Complete mesocolic excision for right hemicolectomy: an updated systematic review and meta-analysis

PURPOSE

Complete mesocolic excision improves lymphadenectomy for right hemicolectomy and respects the embryological planes. However, its effect on cancer-free and overall survival is questioned. Therefore, we aimed to determine the potential benefits of the technique by performing a systematic review of the literature and meta-analysis of the available evidence.

METHODS

Web of Science, PubMed/Medline, and Embase were searched on February 22, 2023. Original studies on short- and long-term oncological outcomes of adult patients undergoing right hemicolectomy with complete mesocolic excision as a treatment for primary colon cancer were considered for inclusion. Outcomes were extracted and pooled using a model with random effects.

RESULTS

A total of 586 publications were identified through database searching, and 18 from citation searching. Exclusion of 552 articles left 24 articles for inclusion. Meta-analysis showed that complete mesocolic excision increased the lymph node harvest (5 studies, 1479 patients, MD 9.62, 95% CI 5.83-13.41, p > 0.0001, I2 84%), 5-year overall survival (5 studies, 2381 patients, OR 1.88, 95% CI 1.14-3.09, p = 0.01, I2 66%), 5-year disease-free survival (4 studies, 1376 patients, OR 2.21, 95% CI 1.51-3.23, p < 0.0001, I2 0%) and decreased the incidence of local recurrence (4 studies, 818 patients, OR 0.27, 95% CI 0.09-0.79, p = 0.02, I2 0%) when compared to standard right hemicolectomy. Perioperative morbidity was similar between the techniques (8 studies, 3899 patients, OR 1.04, 95% CI 0.89-1.22, p = 0.97, I2 0%).

CONCLUSION

Meta-analysis of observational and randomised studies showed that right hemicolectomy with complete mesocolic excision for primary right colon cancer improves oncologic results without increasing morbidity/mortality. These results need to be confirmed by high-quality evidence and randomised trials in selected patients to assess who may benefit from the procedure.

Implementation of totally robotic right hemicolectomy: lessons learned from a prospective cohort

Robotics facilitates the realization of intra-corporeal anastomosis during right hemicolectomy and allows extracting the operative specimen through a C-section, offering potential benefits in terms of post-operative recovery and incidence of incisional hernia. Therefore, we progressively implemented robotic right hemicolectomy (robRHC) in our centre, and would like to report our initial experience with the technique. Consecutive patients who underwent robRHC within a single centre were prospectively included. Variables related to patients' demographics, surgical procedures, post-operative recovery and pathological outcomes were collected. Sixty patients underwent robRHC in our centre. Indications for robRHC were colon cancer in 58 patients (96.7%) and polyps not amenable to endoscopic resection in 2 patients (3.3%). Fifty-eight patients underwent robRHC with D2 lymphadenectomy and central vessel ligation (96.7%), and two patients (3.3%) had robRHC associated with another procedure. All patients had intra-corporeal anastomosis. The mean ± operative time was of 200.4 ± 114.9 min. Two conversions (3.3%) to open surgery were performed. The mean ± SD length of stay was of 5.4 ± 3.8 days. Seven patients (11.7%) experienced a post-operative complication with a Clavien-Dindo score ≥ 2. Two patients (3.5%) had an anastomotic leak. The mean ± SD number of harvested lymph nodes was of 22.4 ± 7.6. All patients had negative pathological margins (R0 resection). To conclude, robotic RHC is a safe procedure, which can be implemented with satisfying peri- and post-operative outcomes. The potential benefits of the technique remain to be demonstrated by randomized controlled trials.

