longer duration of surgery (OR = 1.007 per min; p = 0.0037), open approach (OR = 1.9; p = 0.0037), and stapled anastomosis (OR = 1.5; p = 0.041).

LIMITATIONS

This is an observational study, and therefore selection bias could be present. For this reason, a multivariable logistic regression model was performed, trying to correct possible confounding factors.

CONCLUSIONS

Anastomotic leak after oncologic right hemicolectomy is a frequent complication, and it is associated with increased mortality. The key contributing surgical factors for anastomotic leak were anastomotic technique, surgical approach, and duration of surgery. See Video Abstract at http://links.lww.com/DCR/B165. PREDICTORES DE FUGA ANASTOMóTICA, COMPLICACIONES POSTOPERATORIAS Y MORTALIDAD DESPUéS DE LA COLECTOMíA DERECHA POR CáNCER: RESULTADOS DE UNA AUDITORíA INTERNACIONAL DE CORTO PLAZO: La hemicolectomía derecha se encuentra entre las operaciones más frecuentemente realizadas para cáncer de colon, pero faltan datos modernos multinacionales de alta calidad, que aborden las tasas de morbilidad y mortalidad.Reportar la tasa de morbilidad y mortalidad para cáncer de colon del lado derecho, e identificar predictores de resultados desfavorables a corto plazo, después de la hemicolectomía derecha.Estudio prospectivo observacional de corto plazo.Estudio multicéntrico internacional.El estudio de corto plazo de la Sociedad Europea de Coloproctología de 2015, fue una serie prospectiva multicéntrica internacional, que incluyó a todos los pacientes sometidos a hemicolectomía derecha electiva, de emergencia o resección ileocecal, por un período de dos meses y a principios de 2015. Este es un subanálisis, cohorte de pacientes con cáncer de colon.Los predictores de fuga anastomótica, morbilidad y mortalidad postoperatorias a los 30 días, se evaluaron usando modelos de regresión logística de efectos multivariables mixtos, después de la selección de variables con el método Lasso.De los 2,515 pacientes incluidos, se realizó una anastomosis en el 97,2% (n = 2,444); sutura manual en 38.5% (n = 940) y por engrapadora en 61.5% (n = 1504) casos. La tasa global de fuga anastomótica fue del 7,4% (180/2,444), morbilidad a los 30 días fue del 38,0% (n = 956) y la mortalidad fue del 2,6% (n = 66). Los pacientes con fuga anastomótica tuvieron una tasa de mortalidad significativamente mayor (10,6% frente al 1,6% de pacientes sin fuga, p> 0,001). En el análisis multivariable, las siguientes variables se asociaron con la fuga anastomótica: mayor duración de la cirugía (OR 1.007 por minuto, p = 0.0037), abordaje abierto (OR 1.9, p = 0.0037) y anastomosis por engrapadora (OR 1.5, p = 0.041).Este es un estudio observacional y por lo tanto podría estar presente el sesgo de selección. Por esta razón, se realizó un modelo de regresión logística multivariable, tratando de corregir posibles factores de confusión.La fuga anastomótica después de la hemicolectomía derecha oncológica, es una complicación frecuente y asociada a mayor mortalidad. Los factores quirúrgicos clave que contribuyeron a la fuga anastomótica, fueron la técnica anastomótica, abordaje quirúrgico y duración de la cirugía. Consulte Video Resumen en http://links.lww.com/DCR/B165. (Traducción-Dr. Fidel Ruiz Healy).

Risk factors for anastomotic leakage after anterior resection for rectal cancer (RALAR study): A nationwide retrospective study of the Italian Society of Surgical Oncology Colorectal Cancer Network Collaborative Group

AIM

Anastomotic leakage after restorative surgery for rectal cancer shows high morbidity and related mortality. Identification of risk factors could change operative planning, with indications for stoma construction. This retrospective multicentre study aims to assess the anastomotic leak rate, identify the independent risk factors and develop a clinical prediction model to calculate the probability of leakage.

METHODS

The study used data from 24 Italian referral centres of the Colorectal Cancer Network of the Italian Society of Surgical Oncology. Patients were classified into two groups, AL (anastomotic leak) or NoAL (no anastomotic leak). The effect of patient-, disease-, treatment- and postoperative outcome-related factors on anastomotic leak after univariable and multivariable analysis was measured.

RESULTS

A total of 5398 patients were included, 552 in group AL and 4846 in group NoAL. The overall incidence of leaks was 10.2%, with a mean time interval of 6.8 days. The 30-day leak-related mortality was 2.6%. Sex, body mass index, tumour location, type of approach, number of cartridges employed, weight loss, clinical T stage and combined multiorgan resection were identified as independent risk factors. The stoma did not reduce the leak rate but significantly decreased leak severity and reoperation rate. A nomogram with a risk score (RALAR score) was developed to predict anastomotic leak risk at the end of resection.

