Anastomotic dehiscence (AD) is the "Achilles heel" for resectional colorectal pathology and is the most common cause of postoperative morbidity and mortality. AD incidence is 3-8%; mortality rate due ...to AD two decades ago was around 60% and at present is 10%. This paper analyzes the incidence of AD after colorectal resection performed both in emergency and elective situations, depending on the way it is done: manually or mechanically.
Retrospective, single-center, observational study of patients operated in the period from 1st of January 2009 to 31th of December 2011 for malignant colorectal pathology in the Emergency Clinical Hospital of Bucharest. We evaluated the incidence of digestive fistulas according to the segment of digestive tract and time from hospital admission, to the way the anastomosis was achieved (mechanical vs. Manual), to the complexity of intervention, to the transfusion requirements pre/intra or postoperative, to the past medical history of patients (presence of colorectal inflammatory diseases: ulcerative colitis and Crohn's disease), to the average length of hospital stay and time of postoperative resumption of bowel transit.
We included 714 patients who had surgery between 1st of January 2009 and 31th of December 2011. 15.26% (109/714) of the cases were operated in emergency conditions. Of the 112 cases of medium and lower rectum, 76 have "benefited" from preoperative radiotherapy with a fistula rate of 22.36% (17/76). The incidence of anastomotic dehiscence in the group with preoperative radiotherapy and mechanical anastomosis was 64.7% (11/17) versus 35.3% (6/17) incidence recorded in the group with manual anastomosis. Colorectal inflammatory diseases have been found as a history of pathology in 41 patients--incidence of fistulas in this group was of 12.2% (5/41), compared to only 6.83% (46/673) incidence seen in patients without a history of such disease. For the group with bowel inflammatory disease, anastomotic dehiscence incidence was of 13.8% (4/29) when using mechanical suture and 8.3% (1/12) when using manual suturing. The period required for postoperative resumption of intestinal transit was of 3.12 days for mechanical suturing and 3.93 days in case of manual suture. The mean time (MT) to perform the ileocolic and colocolic mechanical anastomosis is 9 ± 2 minutes. If anastomosis is "cured" with surjet wire or separate threads, MT is 11 ± 5 minutes. MT to perform the ileocolic and colocolic manual anastomosis is 9 ± 3 minutes for surjet wire and 18 ± 5 minutes for separate threads. MT to perform the colorectal mechanical anastomosis is 15 ± 4 minutes. MT to perform the colorectal manual anastomosis is 30 ± 7 minutes (using separate threads). Detailing the nature of the surgical reinterventions, we have found: 7 reinterventions for AD post mechanical anastomoses (1 case of suture defect, 2 cases of resection and re-anastomoses, 4 cases with external branching stoma); 5 reinterventions for AD post manual anastomoses (0 cases of suture defect, 1 case of resection with re-anastomosis, 4 cases of external shunt stoma). In the analyzed group, we recorded a total of 57 deaths from a total of 714 cases resulting in a mortality rate of 7.98%.
Mechanical suture technique is not ideal for making digestive sutures. With the exception of low colorectal anastomoses where mechanical sutures are preferable, we cannot claim the superiority of mechanical anastomoses over those manually made, for colorectal neoplasia.
Selective nonoperative management of abdominal visceral lesions is one of the most important and challenging changes that occurred in the traumatized patient care over the last 20 years. The main ...advantage of this type of management is the avoidance of unnecessary/nontherapeutic laparotomies. The trauma surgeons who deal with this type of treatment are worried of missed abdominal injuries. Modern diagnostic tools (spiral CT, ultrasound, angiography, laparoscopy) allow the trauma surgeon to accurately characterize the lesions to be nonoperative addressed. This literature review discusses the main elements of selective nonoperative management of principle solid visceral lesions (liver, spleen, kidney). We highlight the advantages and limitations of the main diagnostic instruments used for evaluation of trauma patiens allocated to nonoperative management.
The primary aim of this article was to establish the actual prevalence of transposition and duplication of the inferior vena cava and to increase awareness about them.
A meta-analysis of prevalence ...was conducted of cases obtained from PubMed, Web of Science, and Scopus databases.
A total of 48 studies contained data that allowed us to estimate the prevalence of these variants (39 for duplication and 32 for transposition). The overall prevalence of duplication was 0.7%, with a 95% confidence interval between 0.5% and 0.9%; for transposition, the prevalence was 0.3%, with a 95% confidence interval between 0.2% and 0.5%. The publication bias was minimal. Duplication prevalence was significantly higher in anatomy studies compared with imaging and surgery studies; for transposition, there were no statistically significant differences by detection technique.
The overall prevalence of duplication of the inferior vena cava is 0.7%; for transposition, it is 0.3%. Even if they are obviously rare conditions, their presence must be suspected by practitioners as they can have important clinical consequences, may require changes in the surgery protocol, or can be associated with other congenital abnormalities.
