The Operating Room management for emergency Surgical Activity (ORSA) study: a WSES international survey

BACKGROUND

Despite advances and improvements in the management of surgical patients, emergency and trauma surgery is associated with high morbidity and mortality. This may be due in part to delays in definitive surgical management in the operating room (OR). There is a lack of studies focused on OR prioritization and resource allocation in emergency surgery. The Operating Room management for emergency Surgical Activity (ORSA) study was conceived to assess the management of operating theatres and resources from a global perspective among expert international acute care surgeons.

METHOD

The ORSA study was conceived as an international web survey. The questionnaire was composed of 23 multiple-choice and open questions. Data were collected over 3 months. Participation in the survey was voluntary and anonymous.

RESULTS

One hundred forty-seven emergency and acute care surgeons answered the questionnaire; the response rate was 58.8%. The majority of the participants come from Europe. One hundred nineteen surgeons (81%; 119/147) declared to have at least one emergency OR in their hospital; for the other 20/147 surgeons (13.6%), there is not a dedicated emergency operating room. Forty-six (68/147)% of the surgeons use the elective OR to perform emergency procedures during the day. The planning of an emergency surgical procedure is done by phone by 70% (104/147) of the surgeons.

CONCLUSIONS

There is no dedicated emergency OR in the majority of hospitals internationally. Elective surgical procedures are usually postponed or even cancelled to perform emergency surgery. It is a priority to validate an effective universal triaging and scheduling system to allocate emergency surgical procedures. The new Timing in Acute Care Surgery (TACS) was recently proposed and validated by a Delphi consensus as a clear and reproducible triage tool to timely perform an emergency surgical procedure according to the clinical severity of the surgical disease. The new TACS needs to be prospectively validated in clinical practice. Logistics have to be assessed using a multi-disciplinary approach to improve patients' safety, optimise the use of resources, and decrease costs.

Is Precision Surgery Applicable to Colorectal Liver Metastases? A Systematic Review and Meta-analysis of Studies that Investigate the Association of Surgical Technique with Outcomes in the Context of Distinct Tumor Biology

BACKGROUND

Although some data suggest that patients with mutRAS colorectal liver metastases (CRLM) may benefit from anatomic hepatectomy, this topic remains controversial. We performed a systematic review and meta-analysis to determine whether RAS mutation status was associated with prognosis relative to surgical technique [anatomic resection (AR) vs. nonanatomic resection (NAR)] among patients with CRLM.

PATIENTS AND METHODS

A systematic review and meta-analysis of studies were performed to investigate the association of AR versus NAR with overall and liver-specific disease-free survival (DFS and liver-specific DFS, respectively) in the context of RAS mutation status.

RESULTS

Overall, 2018 patients (831 mutRAS vs. 1187 wtRAS) were included from five eligible studies. AR was associated with a 40% improvement in liver-specific DFS [hazard ratio (HR) = 0.6, 95% confidence interval (CI) 0.44-0.81, p = 0.01] and a 28% improvement in overall DFS (HR = 0.72, 95% CI 0.54-0.95, p = 0.02) among patients with mutRAS tumors; in contrast, AR was not associated with any improvement in liver-specific DFS or overall DFS among wtRAS patients. These differences may have been mediated by the 40% decreased incidence in R1 resection among patients with mutRAS tumors who underwent AR versus NAR [relative risk (RR): 0.6, 95% CI 0.40-0.91, p = 0.02]. In contrast, the probability of an R1 resection was not decreased among wtRAS patients who underwent AR versus NAR (RR: 0.93, 95% CI 0.69-1.25, p = 0.62).

CONCLUSIONS

The data suggest that precision surgery may be relevant to CRLM. Specifically, rather than a parenchymal sparing dogma for all patients, AR may have a role in individuals with mutRAS tumors.

Point-of-care diagnostics for sexually transmitted infections among migrants in Greece

SETTING

Sexually transmitted infections (STIs) can impact individuals of any demographic. The most common pathogens causing STIs are Chlamydia trachomatis, Neisseria gonorrhea and Trichomonas vaginalis; these can be treated with specific antibiotics.

OBJECTIVE

To compare the GeneXpert CT/NG test-and-treat algorithm to the syndromic approach algorithm and their impact on antibiotic prescription for gonorrhoea and chlamydia STIs.

DESIGN

A retrospective observational study on women aged ≥18 years who accessed the Médecins Sans Frontières Day Care Centre in Athens with complaints related to urogenital infections between January 2021 and March 2022. Women with abnormal vaginal discharge, excluding clinically diagnosed candidiasis, were eligible for Xpert CT/NG testing.