Long-Term Surgical Outcomes and Pathological Analysis of Proctectomy Specimens after Subtotal Colectomy for Ulcerative Colitis: A Retrospective Cohort Study from a Tertiary Centre

Background: Reconstruction techniques after subtotal colectomy (STC) and end ileostomy for ulcerative colitis (UC), include ileal pouch-anal anastomosis (IPAA), ileorectal anastomosis (IRA) and continent ileostomy. Aim: To assess surgical strategies and outcomes after subtotal colectomy for UC by calculating the proportions of patients who had further surgery 10 years post-STC and those who did not undergo surgery but who were under surveillance, and histological analysis of pathology specimens from STC and proctectomy. Methods: Patients who had STC for UC from 2002 to 2018 were identified. Variables of interest were extracted from electronic records. Survival analysis on reconstruction surgery was performed using Kaplan-Meier curves. Curves were censored for loss from follow-up and death. Subtotal colectomy and proctectomy specimens were assessed by a pathologist for acute inflammation at the distal resection margin and within the resected bowel, and for dysplasia or cancer. Results: One hundred and ninety-two patients were included. Eighty-nine (46.3%) underwent proctectomy: eight had panproctocolectomy; thirty had completion proctectomy and the remaining fifty-one of the eighty-nine patients (27%) had IPAA. One patient who did not undergo a proctectomy had an ileorectal anastomosis. Sixty-one (69%) proctectomy specimens had active inflammation, with 29 (48%) including the resection margins. Of the 103 patients who did not have completion surgery, 72 (69%) were under surveillance as of August 2021. No patients in this non-operative group had developed cancer of the residual rectum at follow up. Conclusions: At 10 years after STC for UC, eighty-nine (46.4%) patients had proctectomy, of which fifty-two had IPAA (27%). However, no inflammation was found in the proctectomy specimen in one third of these patients. Therefore, it is possible that IRA may still have a role in the occasional patient with UC.

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

BACKGROUND

Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres.

METHODS

This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low-middle-income countries.

RESULTS

In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of 'single-use' consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low-middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia.

CONCLUSION

This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high- and low-middle-income countries.

Incidence of diverticulitis recurrence after sigmoid colectomy: a retrospective cohort study from a tertiary center and systematic review

INTRODUCTION

Our aim was to determine the incidence of diverticulitis recurrence after sigmoid colectomy for diverticular disease.

METHODS

Consecutive patients who benefited from sigmoid colectomy for diverticular disease from January 2007 to June 2021 were identified based on operative codes. Recurrent episodes were identified based on hospitalization codes and reviewed. Survival analysis was performed and was reported using a Kaplan-Meier curve. Follow-up was censored for last hospital visit and diverticulitis recurrence. The systematic review of the literature was performed according to the PRISMA statement. Medline, Embase, CENTRAL, and Web of Science were searched for studies reporting on the incidence of diverticulitis after sigmoid colectomy. The review was registered into PROSPERO (CRD42021237003, 25/06/2021).

RESULTS

One thousand three-hundred and fifty-six patients benefited from sigmoid colectomy. Four hundred and three were excluded, leaving 953 patients for inclusion. The mean age at time of sigmoid colectomy was 64.0 + / - 14.7 years. Four hundred and fifty-eight patients (48.1%) were males. Six hundred and twenty-two sigmoid colectomies (65.3%) were performed in the elective setting and 331 (34.7%) as emergency surgery. The mean duration of follow-up was 4.8 + / - 4.1 years. During this period, 10 patients (1.1%) developed reccurent diverticulitis. Nine of these episodes were classified as Hinchey 1a, and one as Hinchey 1b. The incidence of diverticulitis recurrence (95% CI) was as follows: at 1 year: 0.37% (0.12-1.13%), at 5 years: 1.07% (0.50-2.28%), at 10 years: 2.14% (1.07-4.25%) and at 15 years: 2.14% (1.07-4.25%). Risk factors for recurrence could not be assessed by logistic regression due to the low number of incidental cases. The systematic review of the literature identified 15 observational studies reporting on the incidence of diverticulitis recurrence after sigmoid colectomy, which ranged from 0 to 15% for a follow-up period ranging between 2 months and over 10 years.

CONCLUSION

The incidence of diverticulitis recurrence after sigmoid colectomy is of 2.14% at 15 years, and is mostly composed of Hinchey 1a episodes. The incidences reported in the literature are heterogeneous.

[Colorectal cancer: technological revolution]

Colorectal cancer represents 4500 incidental cases in Switzerland per year, with an incidence increasing among the youngest patients. Technological innovation guides the management of colorectal cancer. Artificial intelligence in endoscopy optimizes the detection of small colonic lesions. Submucosal dissection allows treating extensive lesions at an early stage of the disease. The improvement of surgical techniques, notably robotic surgery, allows limiting complications and optimizing organ preservation. Molecular tools are leading to the development of promising targeted therapies for localized or advanced disease. The development of reference centers tends to bring together this expertise.

