Genetic newborn screening and digital technologies: A project protocol based on a dual approach to shorten the rare diseases diagnostic path in Europe

Since 72% of rare diseases are genetic in origin and mostly paediatrics, genetic newborn screening represents a diagnostic "window of opportunity". Therefore, many gNBS initiatives started in different European countries. Screen4Care is a research project, which resulted of a joint effort between the European Union Commission and the European Federation of Pharmaceutical Industries and Associations. It focuses on genetic newborn screening and artificial intelligence-based tools which will be applied to a large European population of about 25.000 infants. The neonatal screening strategy will be based on targeted sequencing, while whole genome sequencing will be offered to all enrolled infants who may show early symptoms but have resulted negative at the targeted sequencing-based newborn screening. We will leverage artificial intelligence-based algorithms to identify patients using Electronic Health Records (EHR) and to build a repository "symptom checkers" for patients and healthcare providers. S4C will design an equitable, ethical, and sustainable framework for genetic newborn screening and new digital tools, corroborated by a large workout where legal, ethical, and social complexities will be addressed with the intent of making the framework highly and flexibly translatable into the diverse European health systems.

Prevention and management of anastomotic leakage after colorectal surgery: A Swiss national consensus

Objective

Anastomotic leakage (AL) is one of the most feared complications of colorectal surgery. Despite surgical improvements, AL incidence remains significant and guidance on its prevention and management is lacking. The aim of the study was to achieve a Swiss nationwide consensus on clinical prevention and management of AL.

Methods

A three-step Delphi consensus meeting was performed in 2020 involving 78 Swiss surgeons from 40 centers. A steering-group drafted the questions, gathered best available evidence which was discussed in meetings prior answering the questions. Consensus was defined as ≥70% of agreement.

Results

The three consensus meetings were attended by 66, 57 and 37 surgeons, respectively. Surgeons’ median experience was 14 years, with 47% performing >50 colorectal resections yearly. Consensus was reached on routine use of preoperative nutritional screening (100%) using nutritional scores (88%) and >10% weight loss (95%). but not low BMI (63%) or low albumin (64%). Consensus was reached for no bowel preparation (BP) prior to right colectomy (RC) (76%) and for mechanical BP with oral antibiotics prior anterior resections (AR) (70%). No consensus was found on BP prior left colectomy (LC). Respondents favored a side-to-side anastomosis (76%) after RC, with extra-corporeal confection (70%), without consensus on the anastomosis being stapled or hand-sewn; an end-to-end (73%), stapled (80%) anastomosis after LC and a stapled anastomosis (86%) after AR, irrespective of the anastomosis configuration type. Anastomotic control with transanal leak-test was supported by 92%, while ICG control did not reached consensus (67%). After TME, routine diversion was favored (73%), irrespective of neoadjuvant therapy (94%) or not (70%). Consensus was reached on routine postoperative CRP monitoring (94%). CT-scan with rectal contrast enema was the preferred investigation for suspected AL after RC or LC (82%) and AR (76%). Conservative management of AL, provided appropriate clinical state, was an acceptable option after LC (72%), AR with stoma (95%), but not after RC (59%) or AR without stoma (53%).

Conclusion

Consensus was reached on several clinical aspects for prevention and management of AL among Swiss colorectal surgeons, providing national guidance. Further data is required on intraoperative aspects of anastomosis confection and control to ensure broader consensus.

Compliance to infection-preventing measures in colorectal surgery – a word of caution

Objective

The success of a colorectal surgical site infection (SSI) preventing bundle is dependent on compliance to individual infection-preventing measures. The present study aimed to assess whether challenging circumstances may affect bundle compliance.

Methods

Retrospective analysis including consecutive patients undergoing colorectal surgery and appendectomy between November 2018 and October 2020, after implementation of an evidence-based SSI-preventing care bundle. Bundle items were antibiotic administration, disinfection, core temperature control, glove change, intra-abdominal lavage and drain placement according to pre-defined standards. Compliance to each item was assessed according to surgical duration, patient age and time of surgery.

Results

Over the study period, 463 patients underwent appendectomy, 458 patients colonic surgery and 98 patients rectal resections. Compliance to intraabdominal lavage standards decreased significantly with surgical duration of colonic resections (88% for surgeries lasting <90 minutes vs. 56% for surgeries lasting > 180 minutes), while similar decreasing compliance patterns were observed regarding intraabdominal drain placement (86% vs. 68%) and core temperature control (64% vs. 57%, all p>0.05) with long lasting procedures. Compliance to antibiotic timing and glove change recommendations was higher in patients undergoing day-time colectomies (08 h and 16 h) compared to patients operated on during night shifts (0h-08 h, 93% vs. 69% and 87% vs. 58%, respectively, both p<0.05). Specific compliance patterns were not observed in patients undergoing appendectomy or rectal surgery. Furthermore, patient age had no impact on bundle compliance.

Conclusion

The present study revealed decreasing compliance to several infection-preventing bundle items with increasing surgical duration and during night shifts. This may contribute to worse outcomes in these challenging settings but may be a point of attention that can be corrected.

