ESCP Safe Anastomosis ProGramme in CoLorectal SurgEry (EAGLE): Study protocol for an international cluster randomised trial of a quality improvement intervention to reduce anastomotic leak following right colectomy

AIM

Cohort data suggest that anastomotic leak occurs after 8% of right colectomies causing significant morbidity and mortality. Patient selection, intra-operative factors, and technical variation all contribute to risk of leak. The EAGLE study will assess whether implementation of the European Society of Coloproctology (ESCP) Safe Anastomosis Intervention reduces anastomotic leak following right colectomy.

METHODS

An international, multi-centre, cluster randomised trial will be undertaken with hospitals as clusters. Hospitals will be recruited in a number of distinct phases, with each phase following the same research plan, in which clusters are randomised to one of three, staggered (dog-leg) schedules for implementation of the Safe Anastomosis Intervention.

RESULTS

Results from different phases will be meta-analysed. The intervention is a three-component behavioural change programme for surgeons, anaesthetists and operating room staff, supported by an online learning environment. All colorectal surgical units around the world will be eligible. Adults undergoing elective or emergency right colectomy or ileocaecal resection, by any approach and for any indication will be included. The primary outcome is 30-day anastomotic leak rate, defined as clinical or radiologically-detected leak or intra-abdominal or pelvic collection. Assuming hospitals provide data for an average of 10 patients per two month recruitment period, 333 clusters (4440 patients in total) will allow for detection of an absolute risk reduction of anastomotic leak from 8.1% to 5.6% (relative risk reduction 30%). This protocol adheres to Standard Protocol Items: Recommendations for Intervention Trials (SPIRIT).

DISCUSSION

The protocol describes the methods for an evaluation of a hospital-level, education-based quality improvement intervention targeted to reduce the life-threatening surgical complication of anastomotic leak.

Magnetic resonance imaging reduces the rate of unnecessary operations in pregnant patients with suspected acute appendicitis: a retrospective study

Purpose

This is a retrospective single-institution study performed to compare the rate of unnecessary operations in pregnant women with suspected acute appendicitis with and without the use of MRI.

Methods

The study subjects were all pregnant women with suspected acute appendicitis admitted to a tertiary institution from January 2012 to December 2019. If acute appendicitis was not excluded clinically and by ultrasound (US), laparoscopies were performed until May 2017 (US-only group). MRI was added as a diagnostic tool when US was inconclusive from May 2017 (US + MRI group). Surgery was considered unnecessary when no inflamed appendix was found. The rate of unnecessary surgery, postoperative complications, length of stay were analyzed.

Results

Seventy-six women were included in the study; 38 women in the US-only group and 38 women in the US + MRI group. There were no differences in admission characteristics between the groups. One of 38 women (2.6%) underwent unnecessary surgery in the US + MRI group vs. 10 of 38 (26.3%) in the US-only group (P = 0.007). The patients in the US + MRI group were significantly less likely to undergo a diagnostic operation than in the US-only group (5.26% vs. 55.3%, respectively; P < 0.001) and their hospital stay was significantly shorter (0.74 ± 1.64 days vs. 3.7 ± 3.0 days, respectively; P < 0.001). The obstetric outcomes were not different between the groups. MRI had a sensitivity of 83.3% and specificity of 100% in the series.

Conclusion

The rate of unnecessary surgery was significantly reduced in pregnant women, who underwent MRI after inconclusive transabdominal US.

Tissue Coagulation in Laser Hemorrhoidoplasty - An Experimental Study

Background

Laser hemorrhoidoplasty (LHP) is a new technique for treatment of hemorrhoids. The exact extent of coagulation is not visible at the time of the procedure. There currently is no experimental or clinical data on the subject.

Objective

To evaluate the length of coagulation defect according to power and activation time of 1470nm diode laser on the perianal tissue model.

Methods

Fresh anorectal tissue of twenty-four pigs was used to produce 54 experimental samples. Each sample was randomly assigned to the laser power of 6, 8 and 10 W and 1, 2 or 3-second pulses. The procedure was performed using Biolitec Ceralas © diode laser with 1.85 mm optical fiber. The fiber was inserted in a manner, similar to intrahemorrhoidal laser application. Samples were evaluated using low-power and high-power light microscopy by a single pathologist. The length of tissue injury was measured on high-magnification microscopy.

Results

The longest tissue injury (mean 3.93 mm) was caused by the longest laser exposure time (3 sec) with no significant difference between laser power used.

Conclusions

8 W 3-second application of the 1470nm diode laser results in coagulation area approximately 4 mm, and further coagulation should be initiated approximately 5 mm from the first one.

Results of the double-blind randomized controlled trial comparing laser hemorrhoidoplasty with sutured mucopexy and excisional hemorrhoidectomy

PURPOSE

To compare the results of laser hemorrhoidoplasty (LHP), excisional hemorrhoidectomy (EH), and sutured mucopexy (MP).

METHODS

A randomized, parallel-group, double-blinded, single-center prospective study.

PATIENTS

Symptomatic 2nd- or 3rd-degree hemorrhoids patients.

INTERVENTIONS

Computer randomization sequence, patient blinding, operating surgeon blinding, and surgeon-evaluator blinding. LHP was performed using a 1470 nm diode laser. Up to 250 J of energy delivered per 1 hemorrhoid. The procedure was performed circumferentially. MP ligations were placed in the area of visible hemorrhoidal tissue. Standard EH was performed up to the level of the hemorrhoidal pedicle. Follow-up at 1 and 6 weeks and 1 year.

OUTCOME MEASURES

Recurrence of symptoms requiring treatment, intensity, and duration of pain after the operation, patients' quality of life, fecal incontinence, and patients' evaluation of treatment.

RESULTS

A total of 121 patients. Groups were even preoperatively. LHP took 15 min (SD 5.6), MP took 16 min (SD 5.58), and EH took 29 min (SD 10.3). Recurrence requiring treatment rate was 0% after EH, 10% after LHP, and 22% after MP, p = 0.004. LHP and MP were less painful than EH, p < 0.001. Patients after LHP returned to regular activity after 15 days, after MP after 22 days, and after EH after 30 days, p < 0.001. SF-36 scores were better after EH. Symptoms of fecal incontinence improved in all the groups. Patients evaluate LHP better than EH and MP.

LIMITATIONS

Single-center study.

CONCLUSIONS

Laser hemorrhoidoplasty is a safe, minimally invasive option for hemorrhoids, more effective than MP and less effective than EH. Patients evaluate this technique better than the other two.

Echinococcus multilocularis infection of the liver presenting as abdominal wall fistula

Echinococcus multilocularis causes infection where the most commonly affected organ is the liver, followed by the lung, kidney, bone and the brain. Other sites such as the heart, spleen, pancreas and soft tissues are very rarely affected. Surgical treatment combined with chemotherapy using various technical approaches remains the main therapeutic modality for echinococcal liver disease. To the best of our knowledge there are less than five clinical cases of cutaneous presentation of liver alveolar echinococcosis described. We present a unique case of liver echinococcosis presenting as recurrent abdominal wall fistula and abscess in a 29-year-old man. Diagnosis was based on CT imaging, serological analysis and histological findings from the fistula. Medical treatment with albendazole was initiated and liver resection was performed. The patient has no symptoms and signs of recurrence 1 year after operation, while still on albendazole therapy. This case description highlights the importance of early suspicion and treatment of unusual echinococcosis clinical presentations.