Use of Darvadstrocel (Allogenic Stem Cell Therapy) for Crohn's Fistulas in Real Clinical Practice: The National Project to Implement Mesenchymal Stem Cell for the Treatment of Perianal Crohn's Fistula (the PRIME Study)

BACKGROUND

Perianal fistulas may affect 15-50% of patients with Crohn's disease. Treatment is complex, requiring a multidisciplinary approach. Darvadstrocel (allogenic mesenchymal cells obtained from lipoaspirates) was approved in 2018 by the European and Spanish Agencies of Medicines and Medical Products as a treatment for fistulas in Crohn's disease. Recent European Crohn's and Colitis Organisation and Spanish Working Group on Crohn's Disease and Ulcerative Colitis guidelines state that darvadstrocel is effective with a favorable safety profile and a strong level of evidence (2).

OBJECTIVE

Presenting real-world effectiveness data for darvadstrocel in a Spanish population.

DESIGN

Observational retrospective cohort study with prospective data gathering.

SETTINGS

Fourteen institutions.

PATIENTS

From November 2019-April 2022, all patients (73) treated with darvadstrocel in these institutions were included, fulfilling the following criteria: 1) complex fistula/s in a patient with Crohn's disease; 2) failure of conventional and antitumor necrosis factor treatment; 3) absence of collections >2 cm confirmed by pelvic MRI scan at the time of surgery.

INTERVENTIONS

Darvadstrocel treatment.

MAIN OUTCOME MEASURES

Clinical response (closure of ≥50% of external openings), complete clinical closure (100% of external openings) and radiological closure (no fluid collection >2 cm, no edema or inflammation) evaluated 6 months after treatment.

RESULTS

Clinical response was observed in 63 patients (86.3%), complete clinical closure in 50 patients (68.5%) and radiological closure in 45 patients (69.2%). Combined clinical and radiological response was observed in 41 patients (63.1%). Not all clinically healed patients had radiological closure and vice versa. No serious adverse events were reported.

LIMITATIONS

Retrospective.

CONCLUSIONS

Study results were consistent with those reported in previous clinical trials, real-world efficacy findings from the INSPIRE study (assessing darvadstrocel effectiveness in Europe, Israel, Switzerland, UK, and Japan) and previously published literature. Darvadstrocel was effective and demonstrated a favorable safety profile when used in normal clinical practice for treatment of fistulas in Crohn's disease. See Video Abstract.

Disentangling the effect of growth from development in size-related trait scaling relationships

In plant ecology, the terms growth and development are often used interchangeably. Yet these constitute two distinct processes. Plant architectural traits (e.g. number of successive forks) can estimate development stages. Here, we show the importance of including the effect of development stages to better understand size-related trait scaling relationships (i.e. between height and stem diameter). We focused on one common savanna woody species (Senegalia nigrescens) from the Greater Kruger Area, South Africa. We sampled 406 individuals that experience different exposure to herbivory, from which we collected four traits: plant height, basal stem diameter, number of successive forks (proxy for development stage), and resprouting. We analysed trait relationships (using standardized major axis regression) between height and stem diameter, accounting for the effect of ontogeny, exposure to herbivory, and resprouting. The number of successive forks affects the scaling relationship between height and stem diameter, with the slope and strength of the relationship declining in more developed individuals. Herbivory exposure and resprouting do not affect the overall height-diameter relationship. However, when height and stem diameter were regressed separately against number of successive forks, herbivory exposure and resprouting had an effect. For example, resprouting individuals allocate more biomass to both primary and secondary growth than non-resprouting plants in more disturbed conditions. We stress the need to include traits related to ontogeny so as to disentangle the effect of biomass allocation to primary and secondary growth from that of development in plant functional relationships.

European Society of Coloproctology: Guidelines for diagnosis and treatment of cryptoglandular anal fistula

AIM

The primary aim of the European Society of Coloproctology (ESCP) Guideline Development Group (GDG) was to produce high-quality, evidence-based guidelines for the management of cryptoglandular anal fistula with input from a multidisciplinary group and using transparent, reproducible methodology.

METHODS

Previously published methodology in guideline development by the ESCP has been replicated in this project. The guideline development process followed the requirements of the AGREE-S tool kit. Six phases can be identified in the methodology. Phase one sets the scope of the guideline, which addresses the diagnostic and therapeutic management of perianal abscess and cryptoglandular anal fistula in adult patients presenting to secondary care. The target population for this guideline are healthcare practitioners in secondary care and patients interested in understanding the clinical evidence available for various surgical interventions for anal fistula. Phase two involved formulation of the GDG. The GDG consisted of 21 coloproctologists, three research fellows, a radiologist and a methodologist. Stakeholders were chosen for their clinical and academic involvement in the management of anal fistula as well as being representative of the geographical variation among the ESCP membership. Five patients were recruited from patient groups to review the draft guideline. These patients attended two virtual meetings to discuss the evidence and suggest amendments. In phase three, patient/population, intervention, comparison and outcomes questions were formulated by the GDG. The GDG ratified 250 questions and chose 45 for inclusion in the guideline. In phase four, critical and important outcomes were confirmed for inclusion. Important outcomes were pain and wound healing. Critical outcomes were fistula healing, fistula recurrence and incontinence. These outcomes formed part of the inclusion criteria for the literature search. In phase five, a literature search was performed of MEDLINE (Ovid), PubMed, Embase (Ovid) and the Cochrane Database of Systematic Reviews by eight teams of the GDG. Data were extracted and submitted for review by the GDG in a draft guideline. The most recent systematic reviews were prioritized for inclusion. Studies published since the most recent systematic review were included in our analysis by conducting a new meta-analysis using Review manager. In phase six, recommendations were formulated, using grading of recommendations, assessment, development, and evaluations, in three virtual meetings of the GDG.

RESULTS

In seven sections covering the diagnostic and therapeutic management of perianal abscess and cryptoglandular anal fistula, there are 42 recommendations.

CONCLUSION

This is an up-to-date international guideline on the management of cryptoglandular anal fistula using methodology prescribed by the AGREE enterprise.

Crossing barriers: the burden of inflammatory bowel disease across Western Europe

An estimated 2.5-3 million individuals (0.4%) in Europe are affected by inflammatory bowel disease (IBD). Whilst incidence rates for IBD are stabilising across Europe, the prevalence is rising and subsequently resulting in a significant cost to the healthcare system of an estimated 4.6-5.6 billion euros per year. Hospitalisation and surgical resection rates are generally on a downward trend, which is contrary to the rising cost of novel medication. This signifies a large part of healthcare cost and burden. Despite publicly funded healthcare systems in most European countries, there is still wide variation in how patients receive and/or pay for biologic medication. This review will provide an overview and discuss the different healthcare systems within Western Europe and the barriers that affect overall management of a changing IBD landscape, including differences to hospitalisation and surgical rates, access to medication and clinical trial participation and recruitment. This review will also discuss the importance of standardising IBD management to attain high-quality care for all patients with IBD.

Influence of pH and salts on DMF-DMA derivatization for future Space Applications

For gas chromatography - mass spectrometry (GC-MS) analyses performed in situ, pH and salts (e.g., chlorides, sulfates) may enhance or inhibit the detection of targeted molecules of interest for astrobiology (e.g. amino acids, fatty acids, nucleobases). Obviously, salts influence the ionic strength of the solutions, the pH value, and the salting effect. But the presence of salts may also produce complexes or mask ions in the sample (masking effect on hydroxide ion, ammonia, etc.). For future space missions, wet chemistry will be conducted before GC-MS analyses to detect the full organic content of a sample. The defined organic targets for space GC-MS instrument requirements are generally strongly polar or refractory organic compounds, such as amino acids playing a role in the protein production and metabolism regulations for life on Earth, nucleobases essential for DNA and RNA formation and mutation, and fatty acids that composed most of the eukaryote and prokaryote membranes on Earth and resist to environmental stress long enough to still be observed on Mars or ocean worlds in geological well-preserved records. The wet-chemistry chemical treatment consists of reacting an organic reagent with the sample to extract and volatilize polar or refractory organic molecules (i.e. dimethylformamide dimethyl acetal (DMF-DMA) in this study). DMF-DMA derivatizes functional groups with labile H in organics, without modifying their chiral conformation. The influence of pH and salt concentration of extraterrestrial materials on the DMF-DMA derivatization remains understudied. In this research, we studied the influence of different salts and pHs on the derivatization of organic molecules of astrobiological interest with DMF-DMA, such as amino acids, carboxylic acids, and nucleobases. Results show that salts and pH influence the derivatization yield, and that their effect depend on the nature of the organics and the salts studied. Second, monovalent salts lead to a higher or similar organic recovery compared to divalent salts regardless of pH below 8. However, a pH above 8 inhibits the DMF-DMA derivatization influencing the carboxylic acid function to become an anionic group without labile H. Overall, considering the negative effect of the salts on the detection of organic molecules, future space missions may have to consider a desalting step prior to derivatization and GC-MS analyses.