Practice variation in anastomotic leak after esophagectomy: Unravelling differences in failure to rescue

INTRODUCTION

Failure to rescue (FTR) is an important outcome measure after esophagectomy and reflects mortality after postoperative complications. Differences in FTR have been associated with hospital resection volume. However, insight into how centers manage complications and achieve their outcomes is lacking. Anastomotic leak (AL) is a main contributor to FTR. This study aimed to assess differences in FTR after AL between centers, and to identify factors that explain these differences.

METHODS

TENTACLE - Esophagus is a multicenter, retrospective cohort study, which included 1509 patients with AL after esophagectomy. Differences in FTR were assessed between low-volume (<20 resections), middle-volume (20-60 resections) and high-volume centers (≥60 resections). Mediation analysis was performed using logistic regression, including possible mediators for FTR: case-mix, hospital resources, leak severity and treatment.

RESULTS

FTR after AL was 11.7%. After adjustment for confounders, FTR was lower in high-volume vs. low-volume (OR 0.44, 95%CI 0.2-0.8), but not versus middle-volume centers (OR 0.67, 95%CI 0.5-1.0). After mediation analysis, differences in FTR were found to be explained by lower leak severity, lower secondary ICU readmission rate and higher availability of therapeutic modalities in high-volume centers. No statistically significant direct effect of hospital volume was found: high-volume vs. low-volume 0.86 (95%CI 0.4-1.7), high-volume vs. middle-volume OR 0.86 (95%CI 0.5-1.4).

CONCLUSION

Lower FTR in high-volume compared with low-volume centers was explained by lower leak severity, less secondary ICU readmissions and higher availability of therapeutic modalities. To reduce FTR after AL, future studies should investigate effective strategies to reduce leak severity and prevent secondary ICU readmission.

Predictors for selective flexure mobilization during robotic anterior resection for rectal cancer: a prospective cohort analysis

INTRODUCTION

Splenic flexure mobilization (SFM) may be indicated during anterior resection to provide a tension-free anastomosis. However, to date, no score allows identifying patients who may benefit from SFM.

METHODS

Patients who underwent robotic anterior resection for rectal cancer were identified from a prospective register. Demographic and cancer-related variables were extracted, and predictors of SFM were identified using regression models. Thereafter, 20 patients with SFM and 20 patients without SFM were randomly selected and their pre-operative CTscan were reviewed. The radiological index was defined as 1/(sigmoid length/pelvis depth). The optimal cut-off value for predicting SFM was identified using ROC curve analysis.

RESULTS

Five hundred and twenty-four patients were included. SFM was performed in 121 patients (27.8%) and increased operative time by 21.8 min (95% CI: 11.3 to 32.4, p < 0.001). The incidence of postoperative complications did not differ between patient with or without SFM. Realization of an anastomosis was the main predictor for SFM (OR: 42.4, 95% CI: 5.8 to 308.5, p < 0.001). In patients with colorectal anastomosis, both sigmoid length (15 ± 5.1 cm versus 24.2 ± 80.9 cm, p < 0.001) and radiological index (1 ± 0.3 versus 0.6 ± 0.2, p < 0.001) differed between patients who had SFM and patients who did not. ROC curve analysis of the radiological index indicated an optimal cut-off value of 0.8 (sensitivity: 75%, specificity: 90%).

CONCLUSION

SFM was performed in 27.8% of patients who underwent robotic anterior resection, and increased operative time by 21.8 min. For optimal surgical planning, patients requiring SFM can be identified based on pre-operative CT using the index 1/(sigmoid length/pelvis depth) with a cut-off value set at 0.8.

