Patients' Perceived Satisfaction Through Telephone-Assisted Tele-Consultation During the SARS-CoV-2 Pandemic Period: Observational Single-Centre Study at a Tertiary-Referral Colorectal Surgery Department

Introduction: The pandemic produced by SARS-CoV-2 has obliged us to set up the tele-assistance to offer a continuity of care. This implies an innovation, being the degree of satisfaction of patients unknown. Methods: A telephonic survey was conducted with the validated in the Spanish tool Telehealth Usability Questionnaire (Telehealth Usability Questionnaire; rating from 1-7) of all candidate patients assisted consecutively in the Coloproctology Unit. We included demographic variables, education level, job status, diagnosis and consultation type. A descriptive study was done. The relationship between the willingness of consultation model in the future (telemedicine vs traditional) and the categorical variables was analysed through the chi-squared test. Results: A total of 115 patients were included. The average age was 59.9 years, being 60% women. The average score in each of the survey items was higher than 6 in all the questions but 1. 26.1% of the surveyed patients confessed being advocated to tele-assistance in the future. The only factors related to greater willingness to tele-assistance were male gender (37% vs 18.8%; P = .03) and a higher academic preparation level in favour of higher technical studies (35.9%) and university studies (32.4%) opposite to the rest (P = .043). The rest of variables studied, job status, labour regimen, diagnostic group and consultation type did not show any relationship. Conclusions: A vast majority of patients answered favourably to almost all the items of the survey. However, only 26.1% of them would choose a model of tele-assistance without restrictions.

Recommendations on intervention for hepatobiliary oncological surgery during the COVID-19 pandemic

The SARS-CoV-2 (COVID-19) pandemic requires an analysis in the field of oncological surgery, both on the risk of infection, with very relevant clinical consequences, and on the need to generate plans to minimize the impact on possible restrictions on health resources.

The AEC is making a proposal for the management of patients with hepatopancreatobiliary (HPB) malignancies in the different pandemic scenarios in order to offer the maximum benefit to patients, minimising the risks of COVID-19 infection, and optimising the healthcare resources available at any time. This requires the coordination of the different treatment options between the departments involved in the management of these patients: medical oncology, radiotherapy oncology, surgery, anaesthesia, radiology, endoscopy department and intensive care.

The goal is offer effective treatments, adapted to the available resources, without compromising patients and healthcare professionals’ safety.

Recommendations on intervention for hepatobiliary oncological surgery during the COVID-19 pandemic

The SARS-CoV-2 (COVID-19) pandemic requires an analysis in the field of oncological surgery, both on the risk of infection, with very relevant clinical consequences, and on the need to generate plans to minimize the impact on possible restrictions on health resources. The AEC is making a proposal for the management of patients with hepatopancreatobiliary (HPB) malignancies in the different pandemic scenarios in order to offer the maximum benefit to patients, minimising the risks of COVID-19 infection, and optimising the healthcare resources available at any time. This requires the coordination of the different treatment options between the departments involved in the management of these patients: medical oncology, radiotherapy oncology, surgery, anaesthesia, radiology, endoscopy department and intensive care. The goal is offer effective treatments, adapted to the available resources, without compromising patients and healthcare professionals safety.

[Elective surgery during the SARS-CoV-2 pandemic (COVID-19): a morbimortality analysis and recommendations on patient prioritisation and security measures]

INTRODUCTION

The spread of the SARS-CoV-2 infection (COVID-19) has required adaptation by hospitals affected by the pandemic, which has caused a reduction in elective surgical activity.

METHODS

Retrospective study of patients operated on in the previous month and during the peak of the pandemic. We analysed the COVID-19 infection rate, the severity of respiratory infection according to the Brescia respiratory COVID-19 severity scale, the adopted therapeutic measures and the overall postoperative complications.

RESULTS

From 17th February to 31st March 2020, there was a progressive decrease in surgical activity, with only 213 patients operated on. This comprised 59 (27.8%) elective operations for oncological diseases, 97 (45.5%) elective operations for benign diseases and 57 (26.7%) as urgent procedures.There was a progressive increase in the rate of infection by COVID-19, with a total of 15 cases (7%). This included 10 patients (16.9%) in the elective group for oncological disease, 1 (1%) in the elective surgery group for benign disease and 4 (7%) in the urgent surgery group (p < 0.001). Five patients presented with a severe respiratory infection, of which 4 were affected by oncological disease. There were 3 deaths (1.4%), which were all due to the worsening of a respiratory infection.

CONCLUSIONS

The patients undergoing the surgical procedures showed high rates of COVID-19 infection and postoperative complications, especially the patients with oncological diseases. Local resumption of surgical activity must be based on the prioritisation of the cases to be operated on, respecting certain premises of security and optimisation of the available resources.