Multicentre, prospective, randomized control non-inferiority trial of bladder catheter management in colon surgery

AIM

Perioperative bladder catheterization is a controversial issue. Most current recommendations are based on data from open surgery extrapolated to enhanced recovery after surgery or fast-track programmes ranging between 24 and 48 h. The aim of this study is to provide a rationale for reducing catheterization time while at the same time avoiding acute urine retention (AUR), in patients undergoing scheduled laparoscopic colon surgery.

METHOD

This is a multicentre, prospective, controlled, randomized non-inferiority study of bladder catheter management in patients undergoing scheduled laparoscopic colon surgery, randomized into two groups: experimental (with catheter removal immediately after surgery) and control (with catheter removal 24 h post-surgery). The main outcome will be the development of AUR, and secondary outcomes the development of urinary infection within the first 30 days and hospital stay. Demographic, surgical and pathological variables will also be evaluated, especially the development of adverse effects assessed according to the Clavien scale and the Comprehensive Complication Index. Following the literature, we assume an incidence of AUR of 11% and a margin of non-inferiority (delta) of 8% and estimate that a sample size of 208 patients per group will be required (with an estimated 10% of losses per group).

CONCLUSIONS

In this study we try to demonstrate that the bladder catheter can be removed immediately after scheduled laparoscopic colon surgery, without increasing acute urine retention. This measure would offers the benefits of earlier mobilization and reduces catheter-related morbidity.

Abstract WP99: Impact Of Venous Delay Evaluated Before And After Mechanical Thrombectomy On Stroke Outcome

Introduction: We aimed to evaluate venous delay before and after treatment as a marker of radiological and clinical outcome in stroke patients receiving endovascular treatment (EVT).

Methods: Prospective cohort of patients with anterior intracranial occlusion undergoing EVT. Brain MRI was performed on arrival (pre-EVT), <2h after EVT (post-EVT), and 5 days after stroke. Final infarct volume was segmented on DWI at 5 days. We evaluated the veins of Labbé, Trolard and the superficial middle cerebral vein at both hemispheres on the dynamic MR angiography (dmRA) pre-EVT and post-EVT. For each vein we calculated a standardized venous delay measure:[(time to maximum venous contrast filling in the healthy hemisphere-time to maximum venous contrast filling in the affected hemisphere)/time to maximum venous contrast filling in the healthy hemisphere]x100. We defined venous delay as the value of the most delayed vein in each patient. We assessed the association between venous delay pre-EVT and post-EVT and final infarct volume and modified Rankin Scale (mRS) at 90 days, using multivariable regressions adjusted by successful reperfusion (mTICI≥2b) and other relevant variables.

Results: From 98 included patients (median NIHSS 17, final mTICI≥2b 86%), 89 pre-EVT dMRIs and 88 post-EVT dMRIs were evaluable. The median venous delay pre-EVT and post-EVT were -31.9[-58.1;-16.7]% and -13.5[-34.5;-7.5]%, respectively. Venous delay pre-EVT was not related to infarct volume or clinical outcome. When final mTICI≥2B, venous asymmetry decreased but still persisted. For each 10% of increment in venous delay post-EVT, there was an adjusted increase of 0.12[0.05-0.19]ml in the final infarct volume. Venous delay post-EVT was independently associated with mRS at 90 days (cOR 1.013 [95%CI 1.001-1.0256]).

Conclusion: Cortical vein delay assessed after but not before EVT, is associated with a larger final infarct volume and with a worse clinical outcome.

Abstract TMP70: Relevance Of Persistent Perfusion Deficits On Clinical Outcome After Sucessful Endovascular Treatment

Introduction: After achieving successful reperfusion some acute stroke patients still exhibit persistent perfusion deficits. These deficits have been defined in a heterogeneous manner by using CBF, CBV or Tmax maps as a perfusion deficit in the previous ischemic penumbra (impaired microcirculation perfusion-IMP) or inside the infarcted tissue (no reflow-NR). The significance, frequency and pathophysiology of this phenomenon are so far unknown.

Methods: Prospective cohort of patients with isolated anterior intracranial occlusion undergoing endovascular treatment (EVT) and achieving complete recanalization (final mTICI≥2B). Brain MRI was performed on arrival (pre-EVT) and &lt2h after EVT (post-EVT). Infarcted tissue was segmented on DWI pre-EVT. Pre and post-EVT perfusion maps were obtained with Olea software. NR was defined in the post-EVT perfusion maps as the region inside the infarcted tissue which showed a CBV&lt15% compared to the contralateral side, while IMP was the equivalent area inside the previous tissue in penumbra. We evaluated the association between both NR and IMP and NIHSS at 24h, NIHSS at discharge and modified Rankin score (mRS) at three months adjusting by baseline NIHSS and final mTICI.

Results: Thirty-five patients were included. All of them had IMP areas and 25 (71%) had NR areas. The median volume of NR and IMP was 3.43ml [IQR 1.43-8.81], corresponding to 17.9% of the infarcted tissue [IQR 4.2-50.3] and 33.9ml [IQR 14.0-69.3] (27.7% [IQR 8.2-51.2] of the penumbra) respectively. Patients with NR areas had higher NIHSS at 24 h and at discharge and higher mRS at 3 months. Volume of NR was independently associated with higher NIHSS at 24 h and at discharge. No independent association was found with IMP volume. Neither NR nor IMP were associated with hemorrhagic transformation. Patients receiving rTPA previous to EVT showed higher perfusion values inside the infarct than patients with primary EVT (2.31 mL/100g [1.48-2.43] vs 0.92 [0.7-1.47] p=0.02), although NR areas appeared in the same proportion in both groups.

Conclusions: No reflow phenomenon can be a marker of poor outcome in the early evaluation of successfully recanalized stroke patients especially when the persistent perfusion deficit is located inside the infarcted tissue.

Development of a core descriptor set for Crohn's anal fistula

AIM

Crohn's anal fistula (CAF) is a complex condition, with no agreement on which patient characteristics should be routinely reported in studies. The aim of this study was to develop a core descriptor set of key patient characteristics for reporting in all CAF research.

METHOD

Candidate descriptors were generated from published literature and stakeholder suggestions. Colorectal surgeons, gastroenterologists and specialist nurses in inflammatory bowel disease took part in three rounds of an international modified Delphi process using nine-point Likert scales to rank the importance of descriptors. Feedback was provided between rounds to allow refinement of the next ratings. Patterns in descriptor voting were assessed using principal component analysis (PCA). Resulting PCA groups were used to organize items in rounds two and three. Consensus descriptors were submitted to a patient panel for feedback. Items meeting predetermined thresholds were included in the final set and ratified at the consensus meeting.

RESULTS

One hundred and thirty three respondents from 22 countries completed round one, of whom 67.0% completed round three. Ninety seven descriptors were rated across three rounds in 11 PCA-based groups. Forty descriptors were shortlisted. The consensus meeting ratified a core descriptor set of 37 descriptors within six domains: fistula anatomy, current disease activity and phenotype, risk factors, medical interventions for CAF, surgical interventions for CAF, and patient symptoms and impact on quality of life.

