Increased risk of acute stroke among patients with severe COVID-19: a multicenter study and meta-analysis

BACKGROUND AND PURPOSE

Recent observations linked coronavirus disease 2019 (COVID-19) to thromboembolic complications possibly mediated by increased blood coagulability and inflammatory endothelial impairment. We aimed to define the risk of acute stroke in patients with severe and non-severe COVID-19.

METHODS

We performed an observational, multicenter cohort study in four participating hospitals in Saxony, Germany to characterize consecutive patients with laboratory-confirmed COVID-19 who experienced acute stroke during hospitalization. Furthermore, we conducted a systematic review using PubMed/MEDLINE, Embase, Cochrane Library and bibliographies of identified papers following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines including data from observational studies of acute stroke in COVID-19 patients. Data were extracted by two independent reviewers and pooled with multicenter data to calculate risk ratios (RRs) and 95% confidence intervals (95% CIs) for acute stroke related to COVID-19 severity using a random-effects model. Between-study heterogeneity was assessed using Cochran's Q and I2 statistics. International Prospective Register of Systematic Reviews registration number: CRD42020187194.

RESULTS

Of 165 patients hospitalized for COVID-19 (49.1% males, median age = 67 years [57-79 years], 72.1% severe or critical) included in the multicenter study, overall stroke rate was 4.2% (95% CI: 1.9-8.7). Systematic literature search identified two observational studies involving 576 patients that were eligible for meta-analysis. Amongst 741 pooled COVID-19 patients, overall stroke rate was 2.9% (95% CI: 1.9-4.5). Risk of acute stroke was increased for patients with severe compared to non-severe COVID-19 (RR = 4.18, 95% CI: 1.7-10.25; P = 0.002) with no evidence of heterogeneity (I2  = 0%, P = 0.82).

CONCLUSIONS

Synthesized analysis of data from our multicenter study and previously published cohorts indicates that severity of COVID-19 is associated with an increased risk of acute stroke.

[Single-port access cholecystectomy is a safe alternative to conventional laparoscopic cholecystectomy: a retrospective comparison of single-port access versus standard laparoscopic cholecystectomy]

PURPOSE

As laparoscopic surgery develops, one current goal is the reduction of scarring and operative trauma to a minimum. Single-port access surgery (SPA) uses a single small incision hidden in the umbilicus. This report describes our experiences with 69 SPA cholecystectomies compared to the conventional laparoscopic approach.

METHODS

Within two years 69 SPA cholecystectomies were performed. Data including demographic distribution, incision to closure time, duration of the postoperative hospital stay, rates of intraoperative and postoperative complications, and conversion rates were collected retrospectively. Data for a matched control group treated by standard laparoscopic cholecystectomy were gathered within the same time frame and then compared.

RESULTS

There were no significant differences in the rates of intraoperative or postoperative complications in the SPA group when compared to the standard laparoscopy group. The incision-to-closure time strongly depended on the surgeon but did not depend on the method. The duration of postoperative hospital stay was slightly decreased in the SPA group. However, this effect was statistically not significant.

CONCLUSIONS

For selected patient groups, SPA cholecystectomy is on par with the conventional laparoscopic method. The cosmetic advantage that it offers does not come at the cost of any loss of safety.

Intensified surveillance after surgery for colorectal cancer significantly improves survival

Background

Postoperative surveillance after curative resection for colorectal cancer has been demostrated to improve survival. It remains unknown however, whether intensified surveillance provides a significant benefit regarding outcome and survival. This study was aimed at comparing different surveillance strategies regarding their effect on long-term outcome.

Methods

Between 1990 and 2006, all curative resections for colorectal cancer were selected from our prospective colorectal cancer database. All patients were offered to follow our institution's surveillance programm according to the ASCO guidelines. We defined surveillance as "intensive" in cases where > 70% appointments were attended and the program was completed. As "minimal" we defined surveillance with < 70% of the appointments attended and an incomplete program. As "none" we defined the group which did not take part in any surveillance.

