A worldwide survey on proctological practice during COVID-19 lockdown (ProctoLock 2020): a cross-sectional analysis

Three-Year Analysis of the Rectal Cancer Care Trajectory after the COVID-19 Pandemic

The global pandemic period from 2020 to 2022 caused important alterations in oncology care. This study aimed to describe the trends and variations in patient characteristics, comorbidities, and treatment approaches during this time in Romania. We conducted a retrospective database search to identify patients with rectal cancer who underwent surgical intervention between 2020 and 2022 and the year 2019, which served as a pre-pandemic period control. This study included 164 patients, with a yearly increase of approximately 10% in surgical interventions noted from 2020 (1709 interventions) to 2022 (2118 interventions), but an overall 34.4% decrease compared with the pre-pandemic period. Notable shifts were observed in the type of surgeries performed, with laparoscopic procedures doubling from 2020 (25%) to 2022 (47.5%), confirming the decrease in emergency presentations during the last year of the COVID-19 pandemic and a recovery to normality with planned, elective interventions. Elective interventions increased significantly in 2022 (79.7%) compared with the previous years (p = 0.043), with a concurrent rise in neoadjuvant therapy uptake in 2022 (35.6%). However, significant alterations in the TNM staging, from 12.5% stage IV cases in 2020 to 25.4% in 2022 (p = 0.039), indicated an increased diagnosis of advanced stages of rectal cancer as the years progressed. There was a significant difference in albumin levels over the years (p = 0.019) and in the American Society of Anesthesiology (ASA) scores (from 6.2% ASA stage IV in 2020 to 16.9% in 2022), denoting an increase in case complexity (p = 0.043). This study reveals a trend of increasing surgical interventions and the prevalence of more advanced stages of rectal cancer during the pandemic years. Despite the subtle fluctuations in various patient characteristics and treatment approaches, notable shifts were documented in the severity at diagnosis and surgery types, pointing toward more advanced disease presentations and changes in surgical strategies over the period studied. Nevertheless, the trends in ICU admission rates and mortality did not alter significantly during the pandemic period.

Sclerotherapy with 3% polidocanol foam to treat second-degree haemorrhoidal disease: Three-year follow-up of a multicentre, single arm, IDEAL phase 2b trial

BACKGROUND

Sclerotherapy with 3% polidocanol foam is becoming increasingly popular for the treatment of symptomatic I-II or III degree haemorrhoidal disease (HD). However, there are no studies that have reported a follow-up of more than 1 year. The purpose of this study was to analyse the long-term outcomes of sclerotherapy with 3% polidocanol foam in the treatment of II-degree HD.

METHODS

This was an open label, single-arm, phase 2b trial conducted in 10 tertiary referral centres for HD. A total of 183 patients with II-degree HD, aged between 18 and 75 years with symptomatic HD according to the Goligher classification and unresponsive to medical treatment, were included in the study and underwent sclerotherapy with 3% polidocanol foam. The efficacy was evaluated in terms of bleeding score, haemorrhoidal disease symptom score (HDSS) and short health scale for HD (SHS-HD) score. Successful treatment was defined as the complete absence of bleeding episodes after 7 days (T1) according to the bleeding score.

RESULTS

The overall success rate ranged from 95.6% (175/183) at 1 year to 90.2% (165/183) after the final 3 year follow-up. The recurrence rate, based on the primary outcome, ranged from 12% (15/125) to 28% (35/125). The greatest increase in recurrence (15) was recorded between 12 and 18 months of follow-up, then another five between 18 and 24 months. Both the HDSS and the SHS score remained statistically significant (p < 0.001) from a median preoperative value of 11 (10-13) and 18 (15-20) to 0 (0-2) and 4 (0-4), respectively. Symptom-free (HDSS = 0) patients, excluding patients converted to surgery, increased from 55.5% (101/182) at 1 year to 65.1% at 3 years (110/169). There were no intraoperative complications in redo-sclerotherapy nor additional adverse events (AEs) compared to the first 12 months.