CONCLUSION

The core descriptor set proposed for all future CAF research reflects characteristics important to gastroenterologists and surgeons. This might aid transparent reporting in future studies.

Workflows and Outcomes in Patients With Suspected Large Vessel Occlusion Stroke Triaged in Urban and Nonurban Areas

BACKGROUND

We aim to compare the outcome of patients from urban areas, where the referral center is able to perform thrombectomy, with patients from nonurban areas enrolled in the RACECAT trial (Direct Transfer to an Endovascular Center Compared to Transfer to the Closest Stroke Center in Acute Stroke Patients With Suspected Large Vessel Occlusion).

METHODS

Patients with suspected large vessel occlusion stroke, as evaluated by a Rapid Arterial Occlusion Evaluation score of ≥5, from urban catchment areas of thrombectomy-capable centers during RACECAT trial enrollment period were included in the Stroke Code Registry of Catalonia. Primary outcome was disability at 90 days, as assessed by the shift analysis on the modified Rankin Scale score, in patients with an ischemic stroke. Secondary outcomes included mortality at 90 days, rate of thrombolysis and thrombectomy, time from onset to thrombolysis, and thrombectomy initiation. Propensity score matching was used to assemble a cohort of patients with similar characteristics.

RESULTS

The analysis included 1369 patients from nonurban areas and 2502 patients from urban areas. We matched 920 patients with an ischemic stroke from urban areas and nonurban areas based on their propensity scores. Patients with ischemic stroke from nonurban areas had higher degrees of disability at 90 days (median [interquartle range] modified Rankin Scale score, 3 [2-5] versus 3 [1-5], common odds ratio, 1.25 [95% CI, 1.06-1.48]); the observed average effect was only significant in patients with large vessel stroke (common odds ratio, 1.36 [95% CI, 1.08-1.65]). Mortality rate was similar between groups(odds ratio, 1.02 [95% CI, 0.81-1.28]). Patients from nonurban areas had higher odds of receiving thrombolysis (odds ratio, 1.36 [95% CI, 1.16-1.67]), lower odds of receiving thrombectomy(odds ratio, 0.61 [95% CI, 0.51-0.75]), and longer time from stroke onset to thrombolysis (mean difference 38 minutes [95% CI, 25-52]) and thrombectomy(mean difference 66 minutes [95% CI, 37-95]).

CONCLUSIONS

In Catalonia, Spain, patients with large vessel occlusion stroke triaged in nonurban areas had worse neurological outcomes than patients from urban areas, where the referral center was able to perform thrombectomy. Interventions aimed at improving organizational practices and the development of thrombectomy capabilities in centers located in remote areas should be pursued.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT02795962.

Impact of microsatellite status in early-onset colonic cancer

BACKGROUND

The molecular profile of early-onset colonic cancer is undefined. This study evaluated clinicopathological features and oncological outcomes of young patients with colonic cancer according to microsatellite status.

METHODS

Anonymized data from an international collaboration were analysed. Criteria for inclusion were patients younger than 50 years diagnosed with stage I-III colonic cancer that was surgically resected. Clinicopathological features, microsatellite status, and disease-specific outcomes were evaluated.

RESULTS

A total of 650 patients fulfilled the criteria for inclusion. Microsatellite instability (MSI) was identified in 170 (26.2 per cent), whereas 480 had microsatellite-stable (MSS) tumours (relative risk of MSI 2.5 compared with older patients). MSI was associated with a family history of colorectal cancer and lesions in the proximal colon. The proportions with pathological node-positive disease (45.9 versus 45.6 per cent; P = 1.000) and tumour budding (20.3 versus 20.5 per cent; P = 1.000) were similar in the two groups. Patients with MSI tumours were more likely to have BRAF (22.5 versus 6.9 per cent; P < 0.001) and KRAS (40.0 versus 24.2 per cent; P = 0.006) mutations, and a hereditary cancer syndrome (30.0 versus 5.0 per cent; P < 0.001; relative risk 6). Five-year disease-free survival rates in the MSI group were 95.0, 92.0, and 80.0 per cent for patients with stage I, II, and III tumours, compared with 88.0, 88.0, and 65.0 per cent in the MSS group (P = 0.753, P = 0.487, and P = 0.105 respectively).

CONCLUSION

Patients with early-onset colonic cancer have a high risk of MSI and defined genetic conditions. Those with MSI tumours have more adverse pathology (budding, KRAS/BRAF mutations, and nodal metastases) than older patients with MSI cancers.

Microsatellite instability in young patients with rectal cancer: molecular findings and treatment response

In this study of 400 patients with early-onset rectal cancer, 12.5 per cent demonstrated microsatellite instability (MSI). MSI was associated with a reduced likelihood of nodal positivity, an increased rate of pathological complete response, and improved disease-specific survival.

"Near-TME": proposed standardisation of the technique for proctectomy in male patients with ulcerative colitis

Background

The aim of the present study was to describe in detail an approach to proctectomy in ulcerative colitis (UC), which can be standardized; near-total mesorectal excision (near-TME), to prevent injuries to autonomic pelvic nerves and subsequent sexual dysfunction.

Methods

We demonstrate the technique ex vivo on a cadaver from a male patient in lithotomy position and on a sagittal section of a male pelvis. We also demonstrate the technique in vivo in two male patients diagnosed with UC, with no history of sexual dysfunction or bowel neoplasia. The study was performed at the Human Embryology and Anatomy Department. University of Valencia, Spain.

Results

The posterolateral dissection during a near-TME is similar to that of an oncologic TME, whereas the anterolateral is similar to that of a close rectal dissection. The near-TME technique preserves the superior hypogastric plexus, the hypogastric nerves, the nervi erigentes, the inferior hypogastric plexus, the pelvic plexus and the cavernous nerves.

Conclusion

The near-TME technique is the standardisation of the technique for proctectomy in male patients with ulcerative colitis. Near-TME requires experience in pelvic surgery and an exhaustive knowledge of the embryological development and of the surgical anatomy of the pelvis.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10151-022-02579-z.

Abstract WMP93: Somatosensory Evoked Potentials Monitoring In Acute Ischemic Stroke (Promise) Study: A Biomarker Of Functional Recovery Prior To Mechanical Thrombectomy (clinicaltrials.gov: NCT04099615)

Hypothesis: Somatosensory evoked potentials (SEPs), as surrogate of cerebral blood flow, may give substantial additional predictive value to that provided by clinical and imaging factors and optimize the selection of patients benefiting from mechanical thrombectomy (MT)

Methods: Bilateral median nerve SEPs were recorded before and continuously during MT in consecutive patients with AIS and anterior LVO. N20 response ipsilateral to the ischemic hemisphere was measured. The adjusted predictive value of the N20 on functional Independence (modified Rankin Scale score ≤2) after MT was analyzed by binary logistic regression and its predictive value on the full range of disability by ordinal logistic regression. We constructed different regression models with other clinical and imaging predictors at the pre- and in- hospital setting to determine the independent predictive power of N20 for a potential treatment decision-making

Results: A total of 223 patients were recruited. A blinded reading of SEPs recordings identified presence of N20 in 110 (49.3%), absence in 58 (26%) and not assessable in 55 patients due to radiofrequency interferences. Prior to MT, N20 had positive predictive value (PPV) of 93% (95%CI, 0.8 to 0.98) and increased 10 fold the likelihood of good functional outcome at 7 days (adjusted OR, 9.9; 95%CI, 3.1-44.6). Receiver operating curves showed that N20 had a higher capacity to predict good functional outcome (AUC 0.82) than models constructed with pre-hospital (age, sex, serum glucose, median blood pressure, NIHSS; AUC 0.75) or in-hospital (NIHSS, ASPECTS; AUC 0.72) factors. During MT, N20 had PPV of 100% (95% CI, 0.85-1) and was the unique independent factor associated with functional independence (adjusted OR, 2.74; 95%CI, 1.90-4.29). Perfusion CT or MR was available in a subgroup of 116 patients. Baseline N20 showed a higher capacity to predict good functional outcome (n=168, AUC 0.71) compared with ischemic core (n=127, AUC 0.66), ischemic penumbra (Tmax>6) (n=116, AUC 0.54) and collateral status (n=191, AUC 0.61)

Conclusions: SEPs monitoring is a fast and bedside technique that could complement current clinical factors in terms of increasing the eligibility of AIS patients for MT and improving prognosis.