Results

Out of 1469 patients 858 patients underwent "intensive", 297 "minimal" and 314 "none" surveillance. The three groups were well balanced regarding biographical data and tumor characteristics. The 5-year survival rates were 79% (intensive), 76% (minimal) and 54% (none) (OR 1.480, (95% CI 1.135-1.929); p < 0.0001), respectively. The 10-year survival rates were 65% (intensive), 50% (minimal) and 31% (none) (p < 0.0001), respectively. With a median follow-up of 70 months the median time of survival was 191 months (intensive), 116 months (minimal) and 66 months (none) (p < 0.0001). After recurrence, the 5-year survival rates were 32% (intensive, p = 0.034), 13% (minimal, p = 0.001) and 19% (none, p = 0.614). The median time of survival after recurrence was 31 months (intensive, p < 0.0001), 21 months (minimal, p < 0.0001) and 16 month (none, p < 0.0001) respectively.

Conclusion

Intensive surveillance after curative resection of colorectal cancer improves survival. In cases of recurrent disease, intensive surveillance has a positive impact on patients' prognosis. Large randomized, multicenter trials are needed to substantiate these results.

[Does the third staple line of a new endostapler offer an advantage?]

BACKGROUND

In laparoscopic colon surgery, endostaplers generate 2 parallel rows of staples. The aim of this paper is to analyse whether the introduction of a new endostapler generating a third row of staples influences the rate of anastomotic leakage and bleedings.

METHOD

362 patients of the Department of Surgery, University Clinic of Schleswig-Holstein, Campus Lübeck, were included in this study. All patients underwent colon resection with performance of double-stapling anastomosis. In Group I (n = 148; 7 / 2004 to 12 / 2005), the Endopath TSB 45 endostapler (2 rows of staples) was used, whereas in Group II (n = 214; 7 / 2006 to 12 / 2007), the Echelon60 EC60 stapler (3 rows of staples) was used. All further operational steps were identical for both groups. Target parameters were the postoperative anastomotic leakage and anastomotic bleeding rates.

RESULTS

Between July 2004 and December 2005, the number of anastomotic leaks (Stapler Endopath, TSB 45) was n = 4 (2.7 %), for the second period (Stapler Echelon60 EC60), it was n = 9 (3.7 %) (not significant). Using the Endopath TSB 45 stapler, the number of anastomotic bleedings was n = 12 (8.1 %), and for the Echelon60 EC60 stapler, it was n = 8 (3.7 %) (p = 0.074; not significant). Within the 18-month period between July 2006 and December 2007, the number of endoscopic colon operations (n = 214) rose by 44.6 % compared to the 18-month period between July 2004 and December 2005 (n = 148).

CONCLUSION

The application of the advanced Echelon endostapler has no impact on the number of anastomotic leaks, and reduces the number of anastomotic bleedings slightly but not significantly. The increased number of endoscopic procedures in the second period results both from the growing number of indications for the application of endoscopic techniques and the positive findings of recent studies carried out by our own and other working groups.

[Progress in diagnostics of anorectal disorders. Part I: anatomic background and clinical and neurologic procedures]

Diagnostics and therapy of anorectal disorders are still questions of surgery. Exact knowledge of functional anatomy and precise clinical examination constitute the basis for the resulting therapeutic strategies. Three-dimensional endosonography and technical advances in flexible endoscopy using high-resolution chromoendoscopy and narrow-band imaging enable exact staging and diagnosis, even of malignancies in earliest stages. Furthermore new in-vivo staining methods combined with high-resolution imaging facilitate the discrimination of inflammatory and neoplastic lesions, which often lead to diagnostic difficulties in chronic inflammatory bowel disease. Developments in neurologic testing, including surface electromyography and sacral nerve stimulation, complement the diagnostic armamentarium.

[Recurrence of Crohn's disease after surgery--causes and risks]

BACKGROUND

In spite of the important role of conservative treatment, up to 90 % of all patients with Crohn's disease will undergo an operation during the course of their illness. Up to 50 % even need a second operation or further surgical procedures - with an increasing risk for perioperative complications. This study was designed to identify the risk factors for recurrence in patients with Crohn's disease and the influence of the primary operation.