Swiss consensus on the management of acute diverticulitis

Objective

Acute diverticulitis is a frequent clinical conditions encountered in emergency settings. Despite recent international guidelines, management of acute diverticulitis (AD) varies and is not standardized. The aim of the study was to achieve a Swiss nationwide consensus on clinical management of acute diverticulitis.

Methods

A three-staged consensus meeting according to the Delphi method was performed in 2020 involving 78 Swiss surgeons from 40 hospitals. A steering-group drafted the questionnaires, gathered best available evidence which was presented and discussed in meetings prior answering the questions. Consensus was defined as ≥70% of agreement.

Results

57 surgeons answered all the 3 rounds and 28 (53%) performed > 50 colorectal resections per year. On initial workup in the emergency setting, performing leucocytes count (87%), CRP (98%) and CT imaging (98%) reached consensus for the diagnosis, but no uniform classification system of AD was retained. Signs of generalized peritonitis (100%), requiring intravenous pain medication (98%), inability to tolerate oral intake (95%), lack of adequate social support (86%), immunosuppression (96%), and complicated AD on CT (84%) were criteria for hospitalization. Persisting symptoms (95%) and immunosuppression (89%) were criteria for elective colonic resection, while the number of AD episodes were not (27%). In case of abscess, a size ≥ 4 cm reached consensus for percutaneous drainage (88%). No consensus were reached for surgical approach and techniques in the emergency settings, apart from damage control surgery for instable patients (70%). In the follow-up, recommendation for dietary restrictions or lifestyle habits did not reach reach consensus.

Conclusion

Swiss colorectal surgeons reached consensus for several diagnostics, hospitalization, and elective surgery criterias. However, emergency surgical management and follow-up are less standardized. These variations should be further assessed, and particularly in the context the latest published recommendations.

Prospective surveillance after implementation of a colorectal surgical site infection prevention bundle

Objective

Surgical site infections (SSI) are the most frequent complications after colorectal surgery. The aim of the present study was to evaluate the impact of a standardized SSI prevention bundle.

Methods

The multimodal, evidence-based care bundle included 9 intraoperative items (antibiotic type, timing and re-dosing, desinfection, induction temperature control >36.5°, glove change, intracavity lavage, wound protection and closure strategy). The bundle was implemented in November 2018 and applied to all consecutive patients undergoing colonic resections. Demographics, surgical specifics and overall compliance to the care bundle were prospectively assessed until October 2020. The primary outcome SSI was defined according to the definition of the Center for Disease Control (CDC) and independently assessed by the National Infection Surveillance Committee (Swissnoso) up to 30 postoperative days. A historical, institutional pre-implementation control group (2012-2017, DOI: 10.1016/j.jhin.2018.09.011) with identical methodology was used for comparison.

Results

In total, 243 patients were included. The control group included 1’263 patients. Both groups were comparable regarding main demographics (age, sex, body mass index, American Society of Anaesthesiologists class) and surgical characteristics (type and duration of surgery). Overall compliance to the care bundle was 77% (IQR 77-88). Lowest compliance was observed for temperature control (48%), intracavity lavage (59%) and predefined wound closure strategy (74%). Surgical site infections were reported in 54 patients (22.2%) vs. 21.4% in the control group, p = 0.79. Infection rates were comparable throughout the CDC categories: superficial: 11 patients (4.5%) vs. 4.2%, p = 0.82, deep incisional: 9 patients (3.7%) vs. 5.1%, p = 0.34, organ space: 34 (14%) vs. 12.4%, p = 0.48.

Conclusion

Implementation of a standardized surgical care bundle had no impact on SSI rates according to these preliminary results. Improved compliance to individual measures may help to achieve a clinical benefit.

Sarcopenia and surgical outcomes in patients undergoing oncologic colonic surgery

Objective

Sarcopenia is a marker for malnutrition and frailty which could lead to higher complication rate and prolonged length of stay (LOS) after surgery. The study aim was to assess the correlation between sarcopenia and clinical outcomes in oncologic colonic surgery.

Methods

This retrospective study included consecutive patients operated between 2014 and 2019. Three radiological indices of sarcopenia were measured at the level of the third lumbar vertebra on preoperative CT scans: Skeletal Muscle Area (SMA), Skeletal Muscle Radiation Attenuation (SMRA), and Skeletal Muscle Index (SMI). Patients with major complications (> grade 3a) according to Clavien classification were compared to those without. Statistical correlation between sarcopenia indices, LOS and Comprehensive Complication Index (CCI) was tested by use of the Pearson correlation.

Results

A total of 325 patients were included, 50 (15.4%) with and 275 (84.6%) without major complications. SMA and SMI were comparable between both groups (respectively 126.0 vs 125.2 cm2, p = 0.974, and 43.4 vs 44.3 cm2/m2, p = 0.636), while SMRA was significantly lower in patients with major complications (33.6 vs 37.3 HU, p = 0.018). A lower SMRA was correlated with prolonged LOS (r=-0.207, p < 0.01) and higher CCI (r=-0.144, p < 0.01), while the other sarcopenia indices had no influence on surgical outcomes.