The CovidSurg-Cancer Consortium aimed to explore the impact of COVID-19 in surgical patients and services for solid cancers at the start of the pandemic. The CovidSurg-Gynecologic Oncology Cancer ...subgroup was particularly concerned about the magnitude of adverse outcomes caused by the disrupted surgical gynecologic cancer care during the COVID-19 pandemic, which are currently unclear.
This study aimed to evaluate the changes in care and short-term outcomes of surgical patients with gynecologic cancers during the COVID-19 pandemic. We hypothesized that the COVID-19 pandemic had led to a delay in surgical cancer care, especially in patients who required more extensive surgery, and such delay had an impact on cancer outcomes.
This was a multicenter, international, prospective cohort study. Consecutive patients with gynecologic cancers who were initially planned for nonpalliative surgery, were recruited from the date of first COVID-19-related admission in each participating center for 3 months. The follow-up period was 3 months from the time of the multidisciplinary tumor board decision to operate. The primary outcome of this analysis is the incidence of pandemic-related changes in care. The secondary outcomes included 30-day perioperative mortality and morbidity and a composite outcome of unresectable disease or disease progression, emergency surgery, and death.
We included 3973 patients (3784 operated and 189 nonoperated) from 227 centers in 52 countries and 7 world regions who were initially planned to have cancer surgery. In 20.7% (823/3973) of the patients, the standard of care was adjusted. A significant delay (>8 weeks) was observed in 11.2% (424/3784) of patients, particularly in those with ovarian cancer (213/1355; 15.7%; P<.0001). This delay was associated with a composite of adverse outcomes, including disease progression and death (95/424; 22.4% vs 601/3360; 17.9%; P=.024) compared with those who had operations within 8 weeks of tumor board decisions. One in 13 (189/2430; 7.9%) did not receive their planned operations, in whom 1 in 20 (5/189; 2.7%) died and 1 in 5 (34/189; 18%) experienced disease progression or death within 3 months of multidisciplinary team board decision for surgery. Only 22 of the 3778 surgical patients (0.6%) acquired perioperative SARS-CoV-2 infections; they had a longer postoperative stay (median 8.5 vs 4 days; P<.0001), higher predefined surgical morbidity (14/22; 63.6% vs 717/3762; 19.1%; P<.0001) and mortality (4/22; 18.2% vs 26/3762; 0.7%; P<.0001) rates than the uninfected cohort.
One in 5 surgical patients with gynecologic cancer worldwide experienced management modifications during the COVID-19 pandemic. Significant adverse outcomes were observed in those with delayed or cancelled operations, and coordinated mitigating strategies are urgently needed.
Abstract
Background
Postoperative complications might not be accurately registered, leading to weakness in registry data studies.
Aim
To investigate factors that influence postoperative in-hospital ...length of stay (LOS) in patients with Crohn’s disease (CD) undergoing bowel surgery. Furthermore, the study aimed to evaluate LOS as a surrogate for postoperative outcome.
Methods
A multicentre retrospective cohort study. Inclusion criteria were adult patients with CD who underwent bowel surgery with either anastomosis or stricturoplasty. All timings of surgeries are regardless of the method of access to the abdominal cavities. Patients with stoma were excluded. Demographic data, preoperative medications, previous operations for CD, preoperative sepsis, and operation was recorded. The primary outcome was LOS while the secondary outcome variable was postoperative complications.
Results
449 patients who underwent abdominal surgery for CD were included. 265/449 (59%) were female. Median age was 37 years (IQR =20), median LOS was seven days (IQR =6). Patients with longer LOS had higher rates of re-laparotomy/re-laparoscopy (45/228 (19.7%) vs. 9/219 (4.1%) p = 0.01). In multivariate analysis, age (OR = 1.024 CI 95% 1.007–1.041, p = 0.005), preoperative intra-abdominal abscess (OR =0.39 CI 95% 0.185–0.821, p = 0.013), and previous laparotomy/laparoscopy (Or = 0.57 CI 95% 0.334–0.918, p = 0.021) were associated with prolonged LOS. LOS correlated with postoperative complications after adjustment for age, gender, previous laparotomy/laparoscopy, and preoperative intra-abdominal abscesses (OR = 1.28 CI 95% 1.199–1.366, p < 0.0001).
Conclusion
Age, preoperative intra-abdominal abscess, and previous laparotomy/laparoscopy significantly prolonged LOS. LOS correlated with postoperative complications and can, therefore, act as a surrogate for the postoperative outcome.