GMM, Maegele M, Maggiore D, Magnone S, Maier RV, Maier RV, Major P, Manangi M, manetti A, Mantoglu B, Marafante C, Mariani F, Marinis A, Mariot ES, Marseglia GR, Martãnez-Pãrez A, Martines G, Perez AM, Martino C, Mascagni P, Massalou D, Matãas-Garcãa B, Mazzarella G, Mazzarolo G, Melo RB, Mendoza-Moreno F, Meric S, Meyer J, Miceli L, Michalopoulos NV, Milana F, Mingoli A, Mishra TS, Mohamed M, Mohamed MIEA, Mohamedahmed AY, Mohammed MJS, Mohan R, Moore EE, Morales-Garcia D, Muhrbeck M, Mulita F, Mustafa SMS, Muttillo EM, Naimzada MD, Navsaria PH, Negoi I, Nespoli L, Nguyen C, Nidaw MK, Nigri G, Nikolopoulos I, O’Connor DB, Ogundipe HD, Oliveri C, Olmi S, Ong ECW, Orecchia L, Osipov AV, Othman MF, Pace M, Pacilli M, Pagani L, Palomba G, Pantalone D, Panyko A, Paolillo C, Papa MV, Papaconstantinou D, Papadoliopoulou M, Papadopoulos A, Papis D, Pararas N, Parreira JG, Parry NG, Pata F, Patel T, Paterson-Brown S, Pavone G, Pecchini F, Pellino G, Pelloni M, Peloso A, del Pozo EP, Pereira RG, Pereira BM, perez AL, Perra T, Perrone G, Pesce A, Petagna L, Petracca G, Phupong V, Picardi B, Picciariello A, Piccoli M, Piccolo D, Picetti E, Pikoulis Pikoulis E, Pintar T, Pirozzolo G, Piscioneri F, Podda M, Porcu A, Privitera F, Punzo C, Quaresima S, Quiodettis MA, Qvist N, Rahim R, de Almeida FR, Ramely RB, Rasa HK, Reichert M, Reinisch-Liese A, Renne A, Riccetti C, Rodriguez-Luna MR, Roizblatt D, Romanzi A, Romeo L, Roscio FPM, Rosnelifaizur RB, Rossi S, Rubiano AM, Ruiz-Úcar E, Sakakushev BE, Salamea JC, Sall I, Samarakoon LB, Sammartano F, Arteaga AS, Sanchez-Cordero S, Santoanastaso DPM, Sasia D, Sato N, Savchuk A, Sawyer RG, Scaioli G, Schizas D, Sebastiani S, Seeliger B, Lohse HAS, Seretis C, Sermonesi G, Serradilla-Martin M, Shelat VG, Shlyapnikov S, Sidiropoulos T, Simoes RL, Siragusa L, Siribumrungwong B, Slavchev M, Solaini L, soldini G, Sopuev A, Soreide K, Sovatzidis A, Stahel PF, Strickland M, Sultan MAH, Sydorchuk R, Sydorchuk L, Syed SMAM, Syed AM, Tallon-Aguilar L, Tamburini AM, Tamini N, Tan ECTH, Tan JH, Tarasconi A, Tartaglia N, Tartaglia G, Tartaglia D, Taylor JV, Tebala GD, Gonsaga RAT, Teuben M, Theodorou A, Tolonen M, Tomasicchio G, Toro A, Torre B, Triantafyllou T, Trigiante Trigiante G, Tripepi M, Trostchansky J, Tsekouras K, Turrado-Rodriguez V, Tutino R, Uccelli M, Uchikov PA, Ugarte-Sierra B, Ukkonen MT, Vailas M, Vassiliu PG, Vazquez AG, Vazquez RG, Verde JE, Verde JM, Veroux M, Viganò J, Vilallonga R, Visconti D, Vittori A, Waledziak M, Wannatoop T, Widmer LW, Wilson MSJ, Wong TH, Xenaki S, Yu B, Yule S, Zachariah SK, Zacharis G, Zaghi C, Zakaria AD, Zambrano DA, Zampitis N, Zampogna B, Zanghã S, Zapsalis K, Zattoni F, Zese M, Farre SP, Atanasov BT, Pegoraro V, Zantedeschi M, Reitano E, Pizzocaro E. Time for a paradigm shift in shared decision-making in trauma and emergency surgery? Results from an international survey

BACKGROUND

Shared decision-making (SDM) between clinicians and patients is one of the pillars of the modern patient-centric philosophy of care. This study aims to explore SDM in the discipline of trauma and emergency surgery, investigating its interpretation as well as the barriers and facilitators for its implementation among surgeons.