Conclusion

Preoperative SMRA or muscle quality appears to be a weak predictor for adverse outcomes after oncologic colectomy.

Feasibility of a prehabilitation program before major abdominal surgery

Objective

Prehabilitation programs claim to improve exercise capacity and postoperative outcomes. The study aim was to assess the feasibility of a prehabilitation program and its effects on fitness and clinical outcomes after major abdominal surgery.

Methods

In this prospective pilot study, patients were assigned to high-intensity physical exercise training with 3 training sessions per week for 3 weeks preoperatively. Feasibility of this intervention was assessed based on recruitment and adherence to the training program. Impact on fitness (VO2 AT) was evaluated and correlated with complications and length of stay (LOS).

Results

Of 980 eligible patients, 87 patients (8.9%) were approached for inclusion. Main obstacles to not approach patients were insufficient time (< 3 weeks) prior to scheduled surgery (n = 276, 28.2%) or screening failure (n = 312, 31.8%). Out of these 87 patients, 24 (28%) declined to participate, 43 (49%) met exclusion criteria and 20 (23%) were included. Six patients (30%) could not complete the prehabilitation program due to contra-indication for exercise training evidenced during the test (n = 3), lack of motivation (n = 2) and modification of the planned operating date (n = 1). VO2 AT increased from 9.8 to 11.5 ml/min/kg (p = 0.050). There were no correlations between the change in VO2 AT and postoperative complications (r = -0.133, p = 0.649) and LOS (r = -0.94, p = 0.750).

Conclusion

Prehabilitation programs are difficult to implement and many patients are either not eligible or not motivated. Future efforts should concentrate on those patients who are most likely to benefit from these time- and cost-intensive interventions.

A 1.4 kW 780 nm pulsed diode laser, high duty cycle, passively side-cooled pump module

A diode laser module emitting 1.4 kW optical in-pulse power near 780 nm optimized for high (≥ 10%) duty-cycle operation in a micro-channel free design is presented. With full collimation, a beam quality with a nearly symmetric M² of 205 × 295 (vertical × horizontal direction) for a wide range of pulse widths is found.

Biological impact of an enhanced recovery after surgery programme in liver surgery

BACKGROUND

The clinical and economic impacts of enhanced recovery after surgery (ERAS) programmes have been demonstrated extensively. Whether ERAS protocols also have a biological effect remains unclear. This study aimed to investigate the biological impact of an ERAS programme in patients undergoing liver surgery.

METHODS

A retrospective analysis of patients undergoing liver surgery (2010-2018) was undertaken. Patients operated before and after ERAS implementation in 2013 were compared. Surrogate markers of surgical stress were monitored: white blood cell count (WBC), C-reactive protein (CRP) level, albumin concentration, and haematocrit. Their perioperative fluctuations were defined as Δvalues, calculated on postoperative day (POD) 0 for Δalbumin and Δhaematocrit and POD 2 for ΔWBC and ΔCRP.

RESULTS

A total of 541 patients were included, with 223 and 318 patients in non-ERAS and ERAS groups respectively. Groups were comparable, except for higher rates of laparoscopy (24.8 versus 11.2 per cent; P < 0.001) and major resection (47.5 versus 38.1 per cent; P = 0.035) in the ERAS group. Patients in the ERAS group showed attenuated ΔWBC (2.00 versus 2.75 g/l; P = 0.013), ΔCRP (60 versus 101 mg/l; P <0.001) and Δalbumin (12 versus 16 g/l; P < 0.001) compared with those in the no-ERAS group. Subgroup analysis of open resection showed similar results. Multivariable analysis identified ERAS as the only independent factor associated with high ΔWBC (odds ratio (OR) 0.65, 95 per cent c.i. 0.43 to 0.98; P = 0.038), ΔCRP (OR 0.41, 0.23 to 0.73; P = 0.003) and Δalbumin (OR 0.40, 95 per cent c.i. 0.22 to 0.72; P = 0.002).

CONCLUSION

Compared with conventional management, implementation of ERAS was associated with an attenuated stress response in patients undergoing liver surgery.

Current Opinion on Peritoneal Carcinomatosis Treatment: a Survey of the Indian Society of Peritoneal Surface Malignancies (ISPSM)

Purpose

Patients with peritoneal carcinomatosis (PC) are increasingly treated with multidisciplinary combined approaches. The study aim was to assess current practice and perceptions of treatment modalities of PC.

Methods

Indian Society of Peritoneal Surface Malignancies (ISPSM) members were invited to complete an online survey. Current practice and perceptions of treatment modalities were assessed through 19 closed questions. Scores were assessed using a Likert scale (0: not important, 5: very important). Treatment modality satisfaction was assessed using a semantic scale (frustrated: 0, perfectly happy: 10). Participants were sent 3 reminders at 4-week intervals.