CONCLUSIONS

Sclerotherapy with 3% polidocanol foam is gradually establishing itself in the treatment of bleeding HD due to its repeatability, safety, convenience in terms of direct and indirect costs with the absence of discomfort for the patient as well as AEs rather than an excellent overall success rate.

Restructuring surgical training after COVID-19 pandemic: A nationwide survey on the Italian scenario on behalf of the Italian polyspecialistic young surgeons society (SPIGC)

Introduction

The COVID-19 pandemic has led to the disruption of surgical training. Lack of communication, guidelines for managing clinical activity as well as concerns for safety in the workplace appeared to be relevant issues. This study aims to investigate how surgical training has been reorganized in Italy, almost 2 years after the outbreak of COVID-19 pandemic.

Materials and methods

A 16-item-electronic anonymous questionnaire was designed through SurveyMonkey^© web application. This survey was composed of different sections concerning demographic characteristics and impacts of the second COVID-19 pandemic wave on surgical and research/didactic activities. Changes applied in the training programme and activities carried out were also investigated. The survey was carried out in the period between June and October 2021.

Results

Four hundred and thirty responses were collected, and 399 were considered eligible to be included in the study analysis. Three hundred and thirty-five respondents continued working in Surgical Units, with a significant reduction (less than one surgical session per week) of surgical sessions in 49.6% of them. With concern to didactic and research activities, 140 residents maintained their usual activity, while 116 reported a reduction. A sub-group analysis on resident moved to COVID-19 departments showed a reduction of research activities in 35% of them. During the period considered in this survey, the surgical training program was not substantially modified for most of participants (74.6%).

Conclusion

Our survey demonstrated that surgical residency programs haven't improved 2 years after the beginning of the pandemic. Further improvements are needed to guarantee completeness of surgical training, even in emergency conditions.

Anoplasty for anatomical anal stenosis: systematic review of complications and recurrences

AIM

The optimal surgical treatment for anatomical anal stenosis (AS) remains to be determined. The aim of this study was to determine the rates of complications and recurrence after anoplasty for anatomical AS and, wherever feasible, compare the outcomes for the various techniques.

METHOD

A PROSPERO-registered systematic review was reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Medline, PubMed, Embase, Cochrane Library of Systematic Review, Scopus and Web of Science were searched for articles published up to May 2021. Studies that assessed the outcomes of anoplasty in adult patients with anatomical AS were selected. The primary outcomes were complications and recurrence. The methodological quality of studies was appraised using the Joanna Briggs Institute critical appraisal tools.

RESULTS

From the total of 2705 unique screened records, 151 were assessed for eligibility. Only 29 studies (two prospective) met the inclusion criteria, reporting data on 556 patients [mean age 53 (18-83) years, 46% female]. Previous history of surgery for haemorrhoidal disease accounted for three quarters of cases. A total of 14 types of anoplasty were found, with the Y-V flap being the most performed technique [27% of cases (n = 149)]. Complications frequently occurred, with a pooled prevalence of 10.2% (95% CI 3.9%-24.1%) after Y-V flap and 11.5% (5.3%-23.0%) after rhomboid/diamond flap. Patients undergoing house flap achieved better results in terms of clinical improvement, satisfaction and quality of life compared with Y-V flap and rhomboid/diamond flap. When considering only studies with at least 12 months of follow-up, the pooled prevalence of recurrence was 4.7% (2.2%-9.8%), with significantly higher rates observed in the prospective versus retrospective series [pooled prevalence 18.9% (11.5%-29.5%) vs. 3.6% (1.7-7.8%), respectively; p < 0.001].

CONCLUSION

Both complications and recurrence were significantly lower after house flap compared with rhomboid/diamond and Y-V flap. Better designed multicentre studies with longer follow-up are needed to confirm these findings.

PROSPERO REGISTRATION NUMBER

CRD42021239493.