RESULTS

Of the 450 women who accessed care, 84 were eligible for Xpert CT/NG testing, and only one was positive for chlamydia, therefore resulting in saving 81 doses of ceftriaxone and azithromycin, and 19 doses of metronidazole. The cost of Xpert CT/NG testing, including treatment was €4,606.37, while full antibiotic treatment would have costed €536.76.

CONCLUSION

The overall cost of the Xpert CT/NG test-and-treat algorithm was higher than the syndromic approach. However, quality of care should be weighed against the potential benefits of testing and syndromic treatment to determine the best option for each patient; we therefore advocate for decreasing the costs.

Laparoscopic Inguinal Hernia Repair in the Obese Patient Population: A Single-Center Five-Year Experience

Purpose The objective of the present study is to evaluate the distribution of the transabdominal preperitoneal (TAPP) and the totally extraperitoneal repair (TEP) procedures among the obese and non-obese patient populations, to show how obesity impacts daily practice by reviewing the experience of a single center, and finally, to assess the outcomes of the operations. Methods All patients who underwent elective, minimally invasive inguinal hernia repair in our hospital from January 2017 to January 2022 were included in the present study. The data that were analyzed were patient demographics, each individual patient's American Society of Anesthesiology (ASA) score, the minimally invasive technique (TAPP or TEP) utilized, the body mass index (BMI), and other comorbidities such as underlying diabetes, hypertension, and smoking status. Results A total of 109 patients were included in the present analysis, of which 81 (74.3%) underwent elective TEP repairs while 28 (25.7%) underwent elective TAPP repairs. Overall, 39 (35.7%) patients were included in the obesity subgroup with an average BMI of 35.4 ± 4.9, with a range from 30.1 to 52.7, and 70 (64.3%) were included in the non-obese subgroup, with an average BMI of 23.2 ± 3.3 and a range from 16.2 to 29.7. Conclusions The laparoscopic approach to the inguinal hernia repair in obese patients has similar outcomes as an open approach regarding the 30-day events, in the hands of experienced surgeons with the advantages of the laparoscopic approach vs. the open one.

Changes in Cardiovascular and Renal Biomarkers Associated with SGLT2 Inhibitors Treatment in Patients with Type 2 Diabetes Mellitus

Type 2 diabetes mellitus is a major health problem worldwide with a steadily increasing prevalence reaching epidemic proportions. The major concern is the increased morbidity and mortality due to diabetic complications. Traditional but also nontraditional risk factors have been proposed to explain the pathogenesis of type 2 diabetes mellitus and its complications. Hyperglycemia has been considered an important risk factor, and the strict glycemic control can have a positive impact on microangiopathy but not macroangiopathy and its related morbidity and mortality. Thus, the therapeutic algorithm has shifted focus from a glucose-centered approach to a strategy that now emphasizes target-organ protection. Sodium-glucose transporter 2 inhibitors is an extremely important class of antidiabetic medications that, in addition to their glucose lowering effect, also exhibit cardio- and renoprotective effects. Various established and novel biomarkers have been described, reflecting kidney and cardiovascular function. In this review, we investigated the changes in established but also novel biomarkers of kidney, heart and vascular function associated with sodium-glucose transporter 2 inhibitors treatment in patients with type 2 diabetes mellitus.

Enhanced perioperative care in emergency general surgery: the WSES position paper

Enhanced perioperative care protocols become the standard of care in elective surgery with a significant improvement in patients' outcome. The key element of the enhanced perioperative care protocol is the multimodal and interdisciplinary approach targeted to the patient, focused on a holistic approach to reduce surgical stress and improve perioperative recovery. Enhanced perioperative care in emergency general surgery is still a debated topic with little evidence available. The present position paper illustrates the existing evidence about perioperative care in emergency surgery patients with a focus on each perioperative intervention in the preoperative, intraoperative and postoperative phase. For each item was proposed and approved a statement by the WSES collaborative group.

An interpretable AI model for recurrence prediction after surgery in gastrointestinal stromal tumour: an observational cohort study

Background

There are several models that predict the risk of recurrence following resection of localised, primary gastrointestinal stromal tumour (GIST). However, assessment of calibration is not always feasible and when performed, calibration of current GIST models appears to be suboptimal. We aimed to develop a prognostic model to predict the recurrence of GIST after surgery with both good discrimination and calibration by uncovering and harnessing the non-linear relationships among variables that predict recurrence.