Results

Fifty-seven out of 182 members completed the survey (31%). Forty percent of participants had an experience of at least 10 years, and 75% stated treating less than 20 PC patients per year. Main treatment goals for patients with PC were cure (5/5) and symptom relief (4/5). Participant’s satisfaction with treatment modalities for ovarian, colorectal, and gastric PC were 6/10, 5/10, and 2/10, respectively. Hyperthermic intraperitoneal chemotherapy (HIPEC) for ovarian (57%) and colorectal (44%) origins were considered to be useful. Clinical usefulness of chemotherapy for gastric PC was rated to be low (17%).

Conclusions

Current treatment modalities fall short to satisfy the needs (cure, symptom relief) of patients with PC. Alternative systemic and intraperitoneal treatment modalities should be assessed.

Electronic supplementary material

The online version of this article (10.1007/s12029-020-00538-1) contains supplementary material, which is available to authorized users.

Gains and limitations of a connected tracking solution in the perioperative follow-up of colorectal surgery patients

AIM

The means to target shorter hospital stay include information technology strategies to improve communication between caregivers and patients in order to limit potentially avoidable readmissions. The aim of the present study was to analyse the benefits and limitations of a smartphone-based connected tracking solution in the perioperative follow-up of colorectal surgery patients.

METHOD

This was a retrospective monocentric cohort study of consecutive patients after colorectal surgery between February and December 2018. The mobile health application included information delivery and daily structured questionnaires on a personalized patient electronic profile, before the hospital stay and for 7 days post-discharge. The medical team answered automatic alerts in real time.

RESULTS

A total of 93 eligible patients were approached and 36 had to be excluded (26 no smartphone, five no email, five not French speaking). Among the potential users, 50 (88%) engaged in an mHealth app and seven refused. Of these 50 patients, seven dropped out. Of the remaining 43 patients, the app detected 12 adverse events, and 10 (83%) were handled through the app. Healthcare providers responded to patient-generated alerts after a median time of 90 min (range 9-448 min). Patients' mean satisfaction level was 4 ± 0.97 out of 5.

CONCLUSION

In total, 88% of smartphone-equipped patients showed a willingness to engage in mHealth. Reasons for exclusion were the absence of connection tools and a language barrier. Patients who responded to the survey were satisfied with the solution and 83% of post-discharge adverse events were solved through the app, avoiding emergency consultations.

Identification of patients eligible for discharge within 48 h of colorectal resection

BACKGROUND

This study aimed to identify patients eligible for a 48-h stay after colorectal resection, to provide guidance for early discharge planning.

METHODS

A bi-institutional retrospective cohort study was undertaken of consecutive patients undergoing major elective colorectal resection for benign or malignant pathology within a comprehensive enhanced recovery pathway between 2011 and 2017. Overall and severe (Clavien-Dindo grade IIIb or above) postoperative complication and readmission rates were compared between patients who were discharged within 48 h and those who had hospital stay of 48 h or more. Multinominal logistic regression analysis was performed to ascertain significant factors associated with a short hospital stay (less than 48 h).

RESULTS

In total, 686 of 5122 patients (13·4 per cent) were discharged within 48 h. Independent factors favouring a short hospital stay were age below 60 years (odds ratio (OR) 1·34; P = 0·002), ASA grade less than III (OR 1·42; P = 0·003), restrictive fluid management (less than 3000 ml on day of surgery: OR 1·46; P < 0·001), duration of surgery less than 180 min (OR 1·89; P < 0·001), minimally invasive approach (OR 1·92; P < 0·001) and wound contamination grade below III (OR 4·50; P < 0·001), whereas cancer diagnosis (OR 0·55; P < 0·001) and malnutrition (BMI below 18 kg/m² : OR 0·42; P = 0·008) decreased the likelihood of early discharge. Patients with a 48-h stay had fewer overall (10·8 per cent versus 30·6 per cent in those with a longer stay; P < 0·001) and fewer severe (2·6 versus 10·2 per cent respectively; P < 0·001) complications, and a lower readmission rate (9·0 versus 11·8 per cent; P = 0·035).

CONCLUSION

Early discharge of selected patients is safe and does not increase postoperative morbidity or readmission rates. In these patients, outpatient colorectal surgery should be feasible on a large scale with logistical optimization.

Thresholds for optimal fluid administration and weight gain after laparoscopic colorectal surgery

Background

Perioperative fluid overload is an important modifiable risk factor for adverse outcomes after colorectal surgery. This study aimed to define critical thresholds for perioperative fluid management and postoperative weight gain for patients undergoing elective laparoscopic colorectal surgery.

Methods

This was an analysis of consecutive elective laparoscopic colorectal resections at Lausanne University Hospital from May 2011 to May 2017. Main outcomes were overall, major (Clavien–Dindo grade IIIb or above) and respiratory complications, and postoperative ileus. Thresholds regarding perioperative fluid management and postoperative weight gain were identified through receiver operating characteristic (ROC) analysis and clinical judgement. Independent risk factors for all four outcomes were assessed by multinominal logistic regression.