METHODS

Grounding on the literature on the topics of the understanding, barriers, and facilitators of SDM in trauma and emergency surgery, a survey was created by a multidisciplinary committee and endorsed by the World Society of Emergency Surgery (WSES). The survey was sent to all 917 WSES members, advertised through the society's website, and shared on the society's Twitter profile.

RESULTS

A total of 650 trauma and emergency surgeons from 71 countries in five continents participated in the initiative. Less than half of the surgeons understood SDM, and 30% still saw the value in exclusively engaging multidisciplinary provider teams without involving the patient. Several barriers to effectively partnering with the patient in the decision-making process were identified, such as the lack of time and the need to concentrate on making medical teams work smoothly.

DISCUSSION

Our investigation underlines how only a minority of trauma and emergency surgeons understand SDM, and perhaps, the value of SDM is not fully accepted in trauma and emergency situations. The inclusion of SDM practices in clinical guidelines may represent the most feasible and advocated solutions.

Isolation and Characterization of Stem Cells from the Anal Canal Transition Zone in Pigs

BACKGROUND

Utilization of autologous stem cells has been proposed for the treatment of anal incontinence despite a lack of understanding of their mechanism of action and of the physiological healing process of anal sphincters after injury.

AIMS

We aim to develop a technique allowing isolation and further study of local mesenchymal stem cells, directly from anal canal transition zone in pig.

METHODS

Anal canal was resected "en bloc" from two young pigs and further microdissected. The anal canal transition zone was washed and digested with 0.1% type I collagenase for 45 min at 37 °C. The isolated cells were plated on dishes in mesenchymal stem cell medium and trypsinized when confluent. Cells were further used for flow cytometry analysis and differentiation assays.

RESULTS

The anal canal transition zone localization was confirmed with H&E staining. Following culture, cells exhibited a typical "fibroblast-like" morphology typical of stem cells. Isolated cells were positive for CD90 and CD44 but negative for CD14, CD34, CD45, CD105, CD106, and SLA-DR. Following incubation with specific differentiation medium, isolated cells differentiated into adipocytes, osteoblasts, and chondrocytes, confirming in vitro multipotency.

CONCLUSIONS

Herein, we report for the first time the presence of mesenchymal stem cells in the anal canal transition zone in pigs and the feasibility of their isolation. This preliminary study opens the path to the isolation of human anal canal transition zone mesenchymal stem cells that might be used to study sphincters healing and to treat anal incontinence.

Does Prophylactic Negative-Pressure Wound Therapy Prevent Surgical Site Infection After Laparotomy? A Systematic Review and Meta-analysis of Randomized Controlled trials

BACKGROUND

Prophylactic negative-pressure wound therapy (pNPWT) may prevent surgical site infection (SSI) after laparotomy, but existing meta-analyses pooling only high-quality evidence have failed to confirm this effect. Recently, several randomized controlled trials (RCTs) have been published. We performed an updated systematic review and meta-analysis to determine if pNPWT reduces the incidence of SSI after laparotomy.

METHODS

MEDLINE, Embase, CENTRAL and Web of Science were searched on the 25.08.2021 for RCTs reporting on the incidence of SSI in patients who underwent laparotomy with and without pNPWT. The systematic review was compliant with the AMSTAR2 recommendation and registered into PROSPERO. Risk ratios (RR) for SSI in patients with pNPWT, and risk difference (RD) between control and pNPWT patients, were obtained using random effects models. Heterogeneity was quantified using the I² value, and investigated using subgroup analyses, funnel plots and bubble plots. Risk of bias of included RCTs was assessed using the RoB2 tool.

RESULTS

Eleven RCTs were included, representing 973 patients who received pNPWT and 970 patients who received standard wound dressing. Pooled RR and RD between patients with and without pNPWT were of, respectively, 0.665 (95% CI 0.49-0.91, I²: 38.7%, p = 0.0098) and -0.07 (95% CI -0.12 to -0.03, I²: 53.6%, p = 0.0018), therefore demonstrating that pNPWT decreases the incidence of SSI after laparotomy. Investigation of source of heterogeneity identified a potential small-study effect.