CONCLUSIONS

While a defunctioning stoma did not affect the leak risk, it significantly reduced its severity. Surgeons should recognize independent risk factors for leaks at the end of rectal resection and could calculate a risk score to select high-risk patients eligible for protective stoma construction.

Extracorporeal vs. Intracorporeal Ileocolic Stapled Anastomoses in Laparoscopic Right Colectomy: An Interim Analysis of a Randomized Clinical Trial

AIM

The role of intracorporeal anastomosis (IA) in right colectomy is still controversial. Primary endpoint of the present study is to evaluate the impact of IA versus extracorporeal anastomosis (EA) on recovery of bowel function and length of stay in right colon cancer patients.

MATERIALS AND METHODS

Adult patients with histologically proven cancer of the right colon were randomized to laparoscopic right colectomy with IA or EA anastomosis. Admitting a two-sided type I error level of 0.01 and an estimated power of 80%, 79 patients for each group were needed to test the primary endpoint.

RESULTS

At the time of this interim analysis, 60 patients were randomized; 30 were assigned to the IA group and 30 to the EA group. The two groups were homogeneous with respect to demographics, American Surgical Association score, and tumor stage. In the IA group, a longer operating time (P = .04), an earlier recovery of bowel function (P = .048), and a lower incidence of postoperative ileus (P = .05) were observed. No differences were observed between the two groups with respect to length of stay (P = .70) and complication rate (P = .89). Anastomotic leak rate occurred in two patients in the IA group, while no leak occurred in EA.

CONCLUSIONS

Intracorporeal anastomosis could be considered a valuable option in the hands of expert surgeons, with favorable effect on recovery of bowel function and postoperative ileus. Definitive answers on its safety and efficacy will be given once the present randomized controlled trial (RCT) will be complete.

Long-term outcome of Altemeier's procedure for rectal prolapse

INTRODUCTION

Altemeier's procedure is infrequently applied in European countries and because of the small number of patients treated in each center, its long-term reliability is uncertain.

METHODS

Medical records of 93 patients (median age, 77 years) undergoing perineal rectosigmoidectomy associated with levatorplasty in 72 patients (78 percent) were reviewed; 65 patients (70 percent) suffered from major fecal incontinence.

RESULTS

There was no postoperative mortality. Eight (8.6 percent) major complications were observed (3 pelvic hematomas, 1 anastomotic dehiscence, 1 sigmoid perforation, 1 pararectal abscess, and 2 late anal strictures), and 13 (14 percent) minor complications. At a mean follow-up of 41 (range, 12-112) months the complete recurrence rate was 18 percent (17 patients); these patients were treated with a repeat Altemeier's procedure (6 patients), Delorme's operation (1 patient), Wells' rectopexy (1 patient), postanal repair (1 patient), anal bulking agents (2 patients), and sacral nerve stimulation (2 patients). Anal manometry significantly improved postoperatively. Incontinence improved postoperatively in 30 cases (28 percent), deteriorated in 2 patients, while 4 patients developed minor incontinence.

CONCLUSIONS

Perineal rectosigmoidectomy for rectal prolapse is a relatively safe and effective treatment, in particular, for frail, older patients, with a low postoperative morbidity, but the recurrence rate is not negligible and restoration of continence is unpredictable.

Evaluation and management of perianal abscess and anal fistula: SICCR position statement

Perianal sepsis is a common condition ranging from acute abscess to chronic anal fistula. In most cases, the source is considered to be a non-specific cryptoglandular infection starting from the intersphincteric space. Surgery is the main treatment and several procedures have been developed, but the risks of recurrence and of impairment of continence still seem to be an unresolved issue. This statement reviews the pertinent literature and provides evidence-based recommendations to improve individualized management of patients.

A prospective, randomized trial comparing the short- and long-term results of doppler-guided transanal hemorrhoid dearterialization with mucopexy versus excision hemorrhoidectomy for grade III hemorrhoids

BACKGROUND

Few randomized trials have compared the results of Doppler-guided transanal hemorrhoid dearterialization with mucopexy and excisional open hemorrhoidectomy. Few studies have reported long-term results.

OBJECTIVE

The aim of this study is to evaluate the results of Doppler-guided transanal hemorrhoid dearterialization with mucopexy compared with excisional open hemorrhoidectomy in patients with grade III hemorrhoids.

DESIGN

This is a prospective randomized study registered at clinicaltrials.gov (NCT01263431). A power analysis assessed the study's sample size. Patients were randomly assigned to undergo either hemorrhoidectomy or Doppler-guided hemorrhoid dearterialization plus mucopexy. The χ test, Mann-Whitney U test, Student t test, and a regression model were used, as appropriate.