Results

Overall and major complications occurred in 210 (36·2 per cent) and 46 (7·9 per cent) of 580 patients respectively. Twenty‐three patients (4·0 per cent) had respiratory complications and 98 (16·9 per cent) had postoperative ileus. Median length of hospital stay was 5 (i.q.r. 3–9) days. Based on respiratory complications, thresholds for perioperative intravenous fluid administration (postoperative day (POD) 0) were set pragmatically at 3000 ml for colonic (calculated threshold 3120 ml (area under ROC curve (AUROC) 0·63)) and 4000 ml for rectal (AUROC 0·79) procedures. Postoperative weight gain of 2·5 kg at POD 2 was predictive of respiratory complications. Multivariable analysis retained perioperative intravenous fluid administration over the above thresholds as an independent risk factor for overall (odds ratio (OR) 2·25, 95 per cent c.i. 1·23 to 4·11), major (OR 2·49, 1·17 to 5·31) and respiratory (OR 4·71, 1·42 to 15·58) complications. Weight gain above 2·5 kg at POD 2 was identified as a risk factor for respiratory complications (OR 3·58, 1·10 to 11·70) and ileus (OR 1·82, 1·02 to 3·52).

Conclusion

Perioperative intravenous fluid and weight thresholds were associated with postoperative adverse outcomes. These thresholds need independent validation.

Comparison of recovery and outcome after left and right colectomy

AIM

The present study aimed to compare functional recovery and surgical outcomes after left and right colectomies.

METHOD

Consecutive elective left and right colon resections for benign and malignant indications, performed between 2011 and 2016 and recorded in a prospectively maintained enhanced recovery database, were analysed. Demographic and surgical items, as well as functional recovery and 30-day complications, were compared between left-sided and right-sided colectomies. Multivariable analysis was performed to identify risk factors for postoperative ileus (POI).

RESULTS

In total, 1001 left and 1041 right colectomies were comparable regarding demographic factors; only body mass index (BMI) was higher in patients undergoing left-sided resections (> 30 kg/m² : 33% vs 27%, P = 0.004). Malignancy (29% vs 67%, P < 0.001) and Crohn's disease (1% vs 31%, P < 0.001) were preponderant in right colectomies, whereas diverticular disease (68% vs 1%, P < 0.001) was the most common indication for left colectomy. Compliance with the enhanced recovery pathway (ERP) was comparable. While the minimally invasive approach was the preferred approach for both sides (61% vs 64%, P = 0.158), left colectomies took longer (180 ± 80 min vs 150 ± 70 min, P < 0.001), needed more perioperative fluids (3.1 ± 1.4 l vs 2.7 ± 1.5 l, P < 0.001) and resulted in greater postoperative weight gain (3.9 ± 6.5 kg vs 2.6 ± 6 kg, P = 0.025). Crohn's disease (OR = 2.64, 95% CI: 1.27-5.46) and fluid overload (OR = 2.02, 95% CI: 1.06-3.82) were independent risk factors for POI.

CONCLUSION

Despite equal ERP compliance, postoperative ileus was higher after right-sided colectomies. This finding was associated with Crohn's disease and fluid overload.

Receiver operating characteristic analysis to determine optimal fluid management during open colorectal surgery

AIM

The present study aimed to analyse fluid management and to define optimal fluid-related thresholds for elective open colorectal surgery.

METHOD

A retrospective analysis was made of all consecutive elective open colorectal resections performed in our tertiary centre between May 2011 and May 2017. The main outcomes were postoperative complications [overall (I-V) and severe (IIIB-V) according to the Clavien classification], respiratory complications and postoperative ileus (POI). Critical thresholds regarding perioperative fluid management and postoperative weight gain were identified by using receiver operator characteristic (ROC) analysis. Independent risk factors for overall complications were identified by multivariable logistic regression analysis.

RESULTS

Of 121 patients who had open operations, 84 (69%) had some complication and 26 (21%) had severe complications. Respiratory complications and POI occurred in 15 (12%) and 46 patients (38%), respectively. The thresholds for intravenous fluids were 3.5 l at postoperative day (POD) 0 [area under ROC curve (AUROC) 0.7 for any 0.69 for respiratory complications] and 3.5 kg weight gain at POD 2 (AUROC 0.82 for respiratory complications). Multivariable analysis revealed weight gain of > 3.5 kg at POD 2 (OR 5.9; 95% CI 1.3-16.6) as a significant risk factor for overall complications. Acute kidney injury was observed in five patients (4%), three (5%) in the group with > 3.5 l at POD 0 and two (3%) in the group with < 3.5 l at POD 0 (P = 0.64). Creatinine increase was transitory and all patients regained baseline levels before discharge.

CONCLUSION

A weight gain of > 3.5 kg at POD 2 has been identified as the critical threshold for overall and respiratory complications and prolonged length of stay after open elective colorectal surgery.