CONCLUSION

The protective effect of pNPWT against SSI after laparotomy is confirmed by high-quality pooled evidence.

Surgeons' perspectives on artificial intelligence to support clinical decision-making in trauma and emergency contexts: results from an international survey

BACKGROUND

Artificial intelligence (AI) is gaining traction in medicine and surgery. AI-based applications can offer tools to examine high-volume data to inform predictive analytics that supports complex decision-making processes. Time-sensitive trauma and emergency contexts are often challenging. The study aims to investigate trauma and emergency surgeons' knowledge and perception of using AI-based tools in clinical decision-making processes.

METHODS

An online survey grounded on literature regarding AI-enabled surgical decision-making aids was created by a multidisciplinary committee and endorsed by the World Society of Emergency Surgery (WSES). The survey was advertised to 917 WSES members through the society's website and Twitter profile.

RESULTS

650 surgeons from 71 countries in five continents participated in the survey. Results depict the presence of technology enthusiasts and skeptics and surgeons' preference toward more classical decision-making aids like clinical guidelines, traditional training, and the support of their multidisciplinary colleagues. A lack of knowledge about several AI-related aspects emerges and is associated with mistrust.

DISCUSSION

The trauma and emergency surgical community is divided into those who firmly believe in the potential of AI and those who do not understand or trust AI-enabled surgical decision-making aids. Academic societies and surgical training programs should promote a foundational, working knowledge of clinical AI.

Does prophylactic negative pressure wound therapy prevent surgical site infection in abdominal surgery?

OBJECTIVE

To determine if prophylactic negative pressure wound therapy (pNPWT) allows for the prevention of surgical site infections (SSIs) in abdominal surgery.

METHOD

A non-systematic review assessing the evidence was conducted in 2020.

RESULTS

Retrospectve studies comparing patients with pNPWT with patients receiving standard wound dressing after abdominal surgery showed encouragning results in favour of pNPWT for reducing the incidence of SSIs, but randomised controlled trials have so far reported mixed results.

CONCLUSION

New randomised controlled trials including a sufficient number of patients at risk of SSIs are needed for confirming the results of non-interventional studies.

The Role of Preoperative Imaging in the Detection of Lateral Lymph Node Metastases in Rectal Cancer: A Systematic Review and Diagnostic Test Meta-analysis

BACKGROUND

Different techniques exist for the imaging of lateral lymph nodes in rectal cancer.

OBJECTIVE

This study aimed to compare the diagnostic accuracy of pelvic MRI, 18 F-FDG-PET/CT, and 18 F-FDG-PET/MRI for the identification of lateral lymph node metastases in rectal cancer.

DATA SOURCES

Data sources include PubMed, Embase, Cochrane Library, and Google Scholar.

STUDY SELECTION

All studies evaluating the diagnostic accuracy of pelvic MRI, 18 F-FDG-PET/CT, and 18 F-FDG-PET/MRI for the preoperative detection of lateral lymph node metastasis in patients with rectal cancer were selected.

INTERVENTIONS

The interventions were pelvic MRI, 18 F-FDG-PET/CT, and/or 18 F-FDG-PET/MRI.

MAIN OUTCOME MEASURES

Definitive histopathology was used as a criterion standard.

RESULTS

A total of 20 studies (1,827 patients) were included out of an initial search yielding 7,360 studies. The pooled sensitivity of pelvic MRI was 0.88 (95% CI, 0.85-0.91), of 18 F-FDG-PET/CT was 0.83 (95% CI, 0.80-0.86), and of 18 F-FDG-PET/MRI was 0.72 (95% CI, 0.51-0.87) for the detection of lateral lymph node metastasis. The pooled specificity of pelvic MRI was 0.85 (95% CI, 0.78-0.90), of 18 F-FDG-PET/CT was 0.95 (95% CI, 0.86-0.98), and of 18 F-FDG-PET/MRI was 0.90 (95% CI, 0.78-0.96). The area under the curve was 0.88 (95% CI, 0.85-0.91) for pelvic MRI and was 0.83 (95% CI, 0.80-0.86) for 18 F-FDG-PET/CT.

