Goodbye Hartmann trial: a prospective, international, multicenter, observational study on the current use of a surgical procedure developed a century ago

BACKGROUND

Literature suggests colonic resection and primary anastomosis (RPA) instead of Hartmann's procedure (HP) for the treatment of left-sided colonic emergencies. We aim to evaluate the surgical options globally used to treat patients with acute left-sided colonic emergencies and the factors that leading to the choice of treatment, comparing HP and RPA.

METHODS

This is a prospective, international, multicenter, observational study registered on ClinicalTrials.gov. A total 1215 patients with left-sided colonic emergencies who required surgery were included from 204 centers during the period of March 1, 2020, to May 31, 2020. with a 1-year follow-up.

RESULTS

564 patients (43.1%) were females. The mean age was 65.9 ± 15.6 years. HP was performed in 697 (57.3%) patients and RPA in 384 (31.6%) cases. Complicated acute diverticulitis was the most common cause of left-sided colonic emergencies (40.2%), followed by colorectal malignancy (36.6%). Severe complications (Clavien-Dindo ≥ 3b) were higher in the HP group (P < 0.001). 30-day mortality was higher in HP patients (13.7%), especially in case of bowel perforation and diffused peritonitis. 1-year follow-up showed no differences on ostomy reversal rate between HP and RPA. (P = 0.127). A backward likelihood logistic regression model showed that RPA was preferred in younger patients, having low ASA score (≤ 3), in case of large bowel obstruction, absence of colonic ischemia, longer time from admission to surgery, operating early at the day working hours, by a surgeon who performed more than 50 colorectal resections.

CONCLUSIONS

After 100 years since the first Hartmann's procedure, HP remains the most common treatment for left-sided colorectal emergencies. Treatment's choice depends on patient characteristics, the time of surgery and the experience of the surgeon. RPA should be considered as the gold standard for surgery, with HP being an exception.

The ChoCO-W prospective observational global study: Does COVID-19 increase gangrenous cholecystitis?

BACKGROUND

The incidence of the highly morbid and potentially lethal gangrenous cholecystitis was reportedly increased during the COVID-19 pandemic. The aim of the ChoCO-W study was to compare the clinical findings and outcomes of acute cholecystitis in patients who had COVID-19 disease with those who did not.

METHODS

Data were prospectively collected over 6 months (October 1, 2020, to April 30, 2021) with 1-month follow-up. In October 2020, Delta variant of SARS CoV-2 was isolated for the first time. Demographic and clinical data were analyzed and reported according to the STROBE guidelines. Baseline characteristics and clinical outcomes of patients who had COVID-19 were compared with those who did not.

RESULTS

A total of 2893 patients, from 42 countries, 218 centers, involved, with a median age of 61.3 (SD: 17.39) years were prospectively enrolled in this study; 1481 (51%) patients were males. One hundred and eighty (6.9%) patients were COVID-19 positive, while 2412 (93.1%) were negative. Concomitant preexisting diseases including cardiovascular diseases (p < 0.0001), diabetes (p < 0.0001), and severe chronic obstructive airway disease (p = 0.005) were significantly more frequent in the COVID-19 group. Markers of sepsis severity including ARDS (p < 0.0001), PIPAS score (p < 0.0001), WSES sepsis score (p < 0.0001), qSOFA (p < 0.0001), and Tokyo classification of severity of acute cholecystitis (p < 0.0001) were significantly higher in the COVID-19 group. The COVID-19 group had significantly higher postoperative complications (32.2% compared with 11.7%, p < 0.0001), longer mean hospital stay (13.21 compared with 6.51 days, p < 0.0001), and mortality rate (13.4% compared with 1.7%, p < 0.0001). The incidence of gangrenous cholecystitis was doubled in the COVID-19 group (40.7% compared with 22.3%). The mean wall thickness of the gallbladder was significantly higher in the COVID-19 group [6.32 (SD: 2.44) mm compared with 5.4 (SD: 3.45) mm; p < 0.0001].

CONCLUSIONS

The incidence of gangrenous cholecystitis is higher in COVID patients compared with non-COVID patients admitted to the emergency department with acute cholecystitis. Gangrenous cholecystitis in COVID patients is associated with high-grade Clavien-Dindo postoperative complications, longer hospital stay and higher mortality rate. The open cholecystectomy rate is higher in COVID compared with non -COVID patients. It is recommended to delay the surgical treatment in COVID patients, when it is possible, to decrease morbidity and mortality rates. COVID-19 infection and gangrenous cholecystistis are not absolute contraindications to perform laparoscopic cholecystectomy, in a case by case evaluation, in expert hands.