METHODS

Between 1986 and 2004, 412 patients with Crohn's disease required operative treatment. 218 underwent a primary procedure and 194 needed a reoperation. In particular, the indications for surgical treatment, the surgical procedures and the perioperative complications were registered and evaluated in the context of a possible recurrence of Crohn's disease. In this study, "recurrence" is defined as a reoperation because of Crohn's disease after a primary operation.

RESULTS

The most common indications for a surgical treatment were stenosis (58.4 %) and fistulas (38.5 %). As the most frequent procedures, the ileocoecal resection and the partial resection of the small bowel were performed. Altogether, the complication rate was 11.5 %. The primary procedures (6.52 %) had less complications than the operations for a recurrence of Crohn's disease (17.70 %). The rate for the recurrence of Crohn's disease was 17.4 % after 5 years, 36.7 % after 10 years and 52.8 % after 15 years. Patients with fistulas as the indication for primary operation had the highest rate of recurrence (45 %). Patients with an isolated Crohn's lesion of the small intestine had a significantly higher risk for recurrence (59.5 %) than patients with lesions in the ileocoecal region or the colon. The anastomosis region (73 %) was the most common localisation for recurrence.

CONCLUSION

On the basis of defined risk factors, patients with a high risk for recurrence can be identified. This is very important because of the higher risk for complications caused by reoperations compared to primary procedures. That is why interdisciplinary cooperation including postoperative care and optimal conservative treatment are absolutely essential.

Undifferentiated pelvic adenocarcinomas: diagnostic potential of protein profiling and multivariate analysis

BACKGROUND AND AIMS

Despite improved techniques, the determination of tumor origin in poorly differentiated adenocarcinomas still remains a challenge for the pathologist. Here we report the use of protein profiling combined with principal component analysis to improve diagnostic decision-making in tumor samples, in which standard pathologic investigations cannot present reliable results.

MATERIALS AND METHODS

A poorly differentiated adenocarcinoma of unknown origin located in the pelvis, infiltrating the sigmoid colon as well as the ovary, served as a model to evaluate our proteomic approach. Firstly, we characterized the protein expression profiles from eight advanced colon and seven ovarian adenocarcinomas using two-dimensional gel electrophoresis (2-DE). Qualitative and quantitative patterns were recorded and compared to the tumor of unknown origin. Based on these protein profiles, match sets from the different tumors were created. Finally, a multivariate principal component analysis was applied to the entire 2-DE data to disclose differences in protein patterns between the different tumors.

RESULTS

Over 89% of the unknown tumor sample spots could be matched with the colon standard gel, whereas only 63% of the spots could be matched with the ovarian standard. In addition, principal component analysis impressively displayed the clustering of the unknown case within the colon cancer samples, whereas this case did not cluster at all within the group of ovarian adenocarcinomas.

CONCLUSION

These results show that 2-DE protein expression profiling combined with principal component analysis is a sensitive method for diagnosing undifferentiated adenocarcinomas of unknown origin. The described approach can contribute greatly to diagnostic decision-making and, with further technical improvements and a higher throughput, become a powerful tool in the armentarium of the pathologist.

[Progress in diagnostics of anorectal disorders. Part II: radiology]

Diagnostics and therapy of anorectal disorders remain a surgical question. In close cooperation between different departments (radiology and gastroenterology, urology and gynecology, dermatology and psychology), the role of radiologic imaging is of growing importance. Exact knowledge of functional anatomy and precise clinical examination constitute the basis of the according therapeutic strategies. In this context radiology has contributed decisively. Developments in imaging techniques, e.g. dynamic MRI, highly contributed to better understanding of complex functional pelvic floor disorders. The combination of nanotechnology and high-resolution imaging allows precise staging, especially in rectal cancer. Furthermore, advances in virtual colonoscopy could lead to widely acceptable and patient-friendly screening for colorectal malignancies.

Prototype of an intraoperative navigation and documentation system for laparoscopic radiofrequency ablation: First experiences

AIMS

Laparoscopic radiofrequency ablation (RFA) is an accepted approach to treat unresectable liver tumours, distinguishing itself from other techniques by combining minimal invasiveness and the advantages of a surgical approach. The major task of laparoscopic RFA is the accurate needle placement according to preoperative planning to achieve complete tumour ablation. This study investigates the value of an image-guided surgery system to accomplish this task.