Characteristics of Early-Onset vs Late-Onset Colorectal Cancer: A Review

Importance

The incidence of early-onset colorectal cancer (younger than 50 years) is rising globally, the reasons for which are unclear. It appears to represent a unique disease process with different clinical, pathological, and molecular characteristics compared with late-onset colorectal cancer. Data on oncological outcomes are limited, and sensitivity to conventional neoadjuvant and adjuvant therapy regimens appear to be unknown. The purpose of this review is to summarize the available literature on early-onset colorectal cancer.

Observations

Within the next decade, it is estimated that 1 in 10 colon cancers and 1 in 4 rectal cancers will be diagnosed in adults younger than 50 years. Potential risk factors include a Westernized diet, obesity, antibiotic usage, and alterations in the gut microbiome. Although genetic predisposition plays a role, most cases are sporadic. The full spectrum of germline and somatic sequence variations implicated remains unknown. Younger patients typically present with descending colonic or rectal cancer, advanced disease stage, and unfavorable histopathological features. Despite being more likely to receive neoadjuvant and adjuvant therapy, patients with early-onset disease demonstrate comparable oncological outcomes with their older counterparts.

Conclusions and Relevance

The clinicopathological features, underlying molecular profiles, and drivers of early-onset colorectal cancer differ from those of late-onset disease. Standardized, age-specific preventive, screening, diagnostic, and therapeutic strategies are required to optimize outcomes.

Global parental leave in surgical careers: differences according to gender, geographical regions and surgical career stages

BACKGROUND

There is a lack of information regarding the provision of parental leave for surgical careers. This survey study aims to evaluate the experience of maternity/paternity leave and views on work-life balance globally.

METHODS

A 55-item online survey in 24 languages was distributed via social media as per CHERRIES guideline from February to March 2020. It explored parental leave entitlements, attitude towards leave taking, financial impact, time spent with children and compatibility of parenthood with surgical career.

RESULTS

Of the 1393 (male : female, 514 : 829) respondents from 65 countries, there were 479 medical students, 349 surgical trainees and 513 consultants. Consultants had less than the recommended duration of maternity leave (43.8 versus 29.1 per cent), no paid maternity (8.3 versus 3.2 per cent) or paternity leave (19.3 versus 11.0 per cent) compared with trainees. Females were less likely to have children than males (36.8 versus 45.6 per cent, P = 0.010) and were more often told surgery is incompatible with parenthood (80.2 versus 59.5 per cent, P < 0.001). Males spent less than 20 per cent of their salary on childcare and fewer than 30 hours/week with their children. More than half (59.2 per cent) of medical students did not believe a surgical career allowed work-life balance.

CONCLUSION

Surgeons across the globe had inadequate parental leave. Significant gender disparity was seen in multiple aspects.

Patient-Reported Outcome Measures in Colorectal Surgery: Construction of Core Measures Using Open-Source Research Method

Purpose. The primary aim of the study was to review the existing literature about patient-reported outcome measures (PROMs) in colorectal cancer and IBD. The secondary aim was to present a road map to develop a core outcome set via opinion gathering using social media. Method. This study is the first step of a three-step project aimed at constructing simple, applicable PROMs in colorectal surgery. This article was written in a collaborative manner with authors invited both through Twitter via the #OpenSourceResearch hashtag. The 5 most used PROMs were presented and discussed as slides/images on Twitter. Inputs from a wide spectrum of participants including researchers, surgeons, physicians, nurses, patients, and patients' organizations were collected and analyzed. The final draft was emailed to all contributors and 6 patients' representatives for proofreading and approval. Results. Five PROM sets were identified and discussed: EORTC QLQ-CR29, IBDQ short health questionnaire, EORTC QLQ-C30, ED-Q5-5L, and Short Form-36. There were 315 tweets posted by 50 tweeters with 1458 retweets. Awareness about PROMs was generally limited. The general psycho-physical well-being score (GPP) was suggested and discussed, and then a survey was conducted in which more than 2/3 of voters agreed that GPP covers the most important aspects in PROMs. Conclusion. Despite the limitations of this exploratory study, it offered a new method to conduct clinical research with opportunity to engage patients. The general psycho-physical well-being score suggested as simple, applicable PROMs to be eventually combined procedure-specific, disease-specific, or symptom-specific PROMs if needed.

Abstract P75: Cerebrovascular Events and Outcomes in Hospitalized Patients With Covid-19: The Society of Vascular and Interventional Neurology Multinational Registry

Background: Severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) has been associated with a significant risk of thrombotic events in critically ill patients.

Aims: To summarize the findings of a multinational observational cohort of patients with SARS-CoV-2 and cerebrovascular disease.

Methods: Retrospective observational cohort of consecutive adults evaluated in the emergency department and/or admitted with coronavirus disease 2019 (COVID-19) across 31 hospitals in 4 countries (2/1/2020 - 06/16/2020). The primary outcome was the incidence rate of cerebrovascular events, inclusive of acute ischemic stroke, intracranial hemorrhages (ICH), and cortical vein and/or sinus thrombosis (CVST).

Results: Of the 14,483 patients with laboratory-confirmed SARS-CoV-2, 172 were diagnosed with an acute cerebrovascular event (1.13% of cohort; 1130/100,000 patients, 95%CI 970-1320/100,000), 68/171 (40.5%) of whom were female and 96/172 (55.8%) were between the ages 60-79 years. Of these, 156 had acute ischemic stroke (1.08%; 1080/100,000 95%CI 920-1260/100,000), 28 ICH (0.19%; 190/100,000 95%CI 130 - 280/100,000) and 3 with CVST (0.02%; 20/100,000, 95%CI 4-60/100,000). The in-hospital mortality rate for SARS-CoV-2-associated stroke was 38.1% and for ICH 58.3%. After adjusting for clustering by site and age, baseline stroke severity, and all predictors of in-hospital mortality found in univariate regression (p<0.1: male sex, tobacco use, arrival by emergency medical services, lower platelet and lymphocyte counts, and intracranial occlusion), cryptogenic stroke mechanism (aOR 5.01, 95%CI 1.63-15.44, p<0.01), older age (aOR 1.78, 95%CI 1.07-2.94, p=0.03), and lower lymphocyte count on admission (aOR 0.58, 95%CI 0.34-0.98 p=0.04) were the only independent predictors of mortality among patients with stroke and COVID-19.

Conclusions: COVID-19 is associated with a small but significant risk of clinically relevant cerebrovascular events, particularly ischemic stroke. The mortality rate is high for COVID-19 associated cerebrovascular complications, therefore aggressive monitoring and early intervention should be pursued to mitigate poor outcomes.

The Barcelona-Asymptomatic Intracranial Atherosclerosis (AsIA) study: Subclinical cervico-cerebral stenosis and middle cerebral artery pulsatility index as predictors of long-term incident cognitive impairment

BACKGROUND AND AIMS

We aimed to study subclinical non-invasive vascular markers as predictors of incident long-term cognitive impairment in a longitudinal population-based study.

METHODS

The Barcelona-Asymptomatic Intracranial Atherosclerosis (AsIA) study is a population-based study that included a random sample of 933 Caucasian subjects (mean age 66 years, 64% male) with a moderate-high vascular risk and without history of stroke or dementia. Subclinical carotid and intracranial stenosis was assessed at baseline visit by cervical and transcranial color-coded duplex (TCCD) and confirmed by magnetic resonance angiography. Cervico-cerebral stenosis (CCS) was defined as the presence of extra and/or intracranial stenosis >50%. Baseline middle cerebral artery pulsatility index (MCA-PI) was measured bilaterally by TCCD, and mean PI of both sides was considered for analyses. Subjects were followed-up to determine incident long-term cognitive impairment (mild cognitive impairment or dementia).