MicroRNAs 143 and 150 in whole blood enable detection of T-cell immunoparalysis in sepsis

Background

Currently, no suitable clinical marker for detection of septic immunosuppression is available. We aimed at identifying microRNAs that could serve as biomarkers of T-cell mediated immunoparalysis in sepsis.

Methods

RNA was isolated from purified T-cells or from whole blood cells obtained from septic patients and healthy volunteers. Differentially regulated miRNAs were identified by miRNA Microarray (n = 7). Validation was performed via qPCR (n = 31).

Results

T-cells of septic patients revealed characteristics of immunosuppression: Pro-inflammatory miR-150 and miR-342 were downregulated, whereas anti-inflammatory miR-15a, miR-16, miR-93, miR-143, miR-223 and miR-424 were upregulated. Assessment of T-cell effector status showed significantly reduced mRNA-levels of IL2, IL7R and ICOS, and increased levels of IL4, IL10 and TGF-β. The individual extent of immunosuppression differed markedly. MicroRNA-143, − 150 and − 223 independently indicated T-cell immunoparalysis and significantly correlated with patient’s IL7R-/ICOS-expression and SOFA-scores. In whole blood, composed of innate and adaptive immune cells, both traits of immunosuppression and hyperinflammation were detected. Importantly, miR-143 and miR-150 – both predominantly expressed in T-cells – retained strong power of discrimination also in whole blood samples.

Conclusions

These findings suggest miR-143 and miR-150 as promising markers for detection of T-cell immunosuppression in whole blood and may help to develop new approaches for miRNA-based diagnostic in sepsis.

Electronic supplementary material

The online version of this article (10.1186/s10020-018-0056-z) contains supplementary material, which is available to authorized users.

Influence of preoperative life satisfaction on recovery and outcomes after colorectal cancer surgery - a prospective pilot study

Background

Colorectal surgery has an important impact on a patient’s quality of life, and postoperative rehabilitation shows large variations. To enhance the understanding of recovery after colorectal cancer, health-related quality of life has become a standard outcome measurement for clinical care and research. Therefore, we aimed to correlate the influence of preoperative global life satisfaction on subjective feelings of well-being with clinical outcomes after colorectal surgery.

Methods

In this pilot study of consecutive colorectal surgery patients, various dimensions of feelings of preoperative life satisfaction were assessed using a self-rated scale, which was validated in French. Both objective (length of stay and complications) and subjective (pain, subjective well-being and quality of sleep) indicators of recovery were evaluated daily during each patient’s hospital stay.

Results

A total of 112 patients were included. The results showed a negative relationship between life satisfaction and postoperative complications and a significant negative correlation with the length of stay. Moreover, a significant positive correlation between life satisfaction and the combined subjective indicators of recovery was observed.

Conclusion

We have shown the importance of positive preoperative mental states and global life satisfaction as characteristics that are associated with an improved recovery after colorectal surgery. Therefore, patients with a good level of life satisfaction may be better able to face the consequences of colorectal surgery, which is a relevant parameter in supportive cancer care.

Systematic review of pressurized intraperitoneal aerosol chemotherapy for the treatment of advanced peritoneal carcinomatosis

BACKGROUND

Pressurized intraperitoneal aerosol chemotherapy (PIPAC) is a minimally invasive approach under investigation as a novel treatment for patients with peritoneal carcinomatosis of various origins. The aim was to review the available evidence on mechanisms, clinical effects and risks.

METHODS

This was a systematic review of the literature on pressurized intraperitoneal chemotherapy published between January 2000 and October 2016. All types of scientific report were included.

RESULTS

Twenty-nine relevant papers were identified; 16 were preclinical studies and 13 were clinical reports. The overall quality of the clinical studies was modest; five studies were prospective and there was no randomized trial. Preclinical data suggested better distribution and higher tissue concentrations of chemotherapy agents in PIPAC compared with conventional intraperitoneal chemotherapy by lavage. Regarding technical feasibility, laparoscopic access and repeatability rates were 83-100 and 38-82 per cent. Surgery-related complications occurred in up to 12 per cent. Postoperative morbidity was low (Common Terminology Criteria for Adverse Events grade 3-5 events reported in 0-37 per cent), and hospital stay was about 3 days. No negative impact on quality of life was reported. Histological response rates for therapy-resistant carcinomatosis of ovarian, colorectal and gastric origin were 62-88, 71-86 and 70-100 per cent respectively.

CONCLUSION

PIPAC is feasible, safe and well tolerated. Preliminary good response rates call for prospective analysis of oncological efficacy.

Pressurized IntraPeritoneal Aerosol Chemotherapy - Practical aspects

INTRODUCTION

Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC) has been introduced as novel treatment for peritoneal carcinomatosis. Only proper patient selection, stringent safety protocol and careful surgery allow for a secure procedure. We hereby report the essentials for safe implementation.

METHODS

All consecutive procedures within 20 months after PIPAC implementation were analyzed with regards to practical and surgical aspects. Special emphasis was laid on modifications of technique and safety measures during the implementation process with systematic use of a dedicated checklist. Further, surgical difficulty was documented by use of a visual analogue scale (VAS).