Effects of Bariatric Surgery on COVID-19: a Multicentric Study from a High Incidence Area

Introduction

The favorable effects of bariatric surgery (BS) on overall pulmonary function and obesity-related comorbidities could influence SARS-CoV-2 clinical expression. This has been investigated comparing COVID-19 incidence and clinical course between a cohort of patients submitted to BS and a cohort of candidates for BS during the spring outbreak in Italy.

Materials and Methods

From April to August 2020, 594 patients from 6 major bariatric centers in Emilia-Romagna were administered an 87-item telephonic questionnaire. Demographics, COVID-19 incidence, suggestive symptoms, and clinical outcome parameters of operated patients and candidates to BS were compared. The incidence of symptomatic COVID-19 was assessed including the clinical definition of probable case, according to World Health Organization criteria.

Results

Three hundred fifty-three operated patients (Op) and 169 candidates for BS (C) were finally included in the statistical analysis. While COVID-19 incidence confirmed by laboratory tests was similar in the two groups (5.7% vs 5.9%), lower incidence of most of COVID-19-related symptoms, such as anosmia (p: 0.046), dysgeusia (p: 0.049), fever with rapid onset (p: 0.046) were recorded among Op patients, resulting in a lower rate of probable cases (14.4% vs 23.7%; p: 0.009). Hospitalization was more frequent in C patients (2.4% vs 0.3%, p: 0.02). One death in each group was reported (0.3% vs 0.6%). Previous pneumonia and malignancies resulted to be associated with symptomatic COVID-19 at univariate and multivariate analysis.

Conclusion

Patients submitted to BS seem to develop less severe SARS-CoV-2 infection than subjects suffering from obesity.

Urgent and emergency surgery for secondary peritonitis during the COVID-19 outbreak: an unseen burden of a healthcare crisis

The COVID-19 pandemic has raised concerns about the negative impact of the fear of contagion on people’s willingness to seek medical care and the subsequent effects on patients’ prognosis. To date, not much is known about the outcomes of acute surgical diseases in this scenario. The aim of this multicenter observational study is to explore the effects of COVID-19 outbreak on the outcomes of patients who underwent surgery for peritonitis. Patients undergoing surgery for secondary peritonitis during the first COVID-19 surge in Italy (March 23–May 4, 2020—COVID period group) were compared with patients who underwent surgery during the same time interval of year 2019 (no-COVID period group). The primary endpoint was the development of postoperative complications. Logistic regression analysis was conducted to identify predictors of complications. Of the 332 patients studied, 149 were in the COVID period group and 183 were in the no-COVID period group. Patients in the COVID period group had an increased frequency of late presentations to the emergency departments (43% vs. 31.1%; P = 0.026) and a higher rate of postoperative complications (35.6% vs. 18%; P < 0.001). The same results were found in the subset analysis of patients with severe peritonitis at surgical exploration. The ASA score, severity of peritonitis, qSOFA score, diagnosis other than appendicitis, and COVID period resulted independent predictors of complications. During the COVID-19 pandemic patients with peritonitis had a higher rate of complicated postoperative courses, weighing on hospital costs and assistance efforts already pressured by the ongoing sanitary crisis.

Implementation of an Enhanced Recovery Program After Bariatric Surgery: clinical and cost-effectiveness analysis

Enhanced recovery after surgery (ERAS) programs are perioperative evidence-based interventions that have the purpose of making the perioperative pathway more efficient in safeguarding patient safety and quality of care. Recently, several ERAS components have been introduced in the setting of bariatric surgery (Enhanced Recovery After Bariatric Surgery, ERABS). The aim of the present study was to evaluate clinical efficiency and cost-effectiveness of the implementation of an ERABS program. It was a retrospective case-control study comparing a group of adult obese (body mass index >40) patients treated according to the ERABS protocol (2014-2015) with a historical control group that received standard care (2013-2014) in the General and Emergency Surgery Department, Arcispedale S. Maria Nuova Hospital, Reggio Emilia, Italy. Data on the occurrence of complications, mortality, re-admissions and re-operations were extracted retrospectively from medical case notes and emergency patient admission lists. Length of hospital stay was significantly different between the two cohort patients. In the control group, the mean length of stay was 12.6±10.9 days, whereas in the ERABS cohort it was 7.1±2.9 days (p=0.02). During hospital stay, seven patients in the control group developed surgical complications, including one patient with major complications, whereas in the ERABS group three patients developed minor complications. Economic analysis revealed a different cost distribution between the two groups. On the whole, there were significant savings for almost all the variables taken into consideration, mainly driven by exclusion of using intensive care unit, which is by far more expensive than the average cost of post-anesthesia care unit. Our study confirmed the implementation of an ERABS protocol to have shortened hospital stay and was cost-saving while safeguarding patient safety.