RESULTS

After a median of 7.16 [6.91-7.75] years of follow-up, 91 subjects (9.7%) developed cognitive impairment, 27 of them mild cognitive impairment, and 64 dementia. Incidence of cognitive impairment was significantly higher among subjects with subclinical CCS (21.4% versus 9% in those without CCS) and among those with mean MCA-PI>1 (13.5% versus 7.4% in those with MCA-PI<1). In multivariate Cox regression analyses, both CCS and MCA-PI>1 were independently associated with incident cognitive impairment with HR of 2.07 [1.11-3.88] and 1.58 [1.02-2.46], respectively.

CONCLUSIONS

Subclinical cervico-cerebral stenosis and higher MCA-PI are non-invasive neurosonological markers of incident long-term cognitive impairment in our population.

Postoperative Complications in Hemorrhoidal Disease and Special Conditions

BACKGROUND

Hemorrhoidal disease is still one of the most prevalent proctological diseases. Pain is the most common complication after surgery but bleeding, urinary retention and perianal infection are also frequent. There is also an important group of patients, such as those with inflammatory bowel disease, pregnancy or immunosuppression, who can present an increased rate or more severe complications.

OBJECTIVE

To describe the complications following different surgical and instrumental techniques for hemorrhoids in a literature review. Special situations were reviewed to determine how they affect the management of the disease.

METHODS

During August 2019, a narrative review of hemorrhoid surgery complications and special situations was performed using the Pubmed MESH DATABASE.

CONCLUSION

Pain, urinary retention and bleeding remain the most frequent complications after surgery for hemorrhoids; however, special situations must be taken into account in order to choose the best technique to prevent more severe complications.

Adipose stem cells from patients with Crohn's disease show a distinctive DNA methylation pattern

Background

Crohn’s disease (CD) is characterized by persistent inflammation and ulceration of the small or large bowel, and expansion of mesenteric adipose tissue, termed creeping fat (CF). We previously demonstrated that human adipose-derived stem cells (hASCs) from CF of patients with CD exhibit dysfunctional phenotypes, including a pro-inflammatory profile, high phagocytic capacity, and weak immunosuppressive properties. Importantly, these phenotypes persist in patients in remission and are found in all adipose depots explored including subcutaneous fat. We hypothesized that changes in hASCs are a consequence of epigenetic modifications.

Methods

We applied epigenome-wide profiling with a methylation array (Illumina EPIC/850k array) and gene expression analysis to explore the impact of CD on the methylation signature of hASCs isolated from the subcutaneous fat of patients with CD and healthy controls (n = 7 and 5, respectively; cohort I). Differentially methylated positions (p value cutoff < 1 × 10⁻⁴ and ten or more DMPs per gene) and regions (inclusion threshold 0.2, p value cutoff < 1 × 10⁻² and more than 2 DMRs per gene) were identified using dmpfinder and Bumphunter (minfi), respectively. Changes in the expression of differentially methylated genes in hASCs were validated in a second cohort (n = 10/10 inactive and active CD and 10 controls; including patients from cohort I) and also in peripheral blood mononuclear cells (PBMCs) of patients with active/inactive CD and of healthy controls (cohort III; n = 30 independent subjects).

Results

We found a distinct DNA methylation landscape in hASCs from patients with CD, leading to changes in the expression of differentially methylated genes involved in immune response, metabolic, cell differentiation, and development processes. Notably, the expression of several of these genes in hASCs and PBMCs such as tumor necrosis factor alpha (TNFA) and PR domain zinc finger protein 16 (PRDM16) were not restored to normal (healthy) levels after disease remission.

Conclusions

hASCs of patients with CD exhibit a unique DNA methylation and gene expression profile, but the expression of several genes are only partially restored in patients with inactive CD, both in hASCs and PBMCs. Understanding how CD shapes the functionality of hASCs is critical for investigating the complex pathophysiology of this disease, as well as for the success of cell-based therapies.

Graphical abstract

Human adipose-stem cells isolated from subcutaneous fat of patients with Crohn’s disease exhibit an altered DNA methylation pattern and gene expression profile compared with those isolated from healthy individuals, with immune system, cell differentiation, metabolic and development processes identified as the main pathways affected. Interestingly, the gene expression of several genes involved in these pathways is only partially restored to control levels in patients with inactive Crohn’s disease, both in human adipose-stem cells and peripheral blood mononuclear cells. Understanding how Crohn’s disease shapes the functionality of human adipose-stem cells is critical for investigating the complex pathophysiology of this disease, as well as for the success of cell-based therapies.

A video guide of five access methods to the splenic flexure: the concept of the splenic flexure box

AIM

The aim of this study was to describe all the possible approaches for laparoscopic splenic flexure mobilization (SFM), each suitable for specific situations, and create an illustrated system to show SFM approaches in an easy and practical way to make it easy to learn and teach.

METHODS

Two different phases. First part: Cadaver-based study of the colonic splenic flexure anatomy. In order to demonstrate the different approaches, a balloon was placed through the colonic hepatic flexure in the lesser sac without sectioning any of the fixing ligaments of the splenic flexure. Second part: A real case series of laparoscopic SFM.

RESULTS

First part: 11 cadavers were dissected. Five potential approaches to SFM were found: anterior, trans-omentum, lateral, medial infra-mesocolic, and medial trans-mesocolic. The illustrative system developed was named: Splenic Flexure "Box"(SFBox). Second part: One of the types of SFM described in first part was used in five patients with colorectal cancer. Each laparoscopic approach to the splenic flexure was illustrated in a video accompanied by illustration aids delineating the access.

CONCLUSION

With the cadaver dissection and subsequent demonstration in real-life laparoscopic surgery, we have shown five types of laparoscopic splenic flexure mobilization. The Splenic Flexure "Box" is a useful way to learn and teach this surgical maneuver.

Biological Treatment and the Potential Risk of Adverse Postoperative Outcome in Patients With Inflammatory Bowel Disease: An Open-Source Expert Panel Review of the Current Literature and Future Perspectives

Background

There is widespread concern that treatment with biologic agents may be associated with suboptimal postoperative outcome after surgery for inflammatory bowel diseases (IBD).

Aim

We aimed to search and analyze the literature regarding the potential association of biologic treatment on adverse postoperative outcome in patients with IBD. We used the subject as a case in point for surgical research. The aim was not to conduct a new systematic review.

Method

This is an updated narrative review written in a collaborative method by authors invited through Twitter via the following hashtags (#OpenSourceResearch and #SoMe4Surgery). The manuscript was presented as slides on Twitter to allow discussion of each section of the paper sequentially. A Google document was created, which was shared across social media, and comments and edits were verified by the primary author to ensure accuracy and consistency.

Results

Forty-one collaborators responded to the invitation, and a total of 106 studies were identified that investigated the potential association of preoperative biological treatment on postoperative outcome in patients with IBD. Most of these studies were retrospective observational cohorts: 3 were prospective, 4 experimental, and 3 population-based studies. These studies were previously analyzed in 10 systematic/narrative reviews and 14 meta-analyses. Type of biologic agents, dose, drug concentration, antidrug antibodies, interval between last dose, and types of surgery varied widely among the studies. Adjustment for confounders and bias control ranged from good to very poor. Only 10 studies reported postoperative outcome according to Clavien–Dindo classification.

Conclusion

Although a large number of studies investigated the potential effect of biological treatment on postoperative outcomes, many reported divergent results. There is a need for randomized controlled trials. Future studies should focus on the avoiding the weakness of prior studies we identified. Seeking collaborators and sharing information via Twitter was integral to widening the contributors/authors and peer review for this article and was an effective method of collaboration.

Reliability and validity of clinical tests to assess posture, pain location, and cervical spine mobility in adults with neck pain and its associated disorders: Part 4. A systematic review from the cervical assessment and diagnosis research evaluation (CADRE) collaboration

PURPOSE

To determine the reliability and validity of clinical tests to assess posture, pain location, and cervical spine mobility in adults with grades I-IV neck pain and associated disorders (NAD).