RESULTS

127 PIPAC procedures were performed in 58 patients from January 2015 until October 2016. 81% of patients had at least one previous laparotomy. Median operation time was 91 min (87-103) for the first 20 cases, 93 min (IQR 88-107) for PIPAC21-50, and 103 min (IQR 91-121) for the following 77 procedures. Primary and secondary non-access occurred in 3 patients (2%), all of them having prior hyperthermic intraperitoneal chemotherapy (HIPEC). Using open Hasson technique, one single bowel lesion occurred, which was the only intraoperative complication. One 5 mm and another 10/12 mm trocar were used in 88% of procedures while additional trocars were needed in 12%. No leak of cytostatics was observed and no procedure needed to be stopped. VAS for overall difficulty of the procedure was 3 ± 2.4, and 3 ± 2.9 and 3 ± 2.5, respectively, for abdominal access and intraoperative staging.

CONCLUSIONS

With standardized surgical approach and dedicated safety checklist, PIPAC can be safely introduced in clinical routine with minimal learning curve.

Diagnosis and Therapy of Female Pelvic Organ Prolapse. Guideline of the DGGG, SGGG and OEGGG (S2e-Level, AWMF Registry Number 015/006, April 2016)

Aims: The aim was to establish an official interdisciplinary guideline, published and coordinated by the German Society of Gynecology and Obstetrics (DGGG). The guideline was developed for use in German-speaking countries. In addition to the Germany Society of Gynecology and Obstetrics, the guideline has also been approved by the Swiss Society of Gynecology and Obstetrics (SGGG) and the Austrian Society of Gynecology and Obstetrics (OEGGG). This is a guideline published and coordinated by the DGGG. The aim is to provide evidence-based recommendations obtained by evaluating the relevant literature for the diagnostic, conservative and surgical treatment of women with female pelvic organ prolapse with or without stress incontinence. Methods: We conducted a systematic review together with a synthesis of data and meta-analyses, where feasible. MEDLINE, Embase, Cinahl, Pedro and the Cochrane Register were searched for relevant articles. Reference lists were hand-searched, as were the abstracts of the Annual Meetings of the International Continence Society and the International Urogynecological Association. We included only abstracts of randomized controlled trials that were presented and discussed in podium sessions. We assessed original data on surgical procedures published since 2008 with a minimum follow-up time of at least 12 months. If the studies included descriptions of perioperative complications, this minimum follow-up period did not apply. Recommendations: The guideline encompasses recommendations for the diagnosis and treatment of female pelvic organ prolapse. Recommendations for anterior, posterior and apical pelvic organ prolapse with or without concomitant stress urinary incontinence, uterine preservation options, and the pros and cons of mesh placements during surgery for pelvic organ prolapse are presented. The recommendations are based on an extensive and systematic review and evaluation of the current literature and include the experiences and specific conditions in Germany, Austria and Switzerland.

A Compression Kit of a Stocking and Three Superimposed Leggings Is Easy to Don and Dose Adjustable

BACKGROUND

Forty percent of patients with chronic venous insufficiency (CVI) do not wear their indicated and prescribed compression stockings. Difficulties in donning and a feeling of constraint are the most common reasons for non-adherence.

OBJECTIVE

The aim was to develop a compression stocking system that is easy to don and dose adjustable.

METHODS

A modular compression stocking kit composed of an understocking and three superimposable leggings (SLLLs) was developed. Substocking pressures (P) at the thinnest part above the ankle (cB level) were 17 mm (understocking) + 15 + 10 + 10 mmHg (3 superimposed leggings; Hatra method). Twenty healthy subjects and 20 patients over 65 years with CVI donned the SLLL compression kit. P was measured in vivo (Picopress method) at the transition of the Achilles tendon to the calf muscle (level cB1) during rest and ankle movements (DSI; dynamic stiffness index) and compared with a strong compression stocking of 40 mmHg (S40).

RESULTS

Twenty (20/20) patients aged over 65 with CVI (C4-6) successfully donned the SLLL compression kit without aid, compared with 12 (12/20) who were able to don the S40 without aid (p = .02). In vivo resting P at level cB1 was 34.3 mmHg (SLLL) compared with 37.3 mmHg (S40) (p = .1). The DSI was 16.1 (SLLL) compared with 17.9 (p = .79; S40; CVI group).

CONCLUSION

The physical properties of the SLLL compression stocking kit correspond to the characteristics of a strong stocking at rest and exercise (DSI). The donning success rate is excellent (100%). A further potential advantage is that the SLLL leg compression kit is dose adjustable, according to indication or patient tolerance. Wearing comfort over periods of several days and clinical effectiveness need to be investigated in future trials.

Cost-benefit analysis of an enhanced recovery protocol for pancreaticoduodenectomy

BACKGROUND

Enhanced recovery after surgery (ERAS) programmes have been shown to decrease complications and hospital stay. The cost-effectiveness of such programmes has been demonstrated for colorectal surgery. This study aimed to assess the economic outcomes of a standard ERAS programme for pancreaticoduodenectomy.