[OssERvare Project: direct observation of use of the Safety Surgery CheckList in the operating room.]

INTRODUCTION

Safety Surgery CheckList (SSCL) is a support tool for operating teams, used to carry out safety checks while also encouraging compliance with the implementation of recommended quality and safety standards. In Emilia-Romagna it was deemed appropriate to check actual surgical team compliance with correct checklist application in the operating theatre, through a project called "OssERvare".

METHODS

Direct observation was identified as the preferred inspection method. With the use of special report sheets, observers proceeded with the guided observation of behaviour in the operating room, recording any inconsistencies with correct SSCL use methods. The project began in January 2017 and all observations were carried out from 1st January-15th April 2017.

RESULTS

In 43% of observed operation sign in, all three team members were not present, whereas in 7% of observed cases, sign out was not carried out. All three team members were present in 88% of observed operation time out. There are two evidently critical phases: sign in and sign out. Results obtained for time out were better.

DISCUSSION AND CONCLUSION

Compliance data collected from observations differed markedly from reported compliance in administrative flow records. The results of the observational study indicate that the SSCL is not properly filled in many times; there is also a great possibility to improve the correct use of this tool. In conclusion, we think that the combined approach of use of administrative data and assessing compliance appeared to be a useful instrument to investigate the implementation and to promote the real utilization of safety tools such as the SSCL.

Effects on Clinical Outcomes of a 5-Year Surgical Safety Checklist Implementation Experience: A Large-scale Population-Based Difference-in-Differences Study

The adoption of a surgical checklist is strongly recommended worldwide as an effective practice to improve patient safety; however, several studies have reported mixed results and a number of issues are still unresolved. The main objective of this study was to explore the impact of the first 5-year period of a surgical checklist-based intervention in a large regional health care system in Italy (4 500 000 inhabitants). We conducted a retrospective longitudinal study on 1 166 424 patients who underwent surgery in 48 public hospitals between 2006 and 2014. The adherence to the checklist was measured between 2011 and 2013 through a computerized database. The effects of the intervention were explored through multivariable logistic regression and difference-in-differences (DID) approaches, based on current administrative data sources. In-hospital and 30-days mortality, 30-days readmissions and length-of-stay (LOS) ⩾8 days were the observed outcomes. Adherence to the checklist showed marked variations across hospitals (0%-93.3%). A pre/post analysis detected statistically significant differences between surgical interventions performed in hospitals with higher adherence to the checklist (⩾75% of the surgeries) and those performed in other hospitals, as for the 30-days readmissions rate (odds ratio [OR]: 0.96; 95% confidence interval [CI]: 0.94-0.98) and LOS ⩾ 8 days rate (OR: 0.88; 95% CI: 0.87-0.89). These findings were confirmed after risk adjustment and DID analysis. No association was observed with mortality outcomes. On the whole, our study attained mixed results. Although a protective effect of the surgical checklist use could not be proved over the first 5 years of this regional implementation experience, our research offers some methodological insights for practical use in the evaluation process of large-scale implementation projects.

Colonic perforation due to severe cytomegalovirus disease in granulomatosis with polyangiitis after immunosuppression

Granulomatosis with polyangiitis (GPA) is a small-vessel necrotizing granulomatous vasculitis typically involving upper airways, lungs, and kidneys, which may lead to end-organ damage and life-threatening complications. Major infections during GPA course represent a considerable concern in the management of the disease. Cytomegalovirus (CMV) infection and disease are rare but significant complications in the course of GPA being associated with high morbidity and mortality rates. Colonic perforation due to CMV colitis is exceedingly rare and has so far almost exclusively been documented in HIV, renal transplant, and systemic lupus erythematosus patients. We reported the case of a patient affected with upper airways-limited GPA who developed acute renal failure from rapidly progressive glomerulonephritis and then experienced colonic perforation due to CMV colitis a few weeks after immunosuppressive treatment with high-dose steroids and cyclophosphamide (CYC) for remission induction of the disease. We also reviewed the literature on CMV-related gastro-intestinal complications in the course of GPA and discussed contributing factors to severe manifestations of CMV infection and its reactivation.