METHODS

We systematically searched electronic databases to update the systematic review of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Eligible reliability and validity studies were critically appraised using modified versions of the QAREL and QUADAS-2 instruments, respectively. Evidence from low risk of bias studies were synthesized following best evidence synthesis principles.

RESULTS

We screened 14302 articles, critically appraised 46 studies, and found 32 low risk of bias articles (14 reliability and 18 validity studies). We found preliminary evidence of: 1) reliability of visual inspection, aided with devices (CROM and digital caliper) to assess head posture; 2) reliability and validity of soft tissue palpation to locate tender/trigger points in muscles; 3) reliability and validity of joint motion palpation to assess stiffness and pain provocation in combination; and 4) range of motion tests using visual estimation (in cervical extension only) or devices (digital caliper, goniometer, inclinometer) to assess cervical mobility.

CONCLUSIONS

We found little evidence to support the reliability and validity of clinical tests to assess head posture, pain location and cervical mobility in adults with NAD grades I-III. More advanced validity studies are needed to inform the clinical utility of tests used to evaluate patients with NAD.

Tumor Biology as Predictor of Mortality in Liver Transplantation for Hepatocellular Carcinoma

BACKGROUND

Hepatocellular carcinoma (HCC) is the most frequent primary malignant liver tumor, with the Milan criteria considered to be the gold standard for patient selection for liver transplantation (LT).

MATERIALS AND METHODS

We performed a descriptive observational study, reviewing 20 years of experience of LT in patients with HCC in the Fundacion Valle del Lilí in Cali, Colombia. Subgroup analysis was undertaken for periods 1999 to 2007 and 2008 to 2015.

RESULTS

Fifty-seven cases with a pretransplant HCC diagnosis were reviewed. In the first period patients within the Milan criteria had a recurrence-free survival at 5 years of 66.6%, and in those who exceeded the Milan criteria, recurrence-free survival was 75%. In the second period, patients within the Milan criteria, recurrence-free survival at 5 years was 93.5%, and in those who exceeded the Milan criteria, recurrence-free survival was 75.7%. No statistically significant difference was found in either period. For patients with mild and moderate tumor differentiation, the relapse survival rate at 5 years was 69.4% (95% confidence interval [CI] 35.8-87.8) and 74.7% (95% CI 44.5-90), respectively. All patients with poor tumor differentiation relapsed and died within 3 years.

CONCLUSION

Global and recurrence-free survival among patients who met and patients who exceeded the Milan criteria was not significantly different, suggesting an expansion of the Milan criteria to include potential recipients who were previously excluded. Obtaining histologic differentiation and identifying vascular invasion will provide a more worthwhile contribution to LT decision making.

Thrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and Infarct

BACKGROUND

The effect of endovascular thrombectomy that is performed more than 6 hours after the onset of ischemic stroke is uncertain. Patients with a clinical deficit that is disproportionately severe relative to the infarct volume may benefit from late thrombectomy.

METHODS

We enrolled patients with occlusion of the intracranial internal carotid artery or proximal middle cerebral artery who had last been known to be well 6 to 24 hours earlier and who had a mismatch between the severity of the clinical deficit and the infarct volume, with mismatch criteria defined according to age (<80 years or ≥80 years). Patients were randomly assigned to thrombectomy plus standard care (the thrombectomy group) or to standard care alone (the control group). The coprimary end points were the mean score for disability on the utility-weighted modified Rankin scale (which ranges from 0 [death] to 10 [no symptoms or disability]) and the rate of functional independence (a score of 0, 1, or 2 on the modified Rankin scale, which ranges from 0 to 6, with higher scores indicating more severe disability) at 90 days.

RESULTS

A total of 206 patients were enrolled; 107 were assigned to the thrombectomy group and 99 to the control group. At 31 months, enrollment in the trial was stopped because of the results of a prespecified interim analysis. The mean score on the utility-weighted modified Rankin scale at 90 days was 5.5 in the thrombectomy group as compared with 3.4 in the control group (adjusted difference [Bayesian analysis], 2.0 points; 95% credible interval, 1.1 to 3.0; posterior probability of superiority, >0.999), and the rate of functional independence at 90 days was 49% in the thrombectomy group as compared with 13% in the control group (adjusted difference, 33 percentage points; 95% credible interval, 24 to 44; posterior probability of superiority, >0.999). The rate of symptomatic intracranial hemorrhage did not differ significantly between the two groups (6% in the thrombectomy group and 3% in the control group, P=0.50), nor did 90-day mortality (19% and 18%, respectively; P=1.00).

CONCLUSIONS

Among patients with acute stroke who had last been known to be well 6 to 24 hours earlier and who had a mismatch between clinical deficit and infarct, outcomes for disability at 90 days were better with thrombectomy plus standard care than with standard care alone. (Funded by Stryker Neurovascular; DAWN ClinicalTrials.gov number, NCT02142283 .).

Crohn's Disease Disturbs the Immune Properties of Human Adipose-Derived Stem Cells Related to Inflammasome Activation

Crohn's disease (CD) is characterized by the expansion of mesenteric fat, also known as “creeping fat.” We explored the plasticity and immune properties of adipose-derived stem cells (ASCs) in the context of CD as potential key players in the development of creeping fat. Mesenteric CD-derived ASCs presented a more proliferative, inflammatory, invasive, and phagocytic phenotype than equivalent cells from healthy donors, irrespective of the clinical stage. Remarkably, ASCs from the subcutaneous depot of patients with CD also showed an activated immune response that was associated with a reduction in their immunosuppressive properties. The invasive phenotype of mesenteric CD ASCs was governed by an inflammasome-mediated inflammatory state since blocking inflammasome signaling, mainly the secretion of interleukin-1β, reversed this characteristic. Thus, CD alters the biological functions of ASCs as adipocyte precursors, but also their immune properties. Selection of ASCs with the best immunomodulatory properties is advocated for the success of cell-based therapies.

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ASCs isolated from CD patients are highly proliferative, invasive, and phagocytic

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Proliferative ASCs may be responsible for the development of creeping fat

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ASCs from CD patients have dampened immunosuppressive properties

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Selection of the best immunosuppressive ASCs for cell therapy is advocated

Abstract WP17: Effect of Solitaire Retriever-predominant Thrombectomy in Acute Ischemic Stroke: a Pooled, Individual Patient Data, Systematic Analysis

Introduction: Endovascular thrombectomy predominantly with the Solitaire stent retriever results in better outcomes among ischemic stroke patients with proximal, anterior circulation occlusions. The overall effect size and benefit in important subgroups are best estimated using pooled, individual participant-level data meta-analysis.

Methods: The SEER consortium pooled individual patient-level data from the 4 major randomized trials in which Solitaire retrievable stents were the predominant endovascular device, ESCAPE, SWIFT-PRIME, REVASCAT, and EXTEND-IA. A formal statistical analysis plan was pre-specified. The primary outcome is the modified Rankin Score at 90 days. Secondary outcomes include functional independence (mRS 0-2) and mortality at 90 days. Clinical sub-groups assessed are age, sex, NIHSS score, and target occlusion location. Full results will be presented at the meeting.

Results: Among 777 patients randomized (400 intervention, 377 control), mean age was 68 (sd 13), 51% were female, pretreatment NIHSS was median 17 (iqr 7), median ASPECTS score was 8 (iqr 2). More favorable outcomes over the entire mRS were observed with thrombectomy, CMH test p <0.001. Treatment benefit was homogenous across all subgroups of age, sex, baseline NIHSS, and target occlusion location. The rate of functional independence (mRS 0-2) at 90d was 55.0% endovascular vs. 31.5% control (RR = 1.7 CI95 1.4-2.1). The risk of death trended lower in the endovascular group (RR = 0.75 CI95 0.5-1.1). Among 128 patients ≥ 80 years of age, 37.8% (endovascular) vs. 18.5% (control) achieved an independent outcome (RR 2.0 CI95 1.1-3.8). Among 206 subjects with ICA occlusion, 45.9% (endovascular) vs. 18.9% (control) achieved an independent outcome (RR 2.4 CI95 1.5-3.8). Among 561 with MCA occlusions, 58.6% (endovascular) and 38.9% (control) achieved an independent outcome (RR 1.6 CI95 1.3-2.0).