Proctologic emergency consultation during COVID-19: Comparative cross-sectional cohort study

INTRODUCTION

Proctologic issues entail a frequent reason for consultation in the emergency department (ED). We aim to analyze how the SARS-COV-2 pandemic has impacted in the demand for proctological consultations.

MATERIAL AND METHOD

Descriptive comparative retrospective study of cross-sectional cohorts of patients attending the ED for proctological complaints from March to April in 2020 and 2019. Demographic variables, comorbidities, reasons for consultation and diagnosis, treatment and readmission were included. Four periods were analyzed according to the different stages of the pandemic derived limitations.

RESULTS

A total of 191 patients were reviewed, 58 in 2020 and 133 in 2019 with an average age of 48 years (SD 20.1) and 112 (58.6%) males. The average number of daily consultations was 2.18 patients in 2019 versus 0.95 in 2020 (p=0.025) meaning a 56% reduction in consultations for proctological reasons. This difference in average consultations was significant in both periods of lockout (p=0.001) and previous de-escalation (p=0.014). The diagnosis distribution was similar between both periods; however, perianal abscesses doubled their rate in 2020, 22.4% versus 11.3% (p=0.045). There was an increasing need for surgery, 31% vs 15% (p=0.011) with no difference in outpatients regimen after emergency surgery (12.5% vs 7.5%, p=0.201). Three patients in 2020 required readmission to the ED (5.2% vs 12.9%, p=0.086).

CONCLUSION

There was a decrease of a 56% in proctologic emergency consultation, however, the need for surgery was twice more frequent during the study period. Reflection on the use of emergencies for proctological reasons is warranted.

[Infections by OXA-48 carbapenemase-producing Enterobacteriaceae in surgical patients: antibiotic consumption and susceptibility patterns]

Objetivos

Analizar la administración de antibióticos, la evolución temporal de sensibilidades y el tratamiento dirigido de las infecciones asociadas a enterobacterias productoras de carbapenemasas (EPC) OXA-48 en un servicio de Cirugía General y Digestivo.

Material y métodos

Estudio observacional retrospectivo, incluyendo pacientes con cultivo positivo de OXA-48 y datos clínicos de infección activa, hospitalizados en un servicio de Cirugía General y Digestivo entre enero 2013 y diciembre 2018.

Resultados

Se incluyeron 65 pacientes, con 66 aislamientos de OXA-48: Klebsiella pneumoniae, 57 (86,5%); Enterobacter cloacae, 5 (7,6%); Escherichia coli, 3 (4,5%); Morganella morganii, 1 (1,5%). La infección intraabdominal fue la más común (n=39, 60%), y el consumo previo de antibióticos fue: piperacilina-tazobactam (48%), meropenem (45%), ciprofloxacino (25,5%), ertapenem (16,5%), imipenem (12%), amikacina (12%), tigeciclina (12%). La evolución temporal (2013/14, 2015/16 y 2017/18) de las sensibilidades (porcentajes) según antibiograma fue: ceftazidima-avibactam X-X-100; amikacina 100-96-84 (p=0,518); tigeciclina 100-92-80 (p=0,437); colistina 100-67-66 (p<0,001); meropenem 37-64-72 (p=0,214); imipenem 51-41-77 (p=0,109); gentamicina 13-19-18 (p=0,879); ertapenem 35-0-0 (p<0,001). El tratamiento dirigido tuvo una mediana de duración de 14 [RIQ 9-20] días, destacando en frecuencia: tigeciclina (57%); meropenem (40,5%); amikacina (37,5%); ceftazidima-avibactam (9%); imipenem (7,5%); colistina (7,5%). La mortalidad global a 30 días fue del 12% (8 individuos). El tratamiento dirigido fue adecuado según antibiograma en el 87,7%, utilizando un régimen de terapia combinada en el 76,9%, régimen que incluyó algún carbapenémico en el 49,2%.

Conclusiones

En Cirugía General y Digestivo destaca la infección intraabdominal asociada a OXA-48, con elevado consumo previo de antibióticos de amplio espectro. El tratamiento dirigido con mayor sensibilidad de cepas productoras de OXA-48 incluye ceftazidima-avibactam, amikacina, tigeciclina, meropenem e imipenem.

GLUT-1 as a predictor of worse prognosis in pancreatic adenocarcinoma: immunohistochemistry study showing the correlation between expression and survival

BACKGROUND

Various parameters have been considered for predicting survival in pancreatic ductal adenocarcinoma. Information about western population is missing. The aim of this study is to assess the association between Glucose transporter type 1 (GLUT-1) expression and prognosis for patients with PDAC submitted for surgical resection in a European cohort.