Perforated peptic ulcer (PPU) remains a common condition globally with significant morbidity and mortality. Previous work has demonstrated variation in reporting of patient characteristics in PPU ...studies, making comparison of studies and outcomes difficult. The aim of this study was to standardize the reporting of patient characteristics, by creating a core descriptor set (CDS) of important descriptors that should be consistently reported in PPU research.
Candidate descriptors were identified through systematic review and stakeholder proposals. An international Delphi exercise involving three survey rounds was undertaken to obtain consensus on key patient characteristics for future research. Participants rated items on a scale of 1-9 with respect to their importance. Items meeting a predetermined threshold (rated 7-9 by over 70 per cent of stakeholders) were included in the final set and ratified at a consensus meeting. Feedback was provided between rounds to allow refinement of ratings.
Some 116 clinicians were recruited from 29 countries. A total of 63 descriptors were longlisted from the literature, and 27 were proposed by stakeholders. After three survey rounds and a consensus meeting, 27 descriptors were included in the CDS. These covered demographic variables and co-morbidities, risk factors for PPU, presentation and pathway factors, need for organ support, biochemical parameters, prognostic tools, perforation details, and surgical history.
This study defines the core descriptive items for PPU research, which will allow more robust synthesis of studies.
Abstract
Background
Anastomotic leak is a severe complication after oesophagectomy. Anastomotic leak has diverse clinical manifestations and the optimal treatment strategy is unknown. The aim of this ...study was to assess the efficacy of treatment strategies for different manifestations of anastomotic leak after oesophagectomy.
Methods
A retrospective cohort study was performed in 71 centres worldwide and included patients with anastomotic leak after oesophagectomy (2011–2019). Different primary treatment strategies were compared for three different anastomotic leak manifestations: interventional versus supportive-only treatment for local manifestations (that is no intrathoracic collections; well perfused conduit); drainage and defect closure versus drainage only for intrathoracic manifestations; and oesophageal diversion versus continuity-preserving treatment for conduit ischaemia/necrosis. The primary outcome was 90-day mortality. Propensity score matching was performed to adjust for confounders.
Results
Of 1508 patients with anastomotic leak, 28.2 per cent (425 patients) had local manifestations, 36.3 per cent (548 patients) had intrathoracic manifestations, 9.6 per cent (145 patients) had conduit ischaemia/necrosis, 17.5 per cent (264 patients) were allocated after multiple imputation, and 8.4 per cent (126 patients) were excluded. After propensity score matching, no statistically significant differences in 90-day mortality were found regarding interventional versus supportive-only treatment for local manifestations (risk difference 3.2 per cent, 95 per cent c.i. −1.8 to 8.2 per cent), drainage and defect closure versus drainage only for intrathoracic manifestations (risk difference 5.8 per cent, 95 per cent c.i. −1.2 to 12.8 per cent), and oesophageal diversion versus continuity-preserving treatment for conduit ischaemia/necrosis (risk difference 0.1 per cent, 95 per cent c.i. −21.4 to 1.6 per cent). In general, less morbidity was found after less extensive primary treatment strategies.
Conclusion
Less extensive primary treatment of anastomotic leak was associated with less morbidity. A less extensive primary treatment approach may potentially be considered for anastomotic leak. Future studies are needed to confirm current findings and guide optimal treatment of anastomotic leak after oesophagectomy.
The aim of this retrospective cohort study was to investigate the efficacy of different treatment strategies for anastomotic leak after oesophagectomy. The study found that less extensive primary treatment resulted in less morbidity. Therefore, less extensive primary treatment could potentially lead to better clinical outcomes, but findings should be confirmed in future studies.
The congenital absence of the gallbladder in the absence of biliary atresia is extremely rare, world literature recognizing only 413 cases. The aim of this study is to clarify the diagnostic and ...therapeutic approach of this rare condition.
There were retrospectively analyzed the first 2 cases of gallbladder agenesis admitted and surgically approached in the Emergency Hospital, Bucharest.
The first case (woman, 23 years old) had typically biliary complaints at admission, shrinked gallbladder and lithiasis on ultrasound. There was a laparoscopic approach but we didn't find any gallbladder. After a non-therapeutic laparoscopy the biliary symptoms disappeared. In the second case (woman, 52 years old) the admission was for upper abdominal quadrant colicative pain and the transparietal abdominal ultrasound showed chronic cholecystitis. Common bile duct dilatation was revealed during laparoscopy. After conversion to laparotomy there was performed intraoperative colangiography, but no other biliary pathology was revealed. The initial complaints also disappeared after surgery.
We find the laparoscopic approach an effective method for the diagnosis of gallbladder agenesis. Postoperative Magnetic Resonance Cholangiopancreatography represents a very useful imagistic tool to rule out an intrahepatic gallbladder.
In 2016, the World Health Assembly adopted the resolution to eliminate viral hepatitis by 2030. This study aims to provide an overview of the burdens of hepatitis B virus (HBV) and hepatitis C virus ...(HCV) in Europe and their changes from 2010 to 2019 using estimates from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019.