Methods

In this observational cohort study, the data of 395 adult patients who underwent complete resection (R0 or R1) of a localised, primary GIST in the pre-imatinib era at Memorial Sloan Kettering Cancer Center (NY, USA) (recruited 1982-2001) and a European consortium (Spanish Group for Research in Sarcomas, 80 sites) (recruited 1987-2011) were used to train an interpretable Artificial Intelligence (AI)-based model called Optimal Classification Trees (OCT). The OCT predicted the probability of recurrence after surgery by capturing non-linear relationships among predictors of recurrence. The data of an additional 596 patients from another European consortium (Polish Clinical GIST Registry, 7 sites) (recruited 1981-2013) who were also treated in the pre-imatinib era were used to externally validate the OCT predictions with regard to discrimination (Harrell's C-index and Brier score) and calibration (calibration curve, Brier score, and Hosmer-Lemeshow test). The calibration of the Memorial Sloan Kettering (MSK) GIST nomogram was used as a comparative gold standard. We also evaluated the clinical utility of the OCT and the MSK nomogram by performing a Decision Curve Analysis (DCA).

Findings

The internal cohort included 395 patients (median [IQR] age, 63 [54-71] years; 214 men [54.2%]) and the external cohort included 556 patients (median [IQR] age, 60 [52-68] years; 308 men [55.4%]). The Harrell's C-index of the OCT in the external validation cohort was greater than that of the MSK nomogram (0.805 (95% CI: 0.803-0.808) vs 0.788 (95% CI: 0.786-0.791), respectively). In the external validation cohort, the slope and intercept of the calibration curve of the main OCT were 1.041 and 0.038, respectively. In comparison, the slope and intercept of the calibration curve for the MSK nomogram was 0.681 and 0.032, respectively. The MSK nomogram overestimated the recurrence risk throughout the entire calibration curve. Of note, the Brier score was lower for the OCT compared to the MSK nomogram (0.147 vs 0.564, respectively), and the Hosmer-Lemeshow test was insignificant (P = 0.087) for the OCT model but significant (P < 0.001) for the MSK nomogram. Both results confirmed the superior discrimination and calibration of the OCT over the MSK nomogram. A decision curve analysis showed that the AI-based OCT model allowed for superior decision making compared to the MSK nomogram for both patients with 25-50% recurrence risk as well as those with >50% risk of recurrence.

Interpretation

We present the first prognostic models of recurrence risk in GIST that demonstrate excellent discrimination, calibration, and clinical utility on external validation. Additional studies for further validation are warranted. With further validation, these tools could potentially improve patient counseling and selection for adjuvant therapy.

Funding

The NCI SPORE in Soft Tissue Sarcoma and NCI Cancer Center Support Grants.

Demystifying BRAF Mutation Status in Colorectal Liver Metastases : A Multi-institutional, Collaborative Approach to 6 Open Clinical Questions

OBJECTIVE

To investigate the clinical implications of BRAF -mutated (mut BRAF ) colorectal liver metastases (CRLMs).

BACKGROUND

The clinical implications of mut BRAF status in CRLMs are largely unknown.

METHODS

Patients undergoing resection for mut BRAF CRLM were identified from prospectively maintained registries of the collaborating institutions. Overall survival (OS) and recurrence-free survival (RFS) were compared among patients with V600E versus non-V600E mutations, KRAS/BRAF comutation versus mut BRAF alone, microsatellite stability status (Microsatellite Stable (MSS) vs instable (MSI-high)), upfront resectable versus converted tumors, extrahepatic versus liver-limited disease, and intrahepatic recurrence treated with repeat hepatectomy versus nonoperative management.

RESULTS

A total of 240 patients harboring BRAF -mutated tumors were included. BRAF V600E mutation was associated with shorter OS (30.6 vs 144 mo, P =0.004), but not RFS compared with non-V600E mutations. KRAS/BRAF comutation did not affect outcomes. MSS tumors were associated with shorter RFS (9.1 vs 26 mo, P <0.001) but not OS (33.5 vs 41 mo, P =0.3) compared with MSI-high tumors, whereas patients with resected converted disease had slightly worse RFS (8 vs 11 mo, P =0.01) and similar OS (30 vs 40 mo, P =0.4) compared with those with upfront resectable disease. Patients with extrahepatic disease had worse OS compared with those with liver-limited disease (8.8 vs 40 mo, P <0.001). Repeat hepatectomy after intrahepatic recurrence was associated with improved OS compared with nonoperative management (41 vs 18.7 mo, P =0.004). All results continued to hold true in the multivariable OS analysis.