METHODS

Retrospective analysis of PDAC specimens after pancreatoduodenectomy assessing GLUT-1 expression according to intensity (weak vs strong) and extension (low if < 80% cells were stained, high if > 80%) was performed. Statistical analysis was performed using the exact Fisher test, Student t test or the Mann-Whitney U test. Survival was analysed using the Kaplan-Meier method and compared with the Log-rank test. The differences were considered significant at a two-sided p value of < 0.05. All statistical analyses were performed using SPSS® 23.0 for Windows (SPSS Inc., Chicago, IL, USA).

RESULTS

Our study consisted of 39 patients of which 58.9% presented with weak and 41.1% with strong intensity. The median extension was 90%: 28.2% cases presented with a low extension and 71.8% with a high extension. No significant differences related to intensity were found. The high-extension group showed a higher percentage of T3 PDAC (92.9% vs 63.6%, p = 0.042) and LNR20 (35.7% vs 0%, p = 0.037) as well as shorter disease-free survival (17.58 vs 54.46 months; p = 0.048).

CONCLUSIONS

Our findings suggest that GLUT-1 could be related to higher aggressivity in PDAC and could be used as a prognostic marker, identifying patients with a worse response to current therapies who could benefit from more aggressive treatments.

Lymph Node Ratio, Perineural Invasion and R1 Resection as Independent Prognostic Factors in Pancreatic Adenocarcinoma: A Retrospective Cohort Study

INTRODUCTION

The prognosis of pancreatic ductal adenocarcinoma has been associated with several factors. The aim of the present study was to correlate tumor-related factors and pathological findings with disease-free survival (DFS) and overall survival (OS) in patients undergoing pancreaticoduodenectomy.

MATERIAL AND METHODS

From a prospectively maintained database, we reviewed 89 pancreatic ductal adenocarcinomas in patients who underwent pancreaticoduodenectomy from 2010 to 2014. The impact of histopathologic or tumor-related data, including a lymph node ratio greater than 15% (LNR15), on survival was analyzed.

RESULTS

Univariate analysis of DFS and OS showed that vascular resection, pT, pN, LNR15, microvascular, lymphatic, and perineural invasion, and R1 resection influenced survival. Only LNR15, perineural invasion and R1 resection were independent predictors for both DFS (HR 6.39, p = 0.011; HR 8.53, p = 0.003; HR 9.68, p = 0.002, respectively) and OS (HR 4.21, p = 0.039; HR 5.41, p = 0.020; HR 4.41, p = 0.036, respectively).

CONCLUSIONS

This study demonstrates that LNR15, perineural invasion and R1 resection are independently associated with DFS and OS.

Perforated emphysematous cholecystitis and Streptococcus bovis

Streptococcus bovis is an uncommon cause of biliary tract infection, being acute cholecystitis including this microorganism extremely rare. This entity is more frequent in older patients with cardiovascular disease, diabetes, hepatitis, or neoplasms as colon cancer.

Left-sided portal hypertension due to retroperitoneal fibrosis treated with an oesophagus preserving, modified Sugiura procedure

Left-sided portal hypertension is a very uncommon condition and retroperitoneal fibrosis has rarely been reported as a cause. We present the case of a 77-year-old man with retroperitoneal fibrosis obstructing the splenic vein and causing recurrent episodes of upper gastrointestinal bleeding. Computed tomography showed a retroperitoneal mass as being responsible for the obstruction of the splenic vein, splenomegaly, and diffuse varices around the gastrosplenic and gastrohepatic ligaments. An oesophagus preserving, modified Sugiura procedure was performed with disconnection of the gastric vessels on the lesser curve of the stomach, preserving the pylorus branches of the nerves of Latarjet.

Positive Resection Margins Detected by Standardized Study of a Pancreaticoduodenectomy Sample: Is There Any Real Impact on Long-term Survival?

INTRODUCTION

The pathological evaluation of pancreaticoduodenectomy (PD) samples and the impact of R1 resections on survival has recently been questioned. This study evaluates the introduction of a standardized pathology study protocol (PSP) and the prognosis of R1 resections after long-term follow-up.

METHODS

We reviewed data from a prospectively maintained database regarding 109 periampullary tumors treated by PD from 2005 to 2013. The results of the introduction of a PSP were analysed, and the recurrence rate (RR), disease-free survival (DFS) and overall survival (OS) of the R1 resections were evaluated for each positive margin.

RESULTS

The PD specimens of periampullary tumors analyzed by PSP showed a higher rate of isolated lymph nodes (17 vs. 8; P=.003), N+ (60% vs. 31%; P<.001), microvascular invasion (67% vs. 34%; P=.001) and R1 resections (42% vs. 18%; P=.010). Pancreatic adenocarcinomas with R1 resection in the PSP group were compared with R0, presenting higher percentages of vascular resections (P=.033), N+ (P=.029), lymphatic and perineural invasion (P=.047; P=.029), higher RR (P=.026), lower DFS (P=.016) and lower OS (P=.025). Invasion of the medial margin correlated with a worse prognosis.