We used GBD 2019 estimates of the burden associated with HBV-related and HCV-related diseases: acute hepatitis, cirrhosis and other chronic liver diseases, and liver cancer. We report total numbers and age-standardised rates per 100 000 for mortality, prevalence, incidence, and disability-adjusted life-years (DALYs) from 2010 to 2019. For each HBV-related and HCV-related disease and each measure, we analysed temporal changes and percentage changes for the 2010-19 period.
In 2019, across all age groups, there were an estimated 2·08 million (95% uncertainty interval UI 1·66 to 2·54) incident cases of acute hepatitis B and 0·49 million (0·42 to 0·57) of hepatitis C in Europe. There were an estimated 8·24 million (7·56 to 8·88) prevalent cases of HBV-related cirrhosis and 11·87 million (9·77 to 14·41) of HCV-related cirrhosis, with 24·92 thousand (19·86 to 31·03) deaths due to HBV-related cirrhosis and 36·89 thousand (29·94 to 45·56) deaths due to HCV-related cirrhosis. Deaths were estimated at 9·00 thousand (6·88 to 11·62) due to HBV-related liver cancer and 23·07 thousand (18·95 to 27·31) due to HCV-related liver cancer. Between 2010 and 2019, the age-standardised incidence rate of acute hepatitis B decreased (-22·14% 95% UI -35·44 to -5·98) as did its age-standardised mortality rate (-33·27% -43·03 to -25·49); the age-standardised prevalence rate (-20·60% -22·09 to -19·10) and mortality rate (-33·19% -37·82 to -28·13) of HBV-related cirrhosis also decreased in this time period. The age-standardised incidence rate of acute hepatitis C decreased by 3·24% (1·17 to 5·02) and its age-standardised mortality rate decreased by 35·73% (23·48 to 47·75) between 2010 and 2019; the age-standardised prevalence rate (-6·37% -8·11 to -4·32), incidence rate (-5·87% -11·24 to -1·01), and mortality rate (-11·11% -16·54 to -5·53) of HCV-related cirrhosis also decreased. No significant changes were observed in age-standardised rates of HBV-related and HCV-related liver cancer, although we observed a significant increase in numbers of cases of HCV-related liver cancer across all ages between 2010 and 2019 (16·41% 2·81 to 30·91 increase in prevalent cases). Substantial reductions in DALYs since 2010 were estimated for acute hepatitis B (-27·82% -36·92 to -20·24), acute hepatitis C (-27·07% -15·97 to -39·34), and HBV-related cirrhosis (-30·70% -35·75 to -25·03). A moderate reduction in DALYs was estimated for HCV-related cirrhosis (-6·19% -0·19 to -12·57). Only HCV-related liver cancer showed a significant increase in DALYs (10·37% 4·81-16·63). Changes in age-standardised DALY rates closely resembled those observed for overall DALY counts, except for HCV-liver related cancer (-2·84% -7·75 to 2·63).
Although decreases in some HBV-related and HCV-related diseases were estimated between 2010 and 2019, HBV-related and HCV-related diseases are still associated with a high burden, highlighting the need for more intensive and coordinated interventions within European countries to reach the goal of elimination by 2030.
Bill & Melinda Gates Foundation.
Aim
A total of 15–20% of patients with rectal cancer have liver metastases on presentation. The management of these patients is controversial. Heterogeneity in management strategies is considerable, ...with management often being dependent on local resources and available expertise.
Method
Members of the PelvEx Collaborative were invited to participate in the generation of a consensus statement on the optimal management of patients with advanced rectal cancer with liver involvement. Fifteen statements were created for topical discussion on diagnostic and management issues. Panellists were asked to vote on statements and anonymous feedback was given. A collaborative meeting was used to discuss any nuances and clarify any obscurity. Consensus was considered when > 85% agreement on a statement was achieved.
Results
A total of 135 participants were involved in the final round of the Delphi questionnaire. Nine of the 15 statements reached consensus regarding the management of patients with advanced rectal cancer and oligometastatic liver disease. Routine use of liver MRI was not recommended for patients with locally advanced rectal cancer, unless there was concern for metastatic disease on initial computed tomography staging scan. Induction chemotherapy was advocated as first‐line treatment in those with synchronous liver metastases in locally advanced rectal cancer. In the presence of symptomatic primary disease, a diverting stoma may be required to facilitate induction chemotherapy. Overall, only one‐quarter of the panellists would consider simultaneous pelvic exenteration and liver resection.
Conclusion
This Delphi process highlights the diverse treatment of advanced rectal cancer with liver metastases and provides recommendations from an experienced international group regarding the multidisciplinary management approach.
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