Conclusions: Endovascular treatment for anterior circulation, large vessel occlusion ischemic stroke is a robust therapy in old and young, men and women, more and less severe deficits, and both ICA and MCA occlusions. The magnitude of benefit is large and consistent across trials; overall, 1 of every 4 treated patients achieves functional independence as a result of therapy.

Treatment of colorectal cancer in the elderly

Colorectal cancer has a high incidence, and approximately 60% of colorectal cancer patients are older than 70, with this incidence likely increasing in the near future. Elderly patients (> 70-75 years of age) are a very heterogeneous group, ranging from the very fit to the very frail. Traditionally, these patients have often been under-treated and recruited less frequently to clinical trials than younger patients, and thus are under-represented in publications about cancer treatment. Recent studies suggest that fit elderly patients can be treated in the same way as their younger counterparts, but the treatment of frail patients with comorbidities is still a matter of controversy. Many factors should be taken into account, including fitness for treatment, the wishes of the patient and family, and quality of life. This review will focus on the existing evidence for surgical, oncologic, and palliative treatment in patients over 70 years old with colorectal cancer. Careful patient assessment is necessary in order to individualize treatment approach, and this should rely on a multidisciplinary process. More well-designed controlled trials are needed in this patient population.

Abstract W P37: Laterality of the Posterior Cerebral Artery is Associated With a Smaller Volume of Brain Tissue at Risk in Patients With Acute Anterior Circulation Arterial Occlusion

Background: Laterality of the posterior cerebral artery (LPCA) in acute stroke has been related with a better leptomeningeal collateral circulation and with improved functional outcome at 6 months in patients treated with IV tPA. We aim to study the association between LPCA and the amount of brain tissue at risk of infarction in patients with anterior circulation arterial occlusion.

Methods: From our prospective database of ischemic stroke we selected patients with anterior circulation arterial occlusion who underwent multimodal MRI < 12h of symptom onset. We considered LPCA when the following criteria were accomplished: a) ipsilateral PCA to the occlusion site was extended in 1 or more segments compared to the contralateral PCA and b) ipsilateral P4 segment was visible on axial TOF images. Two independent readers blinded to clinical data retrospectively assessed the presence of LPCA (k=0.65). We analyzed the association between LPCA and the volume of ischemic penumbra at baseline (Tmax>6s) and the final infarct volume (CT 24h). Good outcome was defined as mRS ≤ 2 at 90 days.

Results: Seventy-two patients were included in the study (mean age 67y, 45% male). LPCA was present in 39 (54.1%). There were no differences between groups with or without LPCA, except a lower baseline NIHSS in the LPCA group (15 vs 19; p=0.003). Proportion of patients treated with reperfusion therapies was similar between groups. Patients with LPCA had a smaller lesion in Tmax>6s (54 vs 79cc; p=0.02), smaller final infarct volume (47 vs 111cc; p=0.013), and higher proportion of good outcome (52.8% vs 27.3%; p=0.03). In a multivariate analysis, LPCA was independently associated with smaller lesion volume on Tmax>6s (B -18, IC95% [-36,-0.3]), smaller final infarct volume (B -64.8, IC95% [-100,-29]) and better clinical outcome (OR 4.66, IC95% [1.04,20.8]).

Conclusion: LPCA sign in patients with anterior circulation arterial occlusion is associated with smaller volume of brain tissue at risk resulting in smaller infarct volume and better clinical outcome. These findings suggest favorable leptomeningeal collaterals.

Risk factors for prolonged postoperative ileus after colorectal cancer surgery

BACKGROUND

The aim of this study was to analyze factors contributing to prolonged postoperative ileus (POI) after elective bowel resection in patients with colorectal cancer.

METHODS

This was a retrospective review of a prospectively maintained database of patients operated on for colorectal cancer during 2006-2009. Patients with abdominal procedures and bowel resection without anastomotic leakage were included. Prolonged POI was defined as no flatus by postoperative day (POD) 6, with or without intolerance to oral intake by POD 6. Variables studied included demographics, prior medical conditions, details of the surgical procedure, and hospital stay.

RESULTS

A total of 773 patients met the inclusion criteria. POI occurred in 15.9%. The mean hospital stay was 11 days without POI and 20 days for POI patients (P < 0.001). Factors associated with POI in the univariate analysis were ASA III-IV (P < 0.005), male sex (P < 0.004), smoking (P < 0.015), chronic pulmonary disease (COPD) (P < 0.002), rectal cancer (P < 0.02), and ileostomy (P < 0.001). Multivariate logistic regression analysis showed male sex [odds ratio (OR) 1.6, 95% confidence interval (CI) 1.04-3.5]; COPD (OR 1.9, 95% CI 1.25-31.0), and ileostomy (OR 1.9; 95% CI 1.23-3.07) as risk factors for POI.

CONCLUSIONS

The risk of POI seems increased in patients with preoperative COPD and patients with an ileostomy, especially in men. Consideration of these factors could be important for the prevention and treatment of POI.

Impact of age on recurrence and severity of left colonic diverticulitis

AIM

There has been controversy about the presentation and treatment of acute colonic diverticulitis (AD) in young patients. The aim of this observational study was to evaluate the virulence and natural history of AD in three different age groups of patients.

METHOD

The study was performed on 686 patients with the diagnosis of a first episode of AD admitted between January 1998 and December 2008. Patients were classified into three groups: age 45 years or younger (group 1), 45-70 years of age (group 2) and 70 years or more (group 3). The variables studied were gender, American Society of Anesthesiologists status, associated comorbidity, type of treatment, length of hospital stay and recurrence of AD.

RESULTS

Group 1 included 99 (14.4%) patients, group 2 339 (49.4%) and group 3 248 (36.2%). Of these, 144 patients needed emergency operation at the first admission, 25 underwent elective surgery after the first episode of AD and 10 died after medical treatment; 507 patients were followed for recurrence. In all, 104 (20.5%) patients had a recurrence of AD that required hospitalization. Fifty (9.9%) presented with one episode of severe recurrence, without any difference between the groups (P = 0.533). There were no differences in the analysis of cumulative recurrence (Kaplan-Maier) between the three groups.

CONCLUSION

AD does not present a more aggressive clinical course in younger patients and it can be safely managed using the same strategy as in middle aged and older patients.

Recurrence and virulence of colonic diverticulitis in immunocompromised patients

BACKGROUND

To evaluate the probability of recurrence and the virulence of colonic diverticulitis correlated with immunocompromised status.

METHODS

Nine hundred thirty-one patients admitted in a single tertiary referral university hospital over a 14-year period were included. Patients were divided into 2 groups: group 1, 166 immunosuppressed patients, and group 2, 765 nonimmunosuppressed patients. The variables studied were sex, age, American Society of Anesthesiologist status, reasons of immunosuppression (eg, chronic use of corticosteroids, transplant recipients, and diseases affecting the immune system), severity of the diverticulitis episode, recurrence, emergency and elective surgery, and morbidity and mortality rates.

RESULTS

Two hundred thirteen patients underwent an emergency operation during the first hospitalization and 26 patients in further episodes. One hundred thirty-six patients developed 1 or more recurrent episodes of diverticulitis. The overall recurrence rate was similar in both groups. Patients in group 1 with a severe first episode presented significantly higher rates of recurrence and severity without needing more emergency surgery. Mortality after emergency surgery was 33.3% in group 1 and 15.9% in group 2 (P = .004).

CONCLUSIONS

After successful medical treatment of acute diverticulitis, patients with immunosuppression need not be advised to have an elective sigmoidectomy.

Abstract 3579: Prevalence And Distribution Of Asymptomatic Cervicocephalic Atherosclerosis In A Caucasian Population: Risk Factors And Biomarkers

Objective: To study clinical and biological factors associated with the different cervicocephalic location of atherosclerosis in Caucasian stroke-free individuals.