CONCLUSIONS

Our series shows an increase in R1 resection after the introduction of a PSP. Infiltration of the medial margin seems to be associated with a higher RR and a decrease in DFS and OS.

Meckel's diverticulum in the adult: surgical treatment

Introduction: Management of asymptomatic Meckel's diverticulum (MD) incidentally discovered in adults remains controversial. The aim of this study was to determine if incidental diverticula should be removed. Materials and methods: We reviewed a consecutive series of patients surgically managed from January 1994 to December 2016. Patients were divided into two groups according to symptomatic or asymptomatic diverticula, and characteristics were compared. Results: The study included 66 patients: 30 in the symptomatic group (45%) and 36 in the incidental group (55%). We found 12 females (18.2%), and the ratio male:female was higher in the symptomatic group (14:1 vs. 2.6:1). Patients in the symptomatic group were significantly younger: 41.7 ± 18.1 vs. 54.7 ± 19.8 years (p = .007). MD in the symptomatic group tended to be longer (3.8 ± 1.9 vs. 2.6 ± 0.9 cm; p = .003). A MD-associated malignancy was present in three patients (4.5%), all neuroendocrine tumours. Major postoperative complications occurred in 6.6% of symptomatic patients and 0% within the incidental group, without specific morbidity related to prophylactic surgery. No mortality was observed. Conclusion: Resection of incidentally found Meckel's diverticulum can be made because of benefits outweigh the risks in this high-risk area for cancer.

Predictive Factors of Pancreatic Fistula After Pancreaticoduodenectomy and External Validation of Predictive Scores

BACKGROUND/AIM

The Fistula Risk Score (FRS), as other risk scores, is a validated model predicting the development of a clinically relevant post-operative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy (PD). We evaluated risk factors related with CR-POPF and correlated four predictive scores with the likelihood of developing CR-POPF in our cohort.

PATIENTS AND METHODS

The records of 107 patients who underwent PD from 2007 to 2015 were obtained from a prospectively maintained database and reviewed. CR-POPFs were categorized by the International Study Group of Pancreatic Fistula (ISGPF) standards. Firstly, a univariate and multivariate analysis of risk factors related to CR-PPOPF was performed, and then the data were correlated with FRS, Wellner's, Robert's and Yamamoto's scores.

RESULTS

In total, 30 patients developed a CR-POPF. On multivariate analysis, abdominal thickness (OR=1.02, p=0.010), Wirsung's duct diameter (OR=0.57, p=0.029), pancreatic consistency (OR=3.18, p=0.011) and histological diagnosis of the lesion (OR=1.65, p=0.012) represented independent predictive factors of CR-POPF. FRS (R²=0.596, p=0.001), Wellner's score (R²=0.285, p=0.005) and Roberts' score (R²=0.385, p=0.002) correlated with the likelihood of developing CR-POPF.

CONCLUSION

Abdominal thickness, Wirsung's duct diameter, pancreatic consistency and histological diagnosis were independent predictive factors of CR-POPF. Predictive scores reflected the likelihood of CR-POPF, FRS being the score with the highest predictive value.

Analysis of expression of the PD-1/PD-L1 immune checkpoint system and its prognostic impact in gastroenteropancreatic neuroendocrine tumors

The immune checkpoint based therapy targeting the programmed death-1 (PD-1) receptor and its PD-L1 ligand has recently been approved for the therapy of different malignant conditions, but not yet for gastroenteropancreatic neuroendocrine tumors (GEP-NETs). In this context, we evaluated the expression of PD-1 and PD-L1 in GEP-NETs and its potential correlations with clinical outcomes. Expression of PD-1/PD-L1 was analyzed by immunohistochemistry in 116 GEP-NETs and 48 samples of peritumoral tissue. In addition, the expression of these molecules was assessed by flow cytometry in peripheral blood mononuclear cells (PBMC) from patients with GEP-NETs (n = 32) and healthy controls (n = 32) and in intratumoral mononuclear cells (TMCs) (n = 3). Expression of PD-L1 and PD-1 was detected by immunohistochemistry in 6% and 1% of tumor tissue samples, respectively, and in 8% of peritumoral tissue samples, for both markers. We also observed that PD-1 expression by TMCs was associated with metastatic disease at diagnosis, and the levels of circulating PD-1+ PBMCs were associated with progressive disease upon follow-ups. In addition, circulating PD-1+ PBMCs were significantly correlated with PD-L1 expression by tumor cells. Our data suggest that PD-1/PD-L1 is expressed in 1 to 8% of GEP-NETs, and that this feature is significantly associated with disease evolution (p < 0.01).