SETTINGS

This study was conducted at the Department of Surgery, San Raffaele Scientific Institute, Milan, Italy.

PATIENTS

Fifty consecutive patients were treated for grade III hemorrhoids from July to November 2010.

MAIN OUTCOME MEASURES

The primary outcome was postoperative pain. The secondary outcomes included postoperative morbidity, the resumption of social and/or working activity, patient satisfaction, and the relapse of symptoms at 1 and 24 months.

RESULTS

No major complications occurred in either group. The median visual analog scale scores for pain in the hemorrhoidectomy and Doppler-guided dearterialization plus mucopexy groups on days 1, 7, 14, and 30 were 7 vs 5.5, 3 vs 2.5, 1 vs 0, and 0 vs 0 (p> 0.05). The median work resumption day was the 22nd in the hemorrhoidectomy group and the 10th in the Doppler-guided dearterialization plus mucopexy group (p = 0.09). Patient satisfaction at 1 and 24 postoperative months, with the use of a 4-point scale, was 3 vs 4 and 4 vs 4 (p > 0.05). During the follow-up, 2 patients in the dearterialization group required ambulatory treatment, and 1 patient in each group required further surgery for symptom relapse.

LIMITATIONS

Nonvalidated questionnaires were used in the follow-up. Cost analysis was not performed.

CONCLUSION

Compared with hemorrhoidectomy, dearterialization with mucopexy resulted in similar postoperative pain and morbidity, and a similar long-term cure rate.

EuroSurg Collaborative. Body mass index and complications following major gastrointestinal surgery: a prospective, international cohort study and meta-analysis

AIM

Previous studies reported conflicting evidence on the effects of obesity on outcomes after gastrointestinal surgery. The aims of this study were to explore the relationship of obesity with major postoperative complications in an international cohort and to present a meta-analysis of all available prospective data.

METHODS

This prospective, multicentre study included adults undergoing both elective and emergency gastrointestinal resection, reversal of stoma or formation of stoma. The primary end-point was 30-day major complications (Clavien-Dindo Grades III-V). A systematic search was undertaken for studies assessing the relationship between obesity and major complications after gastrointestinal surgery. Individual patient meta-analysis was used to analyse pooled results.

RESULTS

This study included 2519 patients across 127 centres, of whom 560 (22.2%) were obese. Unadjusted major complication rates were lower in obese vs normal weight patients (13.0% vs 16.2%, respectively), but this did not reach statistical significance (P = 0.863) on multivariate analysis for patients having surgery for either malignant or benign conditions. Individual patient meta-analysis demonstrated that obese patients undergoing surgery for malignancy were at increased risk of major complications (OR 2.10, 95% CI 1.49-2.96, P < 0.001), whereas obese patients undergoing surgery for benign indications were at decreased risk (OR 0.59, 95% CI 0.46-0.75, P < 0.001) compared to normal weight patients.

CONCLUSIONS

In our international data, obesity was not found to be associated with major complications following gastrointestinal surgery. Meta-analysis of available prospective data made a novel finding of obesity being associated with different outcomes depending on whether patients were undergoing surgery for benign or malignant disease.

Evaluation and management of perianal abscess and anal fistula: a consensus statement developed by the Italian Society of Colorectal Surgery (SICCR)

Perianal sepsis is a common condition ranging from acute abscess to chronic fistula formation. In most cases, the source is considered to be a non-specific cryptoglandular infection starting from the intersphincteric space. The key to successful treatment is the eradication of the primary track. As surgery may lead to a disturbance of continence, several sphincter-preserving techniques have been developed. This consensus statement examines the pertinent literature and provides evidence-based recommendations to improve individualized management of patients.

Safety and efficacy of non-steroidal anti-inflammatory drugs to reduce ileus after colorectal surgery

BACKGROUND

Ileus is common after elective colorectal surgery, and is associated with increased adverse events and prolonged hospital stay. The aim was to assess the role of non-steroidal anti-inflammatory drugs (NSAIDs) for reducing ileus after surgery.

METHODS

A prospective multicentre cohort study was delivered by an international, student- and trainee-led collaborative group. Adult patients undergoing elective colorectal resection between January and April 2018 were included. The primary outcome was time to gastrointestinal recovery, measured using a composite measure of bowel function and tolerance to oral intake. The impact of NSAIDs was explored using Cox regression analyses, including the results of a centre-specific survey of compliance to enhanced recovery principles. Secondary safety outcomes included anastomotic leak rate and acute kidney injury.