Proctologic Surgery Prioritization After the Lockdown: Development of a Scoring System

Introduction

The coronavirus disease 2019 (COVID-19) pandemic has shown a very critical impact on surgical procedures all over the world. Italy faced the deepest impact from the beginning of March 2020. Elective operations, screening, and follow-up visits had been suspended giving priority to urgent and oncologic surgery.

Patients

An observational study was carried out in the Surgical Coloproctology Unit of the Val Vibrata Hospital on 152 patients awaiting a proctological surgical treatment during the national lockdown.

Methods

In order to monitor the health status of patients and reschedule postlockdown surgical activities, patients were interviewed by telephone submitting a questionnaire based upon the judgment of an expert senior clinician. Following the interview, we calculated a severity index for all the proctologic diseases (hemorrhoidal disease, anal fissure, anal sepsis, slow transit or obstructed defecation, incontinence), classifying the patients according to the score. Mean age of patients was 53 (±16) years, and there were 84 males (55.3%) and 68 females (44.7%). In total, 31% of our patients suffered from anal fissure, 28% suffered from hemorrhoidal disease, 14% suffered from anal sepsis, and the remaining patients suffered from benign anorectal diseases to a lesser extent.

Results

A total of 137 patients were available and divided into three classes: priority surgery (PS) with 49 patients (36.2%), deferrable surgery (DS) with 25 patients (18.1%), and long-term surgery (L-TS) with 63 patients (45.6%). There was a significant correlation between the perceived health status reported during the interview and the priority class index (Spearman's rho = 0.97, p < 0.001).

Differences related to age and sex were not significant (F-test = 0.43, p = 0.653; chi-squared test = 0.693, p = 0.707). 49 patients in class PS needed a prompt surgical treatment, while 24 patients allocated in class DS and 65 patients allocated in class L-TS could wait for a new ride plan for surgery.

Conclusion

New tools, such as this simple score obtained during the telephone interview, can be useful for prioritization of patients on the waiting list for surgical coloproctology after the lockdown without further clinical examination and hospital access.

Open Hemorrhoidectomy With Ligasure™ Under Local or Spinal Anesthesia: A Comparative Study

BACKGROUND

There is increasing evidence that many anorectal surgical procedures may be performed under local anesthesia. The aim of the present study was to evaluate the safety and efficacy of local anesthesia in the outpatient clinic vs spinal anesthesia in the operating room for open hemorrhoidectomy.

METHODS

Sixty-two patients with grade III or IV hemorrhoids underwent open hemorrhoidectomy with LigaSure™ between 2018 and 2020. Of them, 32 procedures were performed in the operating room under spinal anesthesia with hyperbaric bupivacaine and other 30 procedures were undertaken in the outpatient clinic under local anesthesia with ropivacaine.

RESULTS

There were no significant differences regarding age, gender, American Society of Anesthesiologists class, and Goligher's grade in between groups. No significant differences were observed in postoperative pain score (P = .85), perioperative complications (P = .51), and reoperation rate (P = .96). No recurrences and no differences in patients' satisfaction degree (P = .76) were documented at long-term follow-up in both study groups.

DISCUSSION

Our results suggest that open hemorrhoidectomy with LigaSure™ performed in selected patients under local anesthesia in the outpatient clinic is a well-tolerated, safe, and effective procedure.

Insights into the management of anorectal disease in the coronavirus 2019 disease era

Coronavirus 2019 disease (COVID-19) has created major impacts on public health. The virus has plagued a large population requiring hospitalization and resource utilization. Knowledge about the COVID-19 virus continues to grow. It can commonly present with gastrointestinal symptoms; initially, this was considered an atypical presentation, which led to delays in care. The pandemic has posed serious threats to the care of anorectal diseases. Urgent surgeries have been delayed, and the care of cancer patients and cancer screenings disrupted. This had added to patient discomfort and the adverse outcomes on healthcare will continue into the future. The better availability of personal protective equipment to providers and standard checklist protocols in operating rooms can help minimize healthcare-related spread of the virus. Telehealth, outpatient procedures, and biochemical tumor marker tests can help with mitigation of anorectal-disease-related problems. There is limited literature about the clinical management of anorectal diseases during the pandemic. We performed a detailed literature review to guide clinicians around management options for anorectal disease patients. We also highlighted the health challenges seen during the pandemic.