METHODS

An image-guided surgery system for laparoscopic liver treatments (LapAssistent) based on a 3D-navigation scene was developed. A laparoscopic ultrasound probe and a RFA needle could be navigated using an electromagnetic tracking system. The system was studied using a perfused tumour-mimic-model of a porcine liver. Navigating the RFA needle, the tumours were ablated.

RESULTS

The system enables the surgeon to intraoperatively update the three-dimensional planning data in case of new findings. The RFA needle could be placed accurately in a targeted tumour, even out of the ultrasound plane. In case of multiple tumours lying in close spatial relationship, the documentation module helps to keep track of the already ablated tumours and those that still need to be treated.

CONCLUSION

The system adds benefit to laparoscopic RFA enabling the surgeon to place the needle accurately inside the targeted tumours using the navigation scene. A manual alignment of the preoperative data to the physical space produces a feasible result for a restricted region. A precise measurement of the accuracy of this process has to be done. The possibility to update the three-dimensional model with new intraoperative findings enables the surgeon to adapt to a new intraoperative situation. Furthermore the possibility to mark ablated tumours helps to keep track of the operation plan.

[What is the value of minimizing access trauma for patients?]

Minimizing the access trauma of surgical interventions is becoming an essential task in modern surgery in order to make the treatment more comfortable for the patient. Minimally invasive surgery has had a major impact on the improvement of surgical results over the last decade. This is why such surgery is often named as the third patient friendly revolution in surgery after the introduction of asepsis and anesthesia. Operations that caused a huge strain on the patients in the past and led to immense costs for society because of the patient's lost working time and extensive rehabilitation, have lost their fear thanks to this technique. The physical strain is lower, the cosmetic effect is considerable and the costs for society might be reduced due to the significantly shorter duration of convalescence. Despite its known advantages, which have been reported in numerous studies, minimally invasive surgery has recently gained increased interest because of the installation of new accounting systems as well as strict budgeting and restricted resources. Realistic cost-benefit analysis and objectified quality controls are needed in order to guarantee innovative and patient friendly basic approaches in medicine in the future.

Influence of operator experience in radiofrequency ablation of malignant liver tumours on treatment outcome

AIMS

Radiofrequency ablation is gaining popularity as the interventional therapy of choice for unresectable hepatic malignancies. However, little attention has been paid to the importance of operator experience in this therapy. This study aims to evaluate the results of RFA treatment dependent on operator experience and learning curve.

PATIENTS AND METHODS

Between 2/2000 and 11/2004 we have undertaken 116 RFA procedures to ablate 404 unresectable primary or metastatic liver tumours in 84 patients. The clinical data of all patients were recorded prospectively and treatment results of the first 42 patients (group I) and the second 42 patients (group II) were compared. All patients were treated by the same surgeon or interventional radiologist.

RESULTS

RFA was performed percutaneously in 44 procedures (group I n = 35, group II n = 9), via laparotomy in 64 procedures (group I n = 27, group II n = 37) and via laparoscopy in eight procedures (group I n = 1, group II n = 7). The complication rate was comparable in both groups with 7.9% in group I and 7.5% in group II. Group II had a higher complete ablation rate (96.2 vs 93.7%) than group I. One- and two-year survival rates of 92 and 89% in group II were significantly higher than in group I with 69 and 46% (p = 0.015).

CONCLUSION

By the experience conditional optimization of indication and performance by a specialized RFA team the results could be improved significantly. The data on hand speak for a considerable learning curve in the RFA and demonstrate the importance of the experience of the therapist for the outcome of the patients.

[Influence of adjuvant radio-chemotherapy for rectal cancer on quality of life]

INTRODUCTION

Modern therapy for rectal cancer is associated with functional disorders. Dysfunction as a consequence of surgery has to be distinguished from disorders caused by postoperative therapy. Therefore we have compared the long-term functional results of patients who received postoperative radio-chemotherapy or no therapy in conjunction with low anterior resection of the rectum.