RESULTS

A total of 4164 patients were included, with a median age of 68 (i.q.r. 57-75) years (54·9 per cent men). Some 1153 (27·7 per cent) received NSAIDs on postoperative days 1-3, of whom 1061 (92·0 per cent) received non-selective cyclo-oxygenase inhibitors. After adjustment for baseline differences, the mean time to gastrointestinal recovery did not differ significantly between patients who received NSAIDs and those who did not (4·6 versus 4·8 days; hazard ratio 1·04, 95 per cent c.i. 0·96 to 1·12; P = 0·360). There were no significant differences in anastomotic leak rate (5·4 versus 4·6 per cent; P = 0·349) or acute kidney injury (14·3 versus 13·8 per cent; P = 0·666) between the groups. Significantly fewer patients receiving NSAIDs required strong opioid analgesia (35·3 versus 56·7 per cent; P < 0·001).

CONCLUSION

NSAIDs did not reduce the time for gastrointestinal recovery after colorectal surgery, but they were safe and associated with reduced postoperative opioid requirement.

Comparison of glycerine trinitrate and botulinum toxin-a for the treatment of chronic anal fissure: long-term results

PURPOSE

This study was designed to compare the efficacy of two different "chemical sphincterotomies" for chronic anal fissure.

METHODS

From January to December 2001, 30 consecutive patients (17 males; mean age, 41.8 years) with chronic posterior anal fissure were enrolled. The patients were randomly assigned to receive 0.2 percent glycerine trinitrate ointment applied three times daily at the anal margin for eight weeks (Group A) or 20 units Botulinum toxin A injection into the internal anal sphincter on each side of the anterior midline (Group B). The patients were reviewed at 15 days, 1, 3, 6, 12, and every other 12 months. Follow-up ranged between 36 and 46 months. Patients in either group who failed to improve were referred for surgical treatment.

RESULTS

Twelve patients in Group A and 11 in Group B had improvement or relief from symptoms at the first visit. The fissure was healed in ten patients in Group A and in eight in Group B within three months (66.7 and 57.1 percent). Recurrence of the fissure occurred in five patients in each group during the follow-up. The healing rate at three years was 40 and 33.3 percent for Group A and B, respectively. No patients in either group reported serious adverse effects; however, three patients in Group A (20 percent) had transient headache. None had fecal incontinence.

CONCLUSION

Both treatments may be considered as first-line treatment even if less effective than surgery.

Intraoperative use of fluorescence with indocyanine green reduces anastomotic leak rates in rectal cancer surgery: an individual participant data analysis

BACKGROUND

Fluorescence imaging by means of Indocyanine green (ICG) has been applied to intraoperatively determine the perfusion of the anastomosis. The purpose of this Individual Participant Database meta-analysis was to assess the effectiveness in decreasing the incidence of anastomotic leak (AL) after rectal cancer surgery.

METHODS

We searched PubMed, Embase, Cochrane Library and ClinicalTrial.gov, EU Clinical Trials and ISRCTN registries on September 1st, 2019. We considered eligible those studies comparing the assessment of anastomotic perfusion during rectal cancer surgery by intraoperative use of ICG fluorescence compared with standard practice. We defined as primary outcome the incidence of AL at 30 days after surgery. The studies were assessed for quality by means of the ROBINS-I and the Cochrane risk tools. We calculated odds ratios (ORs) using the Individual patient data analysis, restricted to rectal lesions, according to original treatment allocation.

RESULTS

The review of the literature and international registries produced 15 published studies and 5 ongoing trials, for 9 of which the authors accepted to share individual participant data. 314 patients from two randomized trials, 452 from three prospective series and 564 from 4 non-randomized studies were included. Fluorescence imaging significantly reduced the incidence of AL (OR 0.341; 95% CI 0.220-0.530; p < 0.001), independent of age, gender, BMI, tumour and anastomotic distance from the anal verge and neoadjuvant therapy. Also, overall morbidity and reintervention rate were positively influenced by the use of ICG.

CONCLUSIONS

The incidence of AL may be reduced when ICG fluorescence imaging is used to assess the perfusion of a colorectal anastomosis. Limitations relate to the consistent number of non-randomized studies included and their heterogeneity in defining and assessing AL. Ongoing large randomized studies will help to determine the exact role of routine ICG fluorescence imaging may decrease the incidence of AL in surgery for rectal cancer.

Feasibility of an adaptive strategy in preoperative radiochemotherapy for rectal cancer with image-guided tomotherapy: boosting the dose to the shrinking tumor

PURPOSE

To investigate the feasibility of preoperative adaptive radiochemotherapy by delivering a concomitant boost to the residual tumor during the last 6 fractions of treatment.