CONCLUSIONS

Although surgery may be futile in patients with BRAF -mutated CRLM and concurrent extrahepatic disease, resection of converted disease resulted in encouraging survival in the absence of extrahepatic spread. Importantly, second hepatectomy in select patients with recurrence was associated with improved outcomes. Finally, MSI-high status identifies a better prognostic group, with regard to RFS while patients with non-V600E mutations have excellent prognosis.

Dietary Approach of Patients with Hormone-Related Cancer Based on the Glycemic Index and Glycemic Load Estimates

Hormone-related cancers, namely breast, endometrial, cervical, prostate, testicular, and thyroid, constitute a specific group of cancers dependent on hormone levels that play an essential role in cancer growth. In addition to the traditional risk factors, diet seems to be an important environmental factor that partially explains the steadily increased prevalence of this group of cancer. The composition of food, the dietary patterns, the endocrine-disrupting chemicals, and the way of food processing and preparation related to dietary advanced glycation end-product formation are all related to cancer. However, it remains unclear which specific dietary components mediate this relationship. Carbohydrates seem to be a risk factor for cancer in general and hormone-related cancers, in particular, with a difference between simple and complex carbohydrates. Glycemic index and glycemic load estimates reflect the effect of dietary carbohydrates on postprandial glucose concentrations. Several studies have investigated the relationship between the dietary glycemic index and glycemic load estimates with the natural course of cancer and, more specifically, hormone-related cancers. High glycemic index and glycemic load diets are associated with cancer development and worse prognosis, partially explained by the adverse effects on insulin metabolism, causing hyperinsulinemia and insulin resistance, and also by inflammation and oxidative stress induction. Herein, we review the existing data on the effect of diets focusing on the glycemic index and glycemic load estimates on hormone-related cancers.

ECLAPTE: Effective Closure of LAParoTomy in Emergency-2023 World Society of Emergency Surgery guidelines for the closure of laparotomy in emergency settings

Laparotomy incisions provide easy and rapid access to the peritoneal cavity in case of emergency surgery. Incisional hernia (IH) is a late manifestation of the failure of abdominal wall closure and represents frequent complication of any abdominal incision: IHs can cause pain and discomfort to the patients but also clinical serious sequelae like bowel obstruction, incarceration, strangulation, and necessity of reoperation. Previous guidelines and indications in the literature consider elective settings and evidence about laparotomy closure in emergency settings is lacking. This paper aims to present the World Society of Emergency Surgery (WSES) project called ECLAPTE (Effective Closure of LAParoTomy in Emergency): the final manuscript includes guidelines on the closure of emergency laparotomy.

The new timing in acute care surgery (new TACS) classification: a WSES Delphi consensus study

BACKGROUND

Timely access to the operating room for emergency general surgery (EGS) indications remains a challenge across the globe, largely driven by operating room availability and staffing constraints. The "timing in acute care surgery" (TACS) classification was previously published to introduce a new tool to triage the timely and appropriate access of EGS patients to the operating room. However, the clinical and operational effectiveness of the TACS classification has not been investigated in subsequent validation studies. This study aimed to improve the TACS classification and provide further consensus around the appropriate use of the new TACS classification through a standardized Delphi approach with international experts.

METHODS

This is a validation study of the new TACS by a selected international panel of experts using the Delphi method. The TACS questionnaire was designed as a web-based survey. The consensus agreement level was established to be ≥ 75%. The collective consensus agreement was defined as the sum of the percentage of the highest Likert scale levels (4-5) out of all participants. Surgical emergency diseases and correlated clinical scenarios were defined for each of the proposed classes. Subsequent rounds were carried out until a definitive level of consensus was reached. Frequencies and percentages were calculated to determine the degree of agreement for each surgical disease.

RESULTS

Four polling rounds were carried out. The new TACS classification provides 6 colour-code classes correlated to a precise timing to surgery, defined scenarios and surgical condition. The WHITE colour-code class was introduced to rapidly (within a week) reschedule cancelled or postponed surgical procedures. Haemodynamic stability is the main tool to stratify patients for immediate surgery or not in the presence of sepsis/septic shock. Fifty-one surgical diseases were included in the different colour-code classes of priority.

CONCLUSION

The new TACS classification is a comprehensive, simple, clear and reproducible triage system which can be used to assess the severity of the patient and the surgical disease, to reduce the time to access to the operating room, and to manage the emergency surgical patients within a "safe" timeframe. By including well-defined surgical diseases in the different colour-code classes of priority, validated through a Delphi consensus, the new TACS improves communication among surgeons, between surgeons and anaesthesiologists and decreases conflicts and waste and waiting time in accessing the operating room for emergency surgical patients.