The Impact of COVID-19 pandemic on a tertiary referral proctology center: no one should be left behind

BACKGROUND

Coronavirus disease 2019 (COVID-19) has disrupted healthcare delivery. We aimed to describe a novel strategy to mitigate the impact of COVID-19 pandemic on a tertiary referral proctology center during the first wave of infection in Italy.

METHODS

All patients booked appointments at the Proctology Unit between March 9th and May 4th 2020 were identified. Patients booked for a first visit underwent a structured remote consultation. Patients with perianal or sacrococcygeal abscesses, major anorectal bleeding, incoercible anal pain and red flags for malignancy were labelled as 'non-deferrable'. A flowchart was designed to comply with adequate assistance of proctologic patients. Demographics, clinical data and outcomes of in-office procedures were collected.

RESULTS

On a total of 548 booked visits, 198 (36.1%) were cancelled before remote consultation. Of the remaining 350, 112 (32.0%) attended a follow-up visit. Among 238 (68.0%) patients undergoing remote consultation, 88 (25.1%) were deemed 'deferrable' and 148 (42.3%) 'nondeferrable'. 2 (0.6%) were hospitalized for COVID-19 while waiting for an outpatient visit. 25/88 (28.4%) deferrable patients cancelled their appointment as felt no longer necessary. A total of 45/148 (30.4%) non deferrable patients (mean age, 46 years; 31% females) underwent in-office procedures, most often related to anal abscess and/or fistula (48.9%). Final diagnosis of malignancy occurred in 4 cases. A 55% increase in the number of in-office procedures was noted compared to the previous year. None of the attending patients nor staff members resulted COVID-19 positive during the study period.

CONCLUSIONS

Despite the uncertainties accompanying the use of remote consultations in proctology, the results of this study may inform the development of strategies for restructuring activities in response to future emergencies of this magnitude.

E-consensus on telemedicine in proctology: A RAND/UCLA-modified study

BACKGROUND

Coronavirus disease 2019 is revolutionizing healthcare delivery. The aim of this study was to reach a consensus among experts as to the possible applications of telemedicine in the proctologic field.

METHODS

A group of 55 clinical practice recommendations was developed by a clinical guidance group based on coalescence of evidence and expert opinion. The Telemedicine in Proctology Italian Working Group included 47 Italian Society of Colorectal Surgery nominated experts evaluating the appropriateness of each clinical practice recommendations based on published RAND/UCLA methodology in 2 rounds.

RESULTS

Stakeholder median age was 53 years (interquartile range limits 40-60), and 38 (81%) were men. Nine (19%) panelists reported no experience with telemedicine before the pandemic. Agreement was obtained on a minimum of 3 to 5 years of practice in the proctologic field before starting teleconsultations, which should be regularly paid, with advice and prescriptions incorporated into a formal report sent to the patient by e-mail along with a receipt. Of the panelists, 35 of 47 (74%) agreed that teleconsultation carries the risk of misdiagnosis of cancer, thus recommending an in-person assessment before scheduling any surgery. Fifteen additional clinical practice recommendations were re-elaborated in the second round and assessed by 44 of 47 (93.6%) panelists. The application of telemedicine for the diagnosis of common proctologic conditions (eg, hemorrhoidal disease, anal abscess and fistula, anal condylomas, and anal fissure) and functional pelvic floor disorders was generally considered inappropriate. Teleconsultation was instead deemed appropriate for the diagnosis and management of pilonidal disease.

CONCLUSION

This e-consensus revealed the boundaries of telemedicine in Italy. Standardization of infrastructures, logistics, and legality remain to be better elucidated.