METHODS AND MATERIALS

Twenty-five patients with T3/T4N0 or N+ rectal cancer were enrolled. Concomitant chemotherapy consisted of oxaliplatin 100 mg/m(2) on days -14, 0, and +14, and 5-fluorouracil 200 mg/m(2)/d from day -14 to the end of radiation therapy (day 0 is the start of radiation therapy). Radiation therapy consisted of 41.4 Gy in 18 fractions (2.3 Gy per fraction) with Tomotherapy to the tumor and regional lymph nodes (planning target volume, PTV) defined on simulation CT and MRI. After 9 fractions simulation CT and MRI were repeated for the planning of the adaptive phase: PTVadapt was generated by adding a 5-mm margin to the residual tumor. In the last 6 fractions a boost of 3.0 Gy per fraction (in total 45.6 Gy in 18 fractions) was delivered to PTVadapt while concomitantly delivering 2.3 Gy per fraction to PTV outside PTVadapt.

RESULTS

Three patients experienced grade 3 gastrointestinal toxicity; 2 of 3 showed toxicity before the adaptive phase. Full dose of radiation therapy, oxaliplatin, and 5-fluorouracil was delivered in 96%, 96%, and 88% of patients, respectively. Two patients with clinical complete response (cCR) refused surgery and were still cCR at 17 and 29 months. For the remaining 23 resected patients, 15 of 23 (65%) showed tumor regression grade 3 response, and 7 of 23 (30%) had pathologic complete response; 8 (35%) and 12 (52%) tumor regression grade 3 patients had ≤5% and 10% residual viable cells, respectively.

CONCLUSIONS

An adaptive boost strategy is feasible, with an acceptable grade 3 gastrointestinal toxicity rate and a very encouraging tumor response rate. The results suggest that there should still be room for further dose escalation of the residual tumor with the aim of increasing pathologic complete response and/or cCR rates.

Outcomes from elective colorectal cancer surgery during the SARS-CoV-2 pandemic

AIM

This study aimed to describe the change in surgical practice and the impact of SARS-CoV-2 on mortality after surgical resection of colorectal cancer during the initial phases of the SARS-CoV-2 pandemic.

METHOD

This was an international cohort study of patients undergoing elective resection of colon or rectal cancer without preoperative suspicion of SARS-CoV-2. Centres entered data from their first recorded case of COVID-19 until 19 April 2020. The primary outcome was 30-day mortality. Secondary outcomes included anastomotic leak, postoperative SARS-CoV-2 and a comparison with prepandemic European Society of Coloproctology cohort data.

RESULTS

From 2073 patients in 40 countries, 1.3% (27/2073) had a defunctioning stoma and 3.0% (63/2073) had an end stoma instead of an anastomosis only. Thirty-day mortality was 1.8% (38/2073), the incidence of postoperative SARS-CoV-2 was 3.8% (78/2073) and the anastomotic leak rate was 4.9% (86/1738). Mortality was lowest in patients without a leak or SARS-CoV-2 (14/1601, 0.9%) and highest in patients with both a leak and SARS-CoV-2 (5/13, 38.5%). Mortality was independently associated with anastomotic leak (adjusted odds ratio 6.01, 95% confidence interval 2.58-14.06), postoperative SARS-CoV-2 (16.90, 7.86-36.38), male sex (2.46, 1.01-5.93), age >70 years (2.87, 1.32-6.20) and advanced cancer stage (3.43, 1.16-10.21). Compared with prepandemic data, there were fewer anastomotic leaks (4.9% versus 7.7%) and an overall shorter length of stay (6 versus 7 days) but higher mortality (1.7% versus 1.1%).

CONCLUSION

Surgeons need to further mitigate against both SARS-CoV-2 and anastomotic leak when offering surgery during current and future COVID-19 waves based on patient, operative and organizational risks.

Segmental Colonic Resection Is a Safe and Effective Treatment Option for Colon Cancer of the Splenic Flexure: A Nationwide Retrospective Study of the Italian Society of Surgical Oncology-Colorectal Cancer Network Collaborative Group

BACKGROUND

Global experience with splenic flexure cancer is limited because of its low incidence. Both limited (segmental) and extended resections are performed, because agreement on which is the adequate procedure has not been reached.

OBJECTIVE

The purpose of this study was to investigate whether segmental resection is as safe and effective as extended resection.

DESIGN

This nationwide retrospective cohort study included all consecutive resections of splenic flecure cancer between January 2006 and December 2016 using data from the National Colorectal Cancer Network of the Italian Society of Surgical Oncology following the guidelines set out in the STROBE statement.

SETTING

Data were obtained for 31 Italian Referral Centers for Colorectal Surgery.

PATIENTS

A total of 1304 patients were submitted to resection of the splenic flexure (n = 791, 60.7%) or extended procedures (extended right and left colectomies; n = 513, 39.3%).

MAIN OUTCOME MEASURES

We evaluated Clavien-Dindo ≥3 postoperative complications and oncological (number of lymph nodes removed, length of free proximal and distal margins, rate of R0 resections) and survival outcomes.