"Starting from the Image": A Tele-pathology Pre-graduate Course Aimed at Motivating Medical Students

In the tele-course entitled "Starting from the image", medical students are confronted with practical tasks in relevant professional contexts. Initially, a macroscopic or microscopic image of a patient case is presented to learners who then receive relevant information on the patient's history, clinical findings, and other laboratory tests. A pathologist actively discusses the pathological findings; then, a clinician explains their implications for the patient's individualized treatment and prognosis. In this way, pathology's interaction with other medical specialties is highlighted. Students declared that through these simulated professional practice experiences, they strengthened their decision-making skills. Educators should consider upgrading from information-based teaching to practice-focused instruction.

Precision Surgery of Colorectal Liver Metastases in the Current Era: A Systematic Review

Liver resection for colorectal liver metastases (CRLM) is widely considered the treatment with the highest curative potential. However, not all patients derive the same oncological benefit, underlining the need for better patient stratification and treatment allocation. In this context, we performed a systematic review of the literature to determine the role of RAS status in selecting the optimal surgical strategy. Evidence comparing anatomical with non-anatomical resections depending on RAS mutational status was scarce and conflicting, with two studies reporting superiority in mutated RAS (mutRAS) patients and two studies reporting equivalent outcomes. The rate of incomplete microscopic resection (R1) was found to be increased among mutRAS patients, possibly due to higher micrometastatic spread lateral to the primary lesion. The impact of R1 resection margins was evaluated separately for mutRAS and wild-type patients in three studies, of which, two indicated an additive detriment to long-term survival in the former group. In the current era of precision surgery, RAS status can be utilized to predict the efficacy of liver resection in the treatment of CRLM, avoiding a potentially morbid operation in patients with adverse tumor profiles.

The Protective Effect of Bariatric Surgery on the Development of Colorectal Cancer: A Systematic Review and Meta-Analysis

BACKGROUND

Obesity is a known risk factor for developing colorectal cancer (CRC) and is associated with the formation of precancerous colonic adenomas. Bariatric surgery (BRS) is considered to reduce the cancer risk in morbidly obese patients. However, the currently available literature yields contradicting results regarding the impact of bariatric surgery on the incidence of CRC.

METHODS

A systematic literature search of the Medline, Embase, CENTRAL, CINAHL, Web of Science, and clinicaltrials.gov databases was undertaken following the PRISMA guidelines. A random effects model was selected.

RESULTS

Twelve retrospective cohort studies, incorporating a total of 6,279,722 patients, were eligible for inclusion in the final quantitative analysis. Eight studies originated from North America, while four reported on European patients. Patients in the Bariatric Surgery group exhibited a significantly reduced risk for developing colorectal cancer (RR 0.56, 95% CI 0.4-0.8, p < 0.001), while sleeve gastrectomy was found to be significantly associated with a smaller incidence of CRC (RR 0.55, 95% CI 0.36-0.83, p < 0.001), and gastric bypass and banding did not.

CONCLUSIONS

A significant protective effect of BRS against the development of CRC is implied. In the present analysis, the incidence rate of colorectal cancer was approximately halved amongst the obese individuals that were operated on.

Experiential student study groups: perspectives on medical education in the post-COVID-19 period

BACKGROUND

Undergraduate medical curricula often fail to integrate experiential learning methodologies. Thus, a pilot series of interactive pathology lessons was designed and implemented in an attempt to promote experiential learning.

METHODS

Thirty pre-graduate medical students voluntarily participated in the interactive study groups at the First Department of Pathology of the National and Kapodistrian University of Athens, Medical School. A questionnaire was designed to investigate the satisfaction of students regarding their participation in pathology study groups and to identify the characteristics that shape students' perceptions of the foundations of medical education. Descriptive statistics (mean values) were used to describe the students' evaluations of the pathology study groups, and thematic analysis was conducted to investigate the data collected using open-ended questions.

RESULTS

Interactions with the professor and the option of co-observing the slides using dual-view optical microscopes and virtual slides were each evaluated as "Excellent" by ≅ 95% of the students. Four overarching themes were identified regarding the core characteristics of medical education according to the students' perspectives: 1) educational background in medical education, 2) interaction with educators in medical education, 3) educational material in medical education and 4) assessment in medical education.