LIMITATIONS

Heterogeneity in terms of patients' populations, definitions of suspect lateral lymph nodes, and administration of neoadjuvant treatment.

CONCLUSIONS

For the preoperative identification of lateral lymph node metastasis in rectal cancer, this review found compelling evidence that pelvic MRI should constitute the imaging modality of choice. In contrast, to confirm the presence of lateral lymph node metastasis, 18 F-FDG-PET/MRI modalities allow discarding false positive cases because of increased specificity.

PROSPERO REGISTRATION NUMBER

CRD42020200319.

Two years later: Is the SARS-CoV-2 pandemic still having an impact on emergency surgery? An international cross-sectional survey among WSES members

BACKGROUND

The SARS-CoV-2 pandemic is still ongoing and a major challenge for health care services worldwide. In the first WSES COVID-19 emergency surgery survey, a strong negative impact on emergency surgery (ES) had been described already early in the pandemic situation. However, the knowledge is limited about current effects of the pandemic on patient flow through emergency rooms, daily routine and decision making in ES as well as their changes over time during the last two pandemic years. This second WSES COVID-19 emergency surgery survey investigates the impact of the SARS-CoV-2 pandemic on ES during the course of the pandemic.

METHODS

A web survey had been distributed to medical specialists in ES during a four-week period from January 2022, investigating the impact of the pandemic on patients and septic diseases both requiring ES, structural problems due to the pandemic and time-to-intervention in ES routine.

RESULTS

367 collaborators from 59 countries responded to the survey. The majority indicated that the pandemic still significantly impacts on treatment and outcome of surgical emergency patients (83.1% and 78.5%, respectively). As reasons, the collaborators reported decreased case load in ES (44.7%), but patients presenting with more prolonged and severe diseases, especially concerning perforated appendicitis (62.1%) and diverticulitis (57.5%). Otherwise, approximately 50% of the participants still observe a delay in time-to-intervention in ES compared with the situation before the pandemic. Relevant causes leading to enlarged time-to-intervention in ES during the pandemic are persistent problems with in-hospital logistics, lacks in medical staff as well as operating room and intensive care capacities during the pandemic. This leads not only to the need for triage or transferring of ES patients to other hospitals, reported by 64.0% and 48.8% of the collaborators, respectively, but also to paradigm shifts in treatment modalities to non-operative approaches reported by 67.3% of the participants, especially in uncomplicated appendicitis, cholecystitis and multiple-recurrent diverticulitis.

CONCLUSIONS

The SARS-CoV-2 pandemic still significantly impacts on care and outcome of patients in ES. Well-known problems with in-hospital logistics are not sufficiently resolved by now; however, medical staff shortages and reduced capacities have been dramatically aggravated over last two pandemic years.

[Hemorrhoidal disease in 2022 : how to select the most appropriate treatment ?]

Hemorrhoidal disease is frequent and can lead to major alteration of quality of life. Conservative treatment, instrumental therapies and surgical approach play a complementary role in the management of hemorrhoidal disease. Understanding all techniques is mandatory to guide the patient and offer the best individualized treatment. Guidelines issued by scientific societies can facilitate the therapeutic decision.

Mapping of etiologies of computed tomography-proven acute colitis: a prospective cohort study