RESULTS

The 2 arms were well balanced in regard to sex, BMI, ASA and Eastern Cooperative Oncology Group scores, and disease stage. Limited resection was performed more frequently using a minimally invasive approach (62.1% vs 50.9%, p < 0.001) and with shorter operation times than extended procedures (165 vs 189 minutes, p < 0.001), but the same Clavien-Dindo ≥3 postoperative complications (6.44% vs 6.43%, p = 0.99), 30-day mortality (0.63% vs 0.38%), oncological outcomes, and survival rates (5-year overall survival 0.84 vs 0.83, 5-year progression-free survival 0.85 vs 0.84).

LIMITATIONS

There are limitations inherent to the retrospective nature of the study and a potential lack of consistency in treatment across centers over time. Indications as to why a specific operation was chosen were based mostly on surgeons' beliefs.

CONCLUSIONS

Segmental resection is a safe and effective treatment option for cancer of the splenic flexure. See Video Abstract at http://links.lww.com/DCR/B307. LA RESECCIÓN DE COLON SEGMENTARIA ES UNA OPCIÓN DE TRATAMIENTO SEGURA Y EFICAZ PARA EL CÁNCER DE COLON DE LA FLEXIÓN ESPLÉNICA: UN ESTUDIO RETROSPECTIVO A NIVEL NACIONAL DE LA SOCIEDAD ITALIANA DE ONCOLOGÍA QUIRÚRGICA - GRUPO COLABORATIVO RED DE CÁNCER COLORRECTAL: La experiencia global con el cáncer de flexión esplénica es limitada debido a su baja incidencia. Se realizan resecciones limitadas (segmentarias) y extendidas, ya que no se ha llegado a un acuerdo sobre cuál es el procedimiento adecuado.El propósito de este estudio fue investigar si la resección segmentaria es tan segura y efectiva como la resección extendida.Este estudio de cohorte retrospectivo a nivel nacional incluyó todas las resecciones consecutivas de cáncer de flecura esplénica entre enero de 2006 y diciembre de 2016 utilizando datos de la Red Nacional de Cáncer Colorrectal de la Sociedad Italiana de Oncología Quirúrgica siguiendo las pautas establecidas en la declaración STROBE.Se obtuvieron datos para 31 centros de referencia italianos para cirugía colorrectal.Un total de 1304 pacientes fueron sometidos a resección de la flexión esplénica (n = 791, 60.7%) o procedimientos extendidos (colectomías extendidas derecha e izquierda; n = 513, 39.3%).Evaluamos Clavien-Dindo ≥3 complicaciones postoperatorias y oncológicas (número de ganglios linfáticos extirpados, longitud de márgenes proximales y distales libres, tasa de resecciones R0) y resultados de supervivencia.Los dos brazos estaban bien equilibrados en cuanto a sexo, IMC, ASA y puntajes ECOG, y etapa de la enfermedad. La resección limitada se realizó con mayor frecuencia utilizando un enfoque mínimamente invasivo (62.1% versus 50,9%, p < 0.001) y con tiempos de operación más cortos que los procedimientos extendidos (165 min versus 189 min, p <0.001), pero el mismo Clavien-Dindo ≥3 complicaciones postoperatorias (6,44% versus 6,43%, p = 0.99), mortalidad a los 30 días (0,63% versus 0,38%), resultados oncológicos y tasas de supervivencia (5-y OS 0,84 versus 0,83, 5-PFS 0,85 versus 0,84).Existen limitaciones inherentes a la naturaleza retrospectiva del estudio y una posible falta de consistencia en el tratamiento entre centros a lo largo del tiempo. Las indicaciones de por qué se eligió una operación específica se basaron principalmente en crieterios de los cirujanos.La resección segmentaria es una opción de tratamiento segura y efectiva para el cáncer de la flexión esplénica. Consulte Video Resumen en http://links.lww.com/DCR/B307. (Traducción-Dr. Adrian Ortega).

NIHR Global Health Unit on Global Surgery, COVIDSurg Collaborative. Elective surgery system strengthening: development, measurement, and validation of the surgical preparedness index across 1632 hospitals in 119 countries

BACKGROUND

The 2015 Lancet Commission on global surgery identified surgery and anaesthesia as indispensable parts of holistic health-care systems. However, COVID-19 exposed the fragility of planned surgical services around the world, which have also been neglected in pandemic recovery planning. This study aimed to develop and validate a novel index to support local elective surgical system strengthening and address growing backlogs.