CONCLUSIONS

The high rates of acceptance of the pathology study groups reflect the desire and need for active learning methodologies to be implemented in modern medical education. Nearly all the students mentioned the need for practical skill acquisition, the integration of theory into practice and ethics in medical education. The success of these optional pathology study groups highlights the need for similar modalities to be incorporated into the main medical education curriculum.

The effect of hepatocyte growth factor on intestinal adaption in an experimental model of short bowel syndrome

PURPOSE

Nowadays, the standard therapy for patients with short bowel syndrome is parenteral nutrition (PN). Various growth factors have been tested to achieve weaning from prolonged PN administration. We evaluated the effect of hepatocyte growth factor (HGF) on structural intestinal adaptation and cell proliferation in a rat model of SBS.

METHODS

Thirty Sprague-Dawley rats were divided into three groups; group A rats (sham) underwent bowel transection, group B rats underwent a 75% bowel resection, and group C rats underwent the same procedure but were treated postoperatively with HGF. Histopathologic parameters of intestinal adaptation were determined, while microarray and rt-PCR analyses of ileal RNA were also performed.

RESULTS

Treatment with HGF resulted in significant increase in body weight, while the jejunal and ileal villus height and crypt depth were increased in HGF rats (36%, p < 0.05 and 27%, p < 0.05 respectively). Enterocyte proliferation was also significantly increased in HGF rats (21% p < 0.05). Microarray and quantitative rt-PCR analyses showed that the genes hgfac, rac 1, cdc42, and akt 1 were more than twofold up-regulated after HGF treatment.

CONCLUSION

HGF emerges as a growth factor that enhances intestinal adaptation. The future use of HGF may potentially reduce the requirement for PN in SBS patients.

Milder impact of the COVID-19 pandemic on the practice of orthopaedic surgery in Greece and Cyprus than other European countries

PURPOSE

The aim of this study was to highlight the impact of the COVID-19 pandemic on the practice of orthopaedics in Greece and Cyprus.

METHODS

The survey used the online questionnaire from AGA (Gesellschaft für Arthroskopie und Gelenkchirurgie; Society for Arthroscopy and Joint Surgery) to facilitate the comparison between different European countries. The questionnaire was distributed online to members of the HAOST (Hellenic Association of Orthopaedic Surgery and Trauma), the ΟΤΑΜΑΤ (Orthopaedic and Trauma Association of Macedonia and Thrace) and the CAOST (Cypriot Association of Orthopaedic Surgery and Trauma). The questionnaire consisted of 29 questions, which included demographic data, questions on the impact of the pandemic on the practice of orthopaedic surgery and questions on the impact on the personal and family life of orthopaedic surgeons.

RESULTS

The questionnaire was sent to 1350 orthopaedic surgeons in Greece and Cyprus, 303 of whom responded (response rate 22.44%). 11.2% of the participants reported cancellation of overall orthopaedic procedures. According to 35.6-49.8% of the participants, arthroscopic procedures were continued. As regards elective primary arthroplasties, 35.3% of the participants reported that these continued to be performed at their hospitals. Post-operative follow-ups as well as physiotherapy were affected by the pandemic, and changes were also observed in the habits of orthopaedic surgeons in their personal and family lives.

CONCLUSION

The orthopaedic service in Greece and Cyprus decreased during the first wave of the COVID-19 pandemic. Arthroscopic procedures and total joint replacements decreased significantly, but not to the same extent as in other countries. Health systems were not fully prepared for the first wave of the pandemic and the various countries took social measures at different times and to different extents. Thus, studying the impact of the pandemic on the practice of orthopaedic surgery in different countries can help health systems to better prepare for future pandemics; public health can then be shielded and hospitals can continue to provide high-quality orthopaedic care.

LEVEL OF EVIDENCE

Level V.

The ChoCO-W prospective observational global study: Does COVID-19 increase gangrenous cholecystitis?

BACKGROUND

The incidence of the highly morbid and potentially lethal gangrenous cholecystitis was reportedly increased during the COVID-19 pandemic. The aim of the ChoCO-W study was to compare the clinical findings and outcomes of acute cholecystitis in patients who had COVID-19 disease with those who did not.

METHODS

Data were prospectively collected over 6 months (October 1, 2020, to April 30, 2021) with 1-month follow-up. In October 2020, Delta variant of SARS CoV-2 was isolated for the first time. Demographic and clinical data were analyzed and reported according to the STROBE guidelines. Baseline characteristics and clinical outcomes of patients who had COVID-19 were compared with those who did not.