PATIENTS AND METHOD

From 1997 to 2002, a total of 32 patients (16 males and 16 females) after low anterior rectal resection and postoperative radio-chemotherapy or surgical therapy alone was compared using standardized and validated instruments (Short-Form-36-Health-Survey, EORTC QLQ-C30, QLQ-CR 38 and ASCRS fecal incontinence questionnaire) in a matched-pair analysis (age, gender and time of surgery). Mean age was 61.8 (62.1) years and mean follow-up was 4 (3.8) years.

RESULTS

Two out of the 40 examined parameters differed significantly. There were no significant differences in Short-Form-36-Health-Survey and EORTC QLQ-C30 scales between both groups. The QLQ-CR38 scale sexual enjoyment differed significantly, whereas future perspectives, sexual functioning, micturition problems, symptoms in the area of the gastrointestinal tract, weight loss, defecation problems, male and female sexual problems did not differ significantly. The scales Lifestyle, Coping/Behavior and Depression/Self-Perception of the ASCRS fecal incontinence questionnaire also did not differ significantly. The difference for embarrassment was significant.

DISCUSSION

No differences in quality of life after postoperative radio-chemotherapy or no postoperative therapy in conjunction with low anterior rectal resection can be found. There are, however, tendencies that postoperative radio-chemotherapy has more adverse effects on continence and sexual function than low anterior rectal resection alone.

Laparoscopic management of a late-diagnosed major diaphragmatic rupture

A 20-year-old male patient was admitted to our emergency ward because of acute respiratory insufficiency following gastroscopy 2 years after a car accident. The chest radiograph showed migration of the stomach into the left hemithorax. A large diaphragmatic hernia was diagnosed and repaired laparoscopically using slowly resorbable sutures and patches. Diaphragmatic rupture secondary to blunt thoracic or abdominal trauma is a rare injury, whose diagnosis may be delayed. The majority of these defects are diagnosed during laparotomy performed for other major abdominal lesions. If diaphragmatic rupture is suspected, and no lesion of a parenchymatous organ has been diagnosed, there is a role for diagnostic laparoscopy. In the absence of other abdominal injuries, diaphragmatic rupture can be repaired by minimal-access surgery.

Endoscopic treatment of clinically symptomatic leaks of thoracic esophageal anastomoses

BACKGROUND

The mortality of thoracic anastomotic leakage following esophageal reconstruction has been reported to be as high as 60%. Early septic fulminant suture line leaks require rethoracotomy. In addition, however, clinically symptomatic leaks may also occur 2 to 7 days after resection of the esophagus.

METHODS

Among 80 esophageal reconstructions performed between January 1994 and July 1998, a total of 7 (8.75%) clinically apparent leaks of thoracic anastomoses were observed. The standard treatment consisted of endoscopic lavage, drainage and subsequent closure of the defect by repeated intraluminal and submucosal applications of fibrin glue. In 2 patients a novel approach permitting rapid closure by plugging the fistula with a Vicryl-cylinder was tried. In 4 patients the effect of endoscopic treatment on the HLA-DR expression on monocytes was investigated and compared to 6 patients with intact anastomoses.

RESULTS

All 7 patients were successfully treated via endoscopy. The cylinder plug achieved immediate closure of the leak. The measured change in HLA-DR expression reflected the improvement in the inflammatory response and thus documented the success of endoscopic treatment.

CONCLUSIONS

Endoscopic management of thoracic leakages represents a safe and relatively noninvasive therapeutic option.

[Therapy options for postoperative fistulas of the upper gastrointestinal tract]

The mortality of anastomotic leakage following esophageal reconstruction has been reported to be as high as 60%. For the treatment of these dehiscences the use of endoscopy is a tempting option. The standard treatment consisted of endoscopic lavage, drainage and subsequent closure of the leak by application of fibrin glue. 2 patients was tried with a novel approach permitting rapid closure by plugging the fistula with a vicryl cylinder. Endoscopic management of postoperative leaks of the upper gastrointestinal tract represents a safe and relatively gentle therapeutic option.