METHODS

First, we performed an international consultation through a four-stage consensus process to develop a multidomain index for hospital-level assessment (surgical preparedness index; SPI). Second, we measured surgical preparedness across a global network of hospitals in high-income countries (HICs), middle-income countries (MICs), and low-income countries (LICs) to explore the distribution of the SPI at national, subnational, and hospital levels. Finally, using COVID-19 as an example of an external system shock, we compared hospitals' SPI to their planned surgical volume ratio (SVR; ie, operations for which the decision for surgery was made before hospital admission), calculated as the ratio of the observed surgical volume over a 1-month assessment period between June 6 and Aug 5, 2021, against the expected surgical volume based on hospital administrative data from the same period in 2019 (ie, a pre-pandemic baseline). A linear mixed-effects regression model was used to determine the effect of increasing SPI score.

FINDINGS

In the first phase, from a longlist of 103 candidate indicators, 23 were prioritised as core indicators of elective surgical system preparedness by 69 clinicians (23 [33%] women; 46 [67%] men; 41 from HICs, 22 from MICs, and six from LICs) from 32 countries. The multidomain SPI included 11 indicators on facilities and consumables, two on staffing, two on prioritisation, and eight on systems. Hospitals were scored from 23 (least prepared) to 115 points (most prepared). In the second phase, surgical preparedness was measured in 1632 hospitals by 4714 clinicians from 119 countries. 745 (45·6%) of 1632 hospitals were in MICs or LICs. The mean SPI score was 84·5 (95% CI 84·1-84·9), which varied between HIC (88·5 [89·0-88·0]), MIC (81·8 [82·5-81·1]), and LIC (66·8 [64·9-68·7]) settings. In the third phase, 1217 (74·6%) hospitals did not maintain their expected SVR during the COVID-19 pandemic, of which 625 (51·4%) were from HIC, 538 (44·2%) from MIC, and 54 (4·4%) from LIC settings. In the mixed-effects model, a 10-point increase in SPI corresponded to a 3·6% (95% CI 3·0-4·1; p<0·0001) increase in SVR. This was consistent in HIC (4·8% [4·1-5·5]; p<0·0001), MIC (2·8 [2·0-3·7]; p<0·0001), and LIC (3·8 [1·3-6·7%]; p<0·0001) settings.

INTERPRETATION

The SPI contains 23 indicators that are globally applicable, relevant across different system stressors, vary at a subnational level, and are collectable by front-line teams. In the case study of COVID-19, a higher SPI was associated with an increased planned surgical volume ratio independent of country income status, COVID-19 burden, and hospital type. Hospitals should perform annual self-assessment of their surgical preparedness to identify areas that can be improved, create resilience in local surgical systems, and upscale capacity to address elective surgery backlogs.

FUNDING

National Institute for Health Research (NIHR) Global Health Research Unit on Global Surgery, NIHR Academy, Association of Coloproctology of Great Britain and Ireland, Bowel Research UK, British Association of Surgical Oncology, British Gynaecological Cancer Society, and Medtronic.

Impact of previous abdominal surgery on the outcome of laparoscopic colectomy: a case-matched control study

BACKGROUND

Adhesions are a major risk for visceral injury and can increase the difficulty of both laparoscopic and open colectomy. The aim of the present study was to evaluate the impact of previous abdominal surgery on laparoscopic colectomy in terms of early outcome.

METHODS

We performed a case-control study of patients who underwent laparoscopic colectomy for colorectal disease. The case group comprised 91 patients with a history of prior abdominal surgery, while the 91 controls had no such history. Case and controls were matched for age, gender, site of primary disease, comorbidity on admission and body mass index.

RESULTS

The two groups were homogeneous for demographic and clinical characteristics. Conversion rate was 16.5% in the case group and 8.8% in the control group (p=0.18). Of the 7 patients who underwent conversion because of adhesions, six had prior surgery (cases) and one did not (p=0.001). Operative time was 26 minutes longer in the case group than in the control group (p=0.001). Morbidity rate was 25.3% among cases and 23.1% for controls. Patients in the two groups experienced a similar time to recovery of bowel function, length of postoperative stay, and 30-day readmission rate.

CONCLUSIONS

Laparoscopic colectomy in previously operated patients is a time-consuming operation, but it does not appear to affect the short-term postoperative outcome.

Standard versus extralevator abdominoperineal low rectal cancer excision outcomes: a systematic review and meta-analysis

BACKGROUND

The extended, extralevator abdominoperineal excision has been described with the aim of improving oncological low rectal cancer patient outcomes.

MATERIALS AND METHODS

A systematic literature review was conducted using Medline/PubMed, Embase, Cochrane library, and Ovid for standard and extralevator abdominoperineal rectal cancer excision studies between 1995 and 2013. A total of 1,270 articles were identified and screened, and of these, 58 reports (1 randomized, 5 case-control and 52 cohort studies) were included for the qualitative analysis, and 6 were included for the quantitative analysis. The primary endpoints included intraoperative tumor perforation, the circumferential resection margin involvement, local recurrence rate, and the perineal wound complication rate. The secondary endpoints included the length of postoperative hospital stay and quality of life. Comprehensive Rev Men, version 5.2 was used for the statistical calculations.