RESULTS

A total of 2893 patients, from 42 countries, 218 centers, involved, with a median age of 61.3 (SD: 17.39) years were prospectively enrolled in this study; 1481 (51%) patients were males. One hundred and eighty (6.9%) patients were COVID-19 positive, while 2412 (93.1%) were negative. Concomitant preexisting diseases including cardiovascular diseases (p < 0.0001), diabetes (p < 0.0001), and severe chronic obstructive airway disease (p = 0.005) were significantly more frequent in the COVID-19 group. Markers of sepsis severity including ARDS (p < 0.0001), PIPAS score (p < 0.0001), WSES sepsis score (p < 0.0001), qSOFA (p < 0.0001), and Tokyo classification of severity of acute cholecystitis (p < 0.0001) were significantly higher in the COVID-19 group. The COVID-19 group had significantly higher postoperative complications (32.2% compared with 11.7%, p < 0.0001), longer mean hospital stay (13.21 compared with 6.51 days, p < 0.0001), and mortality rate (13.4% compared with 1.7%, p < 0.0001). The incidence of gangrenous cholecystitis was doubled in the COVID-19 group (40.7% compared with 22.3%). The mean wall thickness of the gallbladder was significantly higher in the COVID-19 group [6.32 (SD: 2.44) mm compared with 5.4 (SD: 3.45) mm; p < 0.0001].

CONCLUSIONS

The incidence of gangrenous cholecystitis is higher in COVID patients compared with non-COVID patients admitted to the emergency department with acute cholecystitis. Gangrenous cholecystitis in COVID patients is associated with high-grade Clavien-Dindo postoperative complications, longer hospital stay and higher mortality rate. The open cholecystectomy rate is higher in COVID compared with non -COVID patients. It is recommended to delay the surgical treatment in COVID patients, when it is possible, to decrease morbidity and mortality rates. COVID-19 infection and gangrenous cholecystistis are not absolute contraindications to perform laparoscopic cholecystectomy, in a case by case evaluation, in expert hands.

Prognostic value of primary tumor sidedness in patients with non-metastatic IBD related CRC - Is it the exception to the rule?

BACKGROUND

Although primary tumor sidedness (PTS) has a known prognostic role in sporadic colorectal cancer (CRC), its role in Inflammatory Bowel Disease related CRC (IBD-CRC) is largely unknown. Thus, we aimed to evaluate the prognostic role of PTS in patients with IBD-CRC.

METHODS

All eligible patients with surgically treated, non-metastatic IBD-CRC were retrospectively identified from institutional databases at ten European and Asian academic centers. Long term endpoints included recurrence-free (RFS) and overall survival (OS). Multivariable Cox proportional hazard regression as well as propensity score analyses were performed to evaluate whether PTS was significantly associated with RFS and OS.

RESULTS

A total of 213 patients were included in the analysis, of which 32.4% had right-sided (RS) tumors and 67.6% had left-sided (LS) tumors. PTS was not associated with OS and RFS even on univariable analysis (5-year OS for RS vs LS tumors was 68.0% vs 77.3%, respectively, p = 0.31; 5-year RFS for RS vs LS tumors was 62.8% vs 65.4%, respectively, p = 0.51). Similarly, PTS was not associated with OS and RFS on propensity score matched analysis (5-year OS for RS vs LS tumors was 82.9% vs 91.3%, p = 0.79; 5-year RFS for RS vs LS tumors was 85.1% vs 81.5%, p = 0.69). These results were maintained when OS and RFS were calculated in patients with RS vs LS tumors after excluding patients with rectal tumors (5-year OS for RS vs LS tumors was 68.0% vs 77.2%, respectively, p = 0.38; 5-year RFS for RS vs LS tumors was 62.8% vs 59.2%, respectively, p = 0.98).

CONCLUSIONS

In contrast to sporadic CRC, PTS does not appear to have a prognostic role in IBD-CRC.

Synchronous Sternal Metastasectomy and Total Thyroidectomy for Differentiated Thyroid Cancer: A Rare Case Report

Bone metastases from thyroid cancer are mainly rare, while sternal metastases are extremely uncommon. Bone metastases might be either synchronous or metachronous to primary thyroid cancer. A 60-year-old male patient presented to our department with a painful, fixed and firm sternal mass. Preoperative imaging studies, such as neck ultrasound (US) and computed tomography (CT) of the chest, revealed a 6.5 cm nodule of the right thyroid lobe with high-risk malignancy characteristics and a massive metastatic mass of the anterior mediastinal, which was extended from the sternal notch to the third intercostal space. The diagnosis of papillary thyroid carcinoma with sternal metastatic lesions was established. After meticulous discussion in the multidisciplinary board of our hospital, a total thyroidectomy plus en-bloc resection of this massive sternal metastasis and adjuvant radioiodine therapy were decided. Eight months postoperatively, no recurrence has occurred in this patient. R0 resection of isolated bone metastasis of thyroid origin is still an optimal therapeutic decision for these patients. In cases of sternal metastasis, radical surgical resection with negative margins, including both resection of the lesion and reconstruction of the chest wall, in order to successfully maintain the chest wall's stability, is recommended.