Our objective was to describe the etiologies of acute colitis and to identify patients who require diagnostic endoscopy. Patients with symptoms of gastrointestinal infection and colonic inflammation on CT were prospectively included. Those immunosuppressed, with history of colorectal cancer or inflammatory bowel disease (IBD), were excluded. Microbiological analysis of the feces was performed using PCR assays BD-Max and FilmArray (GI panel,) and fecal cultures. Fecal calprotectin was determined. Patients with negative BD-Max underwent colonoscopy. One hundred and seventy-nine patients were included. BD-Max was positive in 93 patients (52%) and FilmArray in 108 patients (60.3%). Patients with infectious colitis (n = 103, 57.5%) were positive for Campylobacter spp. (n = 57, 55.3%), Escherichia coli spp. (n = 8, 7.8%), Clostridioides difficile (n = 23, 22.3%), Salmonella spp. (n = 9, 8.7%), viruses (n = 7, 6.8%), Shigella spp. (n = 6, 5.8%), Entamoeba histolytica (n = 2, 1.9%) and others (n = 4, 3.9%). Eighty-six patients underwent colonoscopy, which was compatible with ischemic colitis in 18 patients (10.1%) and IBD in 4 patients (2.2%). Fecal calprotectin was elevated in all patients, with a mean concentration of 1922.1 ± 2895.6 μg/g, and was the highest in patients with IBD (8511 ± 9438 μg/g, p < 0.001). After exclusion of patients with infectious etiology, a fecal calprotectin > 625 μg/g allowed identifying patients with IBD with an area under ROC curve of 85.1%. To conclude, computed tomography-proven colitis was of infectious etiology in 57.5% of patients. The main pathogens identified were Campylobacter spp. (55.3%), Clostridioides difficile (22.3%) and Salmonella spp. (8.7%). Ischemic colitis (10.1%) and IBD (2.2%) were seldom represented. No colorectal cancer was found.

Fluorescence angiography likely protects against anastomotic leak in colorectal surgery: a systematic review and meta-analysis of randomised controlled trials

Objective

Observational studies have shown that fluorescence angiography (FA) decreases the incidence of anastomotic leak (AL) in colorectal surgery, but high-quality pooled evidence was lacking. Therefore, we aimed at confirming this preliminary finding using a systematic review and meta-analysis of randomised controlled trials (RCTs) in the field.

Methods

MEDLINE, Embase and CENTRAL were searched for RCTs assessing the effect of intra-operative FA versus standard assessment of bowel perfusion on the incidence of AL of colorectal anastomosis. The systematic review complied with the PRISMA 2020 and AMSTAR2 recommendations and was registered in PROSPERO. Pooled relative risk (RR) and pooled risk difference (RD) were obtained using models with random effects. Heterogeneity was assessed using the Q-test and quantified using the I² value. Certainty of evidence was assessed using the GRADE Pro tool.

Results

One hundred and eleven articles were screened, 108 were excluded and three were kept for inclusion. The three included RCTs compared assessment of the perfusion of the bowel during creation of a colorectal anastomosis using FA versus standard practice. In meta-analysis, FA was significantly protective against AL (3 RCTs, 964 patients, RR: 0.67, 95% CI: 0.46 to 0.99, I²: 0%, p = 0.04). The RD of AL was non-significantly decreased by 4 percentage points (95%CI: − 0.08 to 0, I²: 8%, p = 0.06) when using FA. Certainty of evidence was considered as moderate.

Conclusion

The effect of FA on prevention of AL in colorectal surgery exists but is potentially of small magnitude. Considering the potential magnitude of effect of FA, we advise that future RCTs have an adequate sample size, include a cost-benefit analysis of the technique and better define the subpopulation who could benefit from FA.

Graphical abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s00464-022-09255-1.

Optimized Isolation and Characterization of C57BL/6 Mouse Hepatic Stellate Cells

To obtain meaningful results of hepatic stellate cell (HSC) function, it is crucial to use highly pure HSC populations. Our aim was to optimize HSC isolation from mice livers without exploiting the characteristically transient vitamin A autofluorescence of HSC. HSCs were isolated from C57BL/6 mice using a two-step collagenase digestion and Nycodenz gradient separation followed by CD11b-negative sorting step in order to remove contaminating macrophages and dendritic cells. Isolated cells were analyzed for yield, viability, purity, and potential new markers using immunofluorescence and flow cytometry. We obtained a yield of 350,595 ± 100,773 HSC per mouse liver and a viability of isolated cells of 92.4 ± 3.1%. We observed a low macrophage/dendritic cell contamination of 1.22 ± 0.54%. Using flow cytometry, we demonstrated that CD38 was expressed at the surface of HSC subpopulations and that all expressed intracellular markers specific for HSC in the liver. This isolation method, avoiding fluorescent activated cell sorting (FACS), allowed isolation of HSCs with high purity. Further, flow cytometry analysis suggests that CD38 may be a reliable marker of HSCs and may include subpopulations of HSCs without retinoid droplets.