RESULTS

A significant difference in the circumferential resection margin involvement rate [odds ratio (OR) 2.9; p < .001], intraoperative perforation (OR 4.30; p < .001), local recurrence rate (OR 2.52; p = .02), and length of hospital stay (OR 1.06; p < .001) in favor of the extended group was observed. Additionally, the perineal wound complications were higher in the extended group (OR 0.62; p = .007). No difference in quality of life was observed.

CONCLUSIONS

Our analysis confirms the oncological advantages of the extended abdominoperineal excision method. Although the perineal wound complications were higher, the length of postoperative hospital stay was shorter, and quality of life was not inferior to the conventional resection method.

Italian multi-society modified Delphi consensus on the definition and management of anastomotic leakage in colorectal surgery

INTRODUCTION

The incidence of anastomotic leak (AL) has not decreased over the past decades and some important grey areas remain in its definition, prevention, and management. The aim of this study was to reach a national consensus on the definition of AL and to identify key points to be applied in clinical practice.

METHODS

A 3-step modified Delphi method was used to establish consensus. Ten representative members of the major Italian surgical scientific societies with proven colorectal expertise were selected after a call to action. After a comprehensive literature search, each expert drew a list of evidence-based statements which were voted in round one by the scientific board. Panel members were asked to mark "totally disagree", "partially agree" or "totally agree" for each statement and provide comments. The same voting method was used for round 2. Round 3 consisted of a final face-to-face meeting.

RESULTS

Thirty-three statements (clustered into 14 topics) were included in round 1. Following the third voting round, a final list of 16 items was formulated, which encompass the following 9 topics: AL definition, patient- and operative-related risk factors, prevention measures, bowel preparation, surgical technique, intraoperative assessment, early diagnosis, radiological diagnosis and management of specific patterns of AL. The overall response rate was 100% for all items in all the three rounds.

CONCLUSIONS

This Delphi survey identified items that expert colorectal surgeons agreed were important to be applied in the prevention, diagnosis, and management of AL. This represents the first consensus involving all relevant national scientific societies, defining important and shared concepts in the diagnosis and management of AL.

Bowel perforation in a Covid-19 patient: case report

INTRODUCTION

Since the outbreak of novel coronavirus (2019-nCoV), it became evident that a proportion of patients may present with gastrointestinal symptoms.

CASE

We report the case of a Covid-19-infected patient who, during recovery from the pulmonary pneumonia, had gastrointestinal symptoms followed by a diastasic right colon perforation due to acute over distension of the bowel.

CONCLUSION

This case highlights the importance of paying attention to initial gastrointestinal symptoms in order to prevent possible complications.

2015 European Society of Coloproctology collaborating group. Risk factors for unfavourable postoperative outcome in patients with Crohn's disease undergoing right hemicolectomy or ileocaecal resection An international audit by ESCP and S-ECCO

BACKGROUND

Patient and disease-related factors, as well as operation technique all have the potential to impact on postoperative outcome in Crohn's disease. The available evidence is based on small series and often displays conflicting results.

AIM

To investigate the effect of pre- and intra-operative risk factors on 30-day postoperative outcome in patients undergoing surgery for Crohn's disease.

METHOD

International prospective snapshot audit including consecutive patients undergoing right hemicolectomy or ileocaecal resection. This study analysed a subset of patients who underwent surgery for Crohn's disease. The primary outcome measure was the overall Clavien-Dindo postoperative complication rate. The key secondary outcomes were anastomotic leak, re-operation, surgical site infection and length of stay at hospital. Multivariable binary logistic regression analyses were used to produce odds ratios (OR) and 95% confidence intervals (CI).

RESULTS

Three hundred and seventy five resections in 375 patients were included. The median age was 37 and 57.1% were female. In multivariate analyses, postoperative complications were associated with preoperative parenteral nutrition (OR 2.36 95% CI 1.10-4.97)], urgent/expedited surgical intervention (OR 2.00, 95% CI 1.13-3.55) and unplanned intraoperative adverse events (OR 2.30, 95% CI 1.20-4.45). The postoperative length of stay in hospital was prolonged in patients who received preoperative parenteral nutrition (OR 31, CI [1.08-1.61]) and those who had urgent/expedited operations (OR 1.21, CI [1.07-1.37]).

CONCLUSION

Preoperative parenteral nutritional support, urgent/expedited operation and unplanned intraoperative adverse events were associated with unfavourable postoperative outcome. Enhanced preoperative optimization and improved planning of operation pathways and timings may improve outcomes for patients. This article is protected by copyright. All rights reserved.