Methods: Carotid and intracranial atherosclerosis were assessed in the same lab by ECO-Doppler in a random sample population of 933 Caucasian subjects older than 50, with a moderate-high vascular risk and without history of stroke (64% males, mean age 66 years). Hypertension, dyslipemia, diabetes and smoking habit were defined based on clinical history and/or current medications. The following inflammatory and endothelial dysfunction biomarkers were determined at baseline and considered as continuous variables for the analyses: C-reactive protein (CRP), plasminogen activator inhibitor (PAI-1), resistin and asymmetric dimethylarginine (ADMA).

Results: Subjects were classified according to the cervicocephalic location of atherosclerotic lesions: 449 (48.1%) had no lesions (reference group), 404 (43.3%) had isolated carotid extracranial lesions (EC), 57 (6.1%) had isolated intracranial lesions (IC) and 23 (2.5%) had combined extra-intracranial lesions (C). After multinomial regression analyses, factors independently associated with each location of atherosclerosis compared to the reference group were: with EC, age (OR 1.06[1.04-1.09]p<0.001), male sex (OR 1.8[1.3-2.5]p=0.001), hypertension (OR 1.5[1.1-2]p=0.001), smoking (OR 1.7[1.2-2.4]p=0.004) and ADMA levels (1.7[1.05-2.9]p=0.03); with IC, age (OR 1.07[1.03-1.12]p<0.001), diabetes (OR 3.5[1.7-7.3]p=0.001) and ADMA levels (OR 3.2[1.3-8.1]p=0.01); with C, age (OR 1.2[1.05-1.2]p<0.001), male sex (OR 4.8[1.4-15.9]p<0.001), diabetes (OR 6.4[2.1-19.4]p=0.001), hypertension (OR 7.1[1.5-32.9]p=0.01) and resistin levels (OR 1.1[1.008-1.26]p=0.03).

Conclusions: Our findings show distinct clinical and biological signatures of the cervico-cephalic location of subclinical atherosclerosis.

Current status of the treatment of acute colonic diverticulitis: a systematic review

AIM

This paper addresses the current status of the treatment of acute colonic diverticulitis by an evidence-based review.

METHOD

A systematic search in PUBMED, MEDLINE, EMBASE and Google scholar on colonic diverticulitis was performed. Diagnostic tools, randomized controlled trials, non-randomized comparative studies, observational epidemiological studies, national and international guidelines, reviews of observational studies on elective and emergency surgical treatment of diverticulitis, and studies of prognostic significance were reviewed. Criteria for eligibility of the studies were diagnosis and classification, medical treatment, inpatients and outpatients, diverticulitis in young patients, immunosuppression, recurrence, elective resection, emergency surgery, and predictive factors.

RESULTS

Some 92 publications were selected for comprehensive review. The review highlighted that computed tomography is the most effective test in the diagnosis and staging of acute diverticulitis; outpatient treatment can be performed for uncomplicated diverticulitis in patients without associated comorbidities; conservative treatment is aimed at those patients with uncomplicated acute diverticulitis; elective surgery must be done on an individual basis; laparoscopic approach for elective treatment of diverticulitis is appropriate but may be technically complex; in perforated diverticulitis, resection with primary anastomosis is a safe procedure that requires experience and should take into account strict exclusion criteria.

CONCLUSION

The heterogeneity of patients with colonic diverticular disease means that both elective and urgent treatment should be tailored on an individual basis.

Differences between proximal and distal obstructing colonic cancer after curative surgery

AIM

To study any possible differences in morbidity, mortality and overall survival rate after curative surgery for obstructive colon cancer according to tumour location.

METHOD

From January 1994 to December 2006, patients with colonic cancer presenting as obstruction were analysed. The two groups were defined as proximal and distal according to the tumour location with respect to the splenic flexure. In relation to the surgeon specialization, patients were operated on by a colorectal surgeon and by a general surgeon. Postoperative morbidity and mortality and cancer-related survival at 3 years were analysed.

RESULTS

Of the 377 patients included in the study, there were 173 patients (45.9%) in the proximal group and 204 patients (54.1%) in the distal group. The global morbidity was 54.9% without differences in postoperative morbidity except for anastomotic leakage, which was higher in the proximal group (P < 0.014). No differences in postoperative mortality were observed. After patients were stratified by the tumour node metastasis system, the differences between the groups, with respect to 3-year overall survival, cancer-related survival and probability of being free from recurrence, did not reach statistical significance. The overall survival after radical surgery for colonic obstruction was 57.6%.

CONCLUSION

Mortality and morbidity after emergency surgery for obstructing colon cancer are high. Specialization in colorectal surgery influences postoperative results in terms of lower anastomotic dehiscence rate after emergency proximal colon resection. After radical surgery, tumour location does not appear to influence the prognosis of obstructive colon cancer.

Herniation of the gallbladder within a hernia of the abdominal wall associated with Mirizzi Syndrome

A gallbladder incarcerated hernia associated with Mirizzi syndrome is a very rare entity and to our knowledge this is the first case ever described in literature. An 85-year-old man presented at the emergency department with a tender right upper quadrant mass. Computed Tomography (CT) revealed the presence of a gallbladder lithiasis with signs of acute cholecystitis, herniated through the abdominal wall with an associated Mirizzi syndrome. Laparoscopic cholecystectomy and repair of the abdominal wall defect were performed. The patient recovered very well and the postoperative period was uneventful.

Adherence and satisfaction survey in outpatients on treatment with antipsychotics

Introduction

One of the problems of many studies and clinical trials is that don’t reflect the patient's opinion about the medication that they receive and their satisfaction.

Objetive and aims

The aim of this study was to assess the degree of outpatients satisfaction with antipsychotic treatment in four outpatients clinics in Mallorca. The adherence rates was estimated from information provided by the patients and their psychiatrists.

Methods

A cross.-sectional and descriptive study was conducted during one month, from May to June 2010, by administering several questionnaires to outpatients with psychotic disorders. It was designed a case report data which recorded the following variables: age, gender, diagnosis (schizophreniform, schizophrenia, schizoaffective disorder, delusional, psychotic disorder not otherwise specified), time since diagnosis, substance use, number of antipsychotic drugs, type of antipsychotic (oral and / or im), number of doses per day and number of tablets, via of administration (buttocks or deltoid). The psychometric instruments used were: the Morisky-Green test, Haynes-Sacket test, the MSQ (Medication Satisfaction Questionnaire) and CGI (Clinical Global Impression).

Results

The sample was of 92 patients with a mean age of 42.1 years (SD 12.2): 57.6% male and the most frequent diagnosis was schizophrenia in 65.2%. The duration of treatment from diagnosis was more than 5 years in 66.3%.

Conclusions

The patients on maintenance monotherapy with RLAI showed better adherence rates and more insight, evaluated by their psychiatrits.

78% of patients receiving antipsychotic medication injections were satisfied with the treatment.

Patients with RLAI administrating in deltoid were satisfied in 65.7%.

Maintenance of clinical benefit in Crohn's disease patients after discontinuation of infliximab: long-term follow-up of a single centre cohort

BACKGROUND

Tumour necrosis factor-blockade with infliximab has advanced the treatment of Crohn's disease. While infliximab is efficacious, it remains to be determined whether patients who enter clinical remission with an anti-tumour necrosis factor therapy can have their treatment stopped and retain the state of remission.

AIM

To assess in patients with Crohn's disease who obtained infliximab-induced remission, the proportion who relapsed after infliximab discontinuation.

METHODS

This longitudinal cohort study examined patients from a University-based IBD referral centre. Forty eight patients with Crohn's disease in full clinical remission and who then discontinued infliximab were followed up for up to 7 years. Crohn's disease relapse was defined as an intervention with Crohn's disease medication or surgery.

RESULTS

Kaplan-Meier analysis of the proportion of patients with sustained clinical benefit demonstrated that 50% relapsed within 477 days after infliximab discontinuance. In contrast, 35% of patients remained well, and without clinical relapse, up to the end of the nearly 7-year follow-up.

CONCLUSIONS

In patients with Crohn's disease with an infliximab-induced remission, stopping infliximab results in a predictable relapse in a majority of patients. Nevertheless, a small percentage of patients sustain a long-term remission.