Follow-up strategies for patients with splenic trauma managed non-operatively: the 2022 World Society of Emergency Surgery consensus document

Background

In 2017, the World Society of Emergency Surgery published its guidelines for the management of adult and pediatric patients with splenic trauma. Several issues regarding the follow-up of patients with splenic injuries treated with NOM remained unsolved.

Methods

Using a modified Delphi method, we sought to explore ongoing areas of controversy in the NOM of splenic trauma and reach a consensus among a group of 48 international experts from five continents (Africa, Europe, Asia, Oceania, America) concerning optimal follow-up strategies in patients with splenic injuries treated with NOM.

Results

Consensus was reached on eleven clinical research questions and 28 recommendations with an agreement rate ≥ 80%. Mobilization after 24 h in low-grade splenic trauma patients (WSES Class I, AAST Grades I–II) was suggested, while in patients with high-grade splenic injuries (WSES Classes II–III, AAST Grades III–V), if no other contraindications to early mobilization exist, safe mobilization of the patient when three successive hemoglobins 8 h apart after the first are within 10% of each other was considered safe according to the panel. The panel suggests adult patients to be admitted to hospital for 1 day (for low-grade splenic injuries—WSES Class I, AAST Grades I–II) to 3 days (for high-grade splenic injuries—WSES Classes II–III, AAST Grades III–V), with those with high-grade injuries requiring admission to a monitored setting. In the absence of specific complications, the panel suggests DVT and VTE prophylaxis with LMWH to be started within 48–72 h from hospital admission. The panel suggests splenic artery embolization (SAE) as the first-line intervention in patients with hemodynamic stability and arterial blush on CT scan, irrespective of injury grade. Regarding patients with WSES Class II blunt splenic injuries (AAST Grade III) without contrast extravasation, a low threshold for SAE has been suggested in the presence of risk factors for NOM failure. The panel also suggested angiography and eventual SAE in all hemodynamically stable adult patients with WSES Class III injuries (AAST Grades IV–V), even in the absence of CT blush, especially when concomitant surgery that requires change of position is needed. Follow-up imaging with contrast-enhanced ultrasound/CT scan in 48–72 h post-admission of trauma in splenic injuries WSES Class II (AAST Grade III) or higher treated with NOM was considered the best strategy for timely detection of vascular complications.

Conclusion

This consensus document could help guide future prospective studies aiming at validating the suggested strategies through the implementation of prospective trauma databases and the subsequent production of internationally endorsed guidelines on the issue.

Operative management of acute abdomen after bariatric surgery in the emergency setting: the OBA guidelines

BACKGROUND

Patients presenting with acute abdominal pain that occurs after months or years following bariatric surgery may present for assessment and management in the local emergency units. Due to the large variety of surgical bariatric techniques, emergency surgeons have to be aware of the main functional outcomes and long-term surgical complications following the most performed bariatric surgical procedures. The purpose of these evidence-based guidelines is to present a consensus position from members of the WSES in collaboration with IFSO bariatric experienced surgeons, on the management of acute abdomen after bariatric surgery focusing on long-term complications in patients who have undergone laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass.

METHOD

A working group of experienced general, acute care, and bariatric surgeons was created to carry out a systematic review of the literature following the Preferred Reporting Items for Systematic Review and Meta-analysis Protocols (PRISMA-P) and to answer the PICO questions formulated after the Operative management in bariatric acute abdomen survey. The literature search was limited to late/long-term complications following laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass.

CONCLUSIONS

The acute abdomen after bariatric surgery is a common cause of admission in emergency departments. Knowledge of the most common late/long-term complications (&gt; 4 weeks after surgical procedure) following sleeve gastrectomy and Roux-en-Y gastric bypass and their anatomy leads to a focused management in the emergency setting with good outcomes and decreased morbidity and mortality rates. A close collaboration between emergency surgeons, radiologists, endoscopists, and anesthesiologists is mandatory in the management of this group of patients in the emergency setting.