METHODS

ERAS for pancreaticoduodenectomy was implemented in October 2012. All consecutive patients who underwent pancreaticoduodenectomy until October 2014 were recorded. This group was compared in terms of costs with a cohort of consecutive patients who underwent pancreaticoduodenectomy between January 2010 and October 2012, before ERAS implementation. Preoperative, intraoperative and postoperative real costs were collected for each patient via the hospital administration. A bootstrap independent t test was used for comparison. ERAS-specific costs were integrated into the model.

RESULTS

The groups were well matched in terms of demographic and surgical details. The overall complication rate was 68 per cent (50 of 74 patients) and 82 per cent (71 of 87 patients) in the ERAS and pre-ERAS groups respectively (P = 0·046). Median hospital stay was lower in the ERAS group (15 versus 19 days; P = 0·029). ERAS-specific costs were €922 per patient. Mean total costs were €56 083 per patient in the ERAS group and €63 821 per patient in the pre-ERAS group (P = 0·273). The mean intensive care unit (ICU) and intermediate care costs were €9139 and €13 793 per patient for the ERAS and pre-ERAS groups respectively (P = 0·151).

CONCLUSION

ERAS implementation for pancreaticoduodenectomy did not increase the costs in this cohort. Savings were noted in anaesthesia/operating room, medication and laboratory costs. Fewer patients in the ERAS group required an ICU stay.

[Enhanced Recovery After Surgery--optimal management of the surgical patient]

Enhanced Recovery After Surgery (ERAS) is a multimodal, standardized and evidence-based perioperative care pathway. With ERAS, postoperative complications are significantly lowered, and, as a secondary effect, length of hospital stay and health cost are reduced. The patient recovers better and faster allowing to reduce in addition the workload of healthcare providers. Despite the hospital discharge occurs sooner, there is no increased charge of the outpatient care. ERAS can be safely applied to any patient by a tailored approach. The general practitioner plays an essential role in ERAS by assuring the continuity of the information and the follow-up of the patient.

Cost-effectiveness of the implementation of an enhanced recovery protocol for colorectal surgery

BACKGROUND

Enhanced recovery protocols may reduce postoperative complications and length of hospital stay. However, the implementation of these protocols requires time and financial investment. This study evaluated the cost-effectiveness of enhanced recovery implementation.

METHODS

The first 50 consecutive patients treated during implementation of an enhanced recovery programme were compared with 50 consecutive patients treated in the year before its introduction. The enhanced recovery protocol principally implemented preoperative counselling, reduced preoperative fasting, preoperative carbohydrate loading, avoidance of premedication, optimized fluid balance, standardized postoperative analgesia, use of a no-drain policy, as well as early nutrition and mobilization. Length of stay, readmissions and complications within 30 days were compared. A cost-minimization analysis was performed.

RESULTS

Hospital stay was significantly shorter in the enhanced recovery group: median 7 (interquartile range 5-12) versus 10 (7-18) days (P = 0·003); two patients were readmitted in each group. The rate of severe complications was lower in the enhanced recovery group (12 versus 20 per cent), but there was no difference in overall morbidity. The mean saving per patient in the enhanced recovery group was €1651.

CONCLUSION

Enhanced recovery is cost-effective, with savings evident even in the initial implementation period.

[Surgery]

In 2012, an innovative approach for staged in situ liver transection was proposed that could allow for even more aggressive major hepatectomies. Otherwise, after 25 years, laparoscopy became "traditional" and other minimally invasive techniques continue to be developed but their indications deserve further investigation. Less aggressive treatment in non-complicated diverticulitis becomes more popular, and even antibiotic treatment has been challenged by a randomized study. In colorectal oncology, local resection or observation only seems to become a valuable approach in selected patients with complete response after neo adjuvant chemoradiation. Finally, enhanced recovery pathways (ERAS) have been validated and is increasingly accepted for colorectal surgery and ERAS principles are successfully applied in other surgical fields.

Biological materials in colorectal surgery: current applications and potential for the future

Biological materials are increasingly used in abdominal surgery for ventral, pelvic and perineal reconstructions, especially in contaminated fields. Future applications are multi-fold and include prevention and one-step closure of infected areas. This includes prevention of abdominal, parastomal and pelvic hernia, but could also include prevention of separation of multiple anastomoses, suture- or staple-lines. Further indications could be a containment of infected and/or inflammatory areas and protection of vital implants such as vascular grafts. Reinforcement patches of high-risk anastomoses or unresectable perforation sites are possibilities at least. Current applications are based mostly on case series and better data is urgently needed. Clinical benefits need to be assessed in prospective studies to provide reliable proof of efficacy with a sufficient follow-up. Only superior results compared with standard treatment will justify the higher costs of these materials. To date, the use of biological materials is not standard and applications should be limited to case-by-case decision.