A rare cause of mechanical bowel obstruction: ingested vinyl glove. Unexpected diagnosis at laparoscopy

The report suggests that, when the patient's history, clinical examination, and findings do not lead to a clear diagnosis in case of an acute abdomen, a laparoscopic approach, that has both, diagnostic and therapeutic value, is advised.

Laparoscopic treatment of acute small bowel obstruction due to left paraduodenal hernia: A case report and literature review

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Left paraduodenal hernia is a potentially severe cause of small bowel obstruction.

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Abdominal computed tomography scan is the standard for a correct diagnosis.

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Laparoscopy is feasible and effective, also in emergency situation.

Introduction

Internal hernia is a pathological condition resulting from abnormal protrusion of abdominal viscera through an opening in the intraperitoneal recesses of the abdominal cavity. Small bowel obstruction due to internal hernia is not common (0.25–0.9% of cases). The most common group is that of paraduodenal hernias (53%), of which the left-sided one is the most common type (75%).

Presentation of case

We report a case of a 43 year-old man with a history of recurrent abdominal pain, who was hospitalized because of an episode of acute small bowel obstruction. He had no previous surgery. Computed tomography revealed an encapsulated circumscribed cluster of jejunal loops in the left upper quadrant, near the ligament of Treitz, and the hernia orifice was adjacent to the left side of the inferior mesenteric vessels. Emergency laparoscopic surgery was performed: the small bowel was found completely herniated under the inferior mesenteric vessels. It was gradually reduced and the hernia space was closed with a running suture. The patient was discharged on the fourth day without complications.

Conclusion

Left paraduodenal hernia is a rare cause of small bowel obstruction that should be taken into account in a patient with a history of recurrent abdominal pain or intestinal obstruction, and no previous surgery. Computed tomography is the standard for a correct diagnosis. Surgery is treatment of choice, because it reduces the risk of emergency and complications associated to hernia. Laparoscopic approach is feasible and effective, also in emergency situation.

Total gastrectomy for rare refractory gastroparesis in patient with syringomyelia: A good impact on quality of life

Syringomyelia is a chronic progressive disease of the spinal cord. In symptomatic patients, bilateral sensory motor signs and symptoms prevail, moreover they can develop gastrointestinal disorders, although few studies have succeeded in explaining this correlation so far.

We report a case of a 67-year-old woman with a history of pain in the back-lumbar spine and lower limbs, paresthesia and urinary incontinence. MRI revealed syringomyelia, extended from T3 to the medullary cone. Neurological picture was worsened by progressive and increasingly debilitating gastrointestinal symptoms refractory to dietary changes and medical treatment. Blood tests, gastrointestinal investigations and imaging were all normal apart from scintigraphy which confirmed delayed gastric emptying. The neurological symptoms disappeared after removal of an hemangioblastoma of the medullary cone. The persistent gastroparesis was treated by total gastrectomy with complete resolution of the patient's gastrointestinal symptoms.

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Syringomyelia is a spinal disorder rarely associated with gastrointestinal dysfunction.

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We present a case of refractory gastroparesis in a female patient with syringomyelia.

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Surgery may be indicated if dietary changes and medical management fails.

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We performed a total gastrectomy with improvement in the patient's quality of life.

Laparoscopic removal of gastric band after laparoscopic gastric bypass and following placement of adjustable gastric band

Banded gastric bypass is a bariatric surgical intervention that has been regularly performed in many centers. According to some series, banded gastric bypass is safe and feasible. We describe the case of a 42-year-old woman undergoing laparoscopic gastric bypass in 2008. Subsequently, she underwent surgery in order to place adjustable gastric banding on previous bypass because of gastric pouch dilatation. Five months later, patient showed anorexia and signs of malnutrition. For this reason, she underwent laparoscopic removal of gastric banding. In our opinion, placing a device to restrict an already dilated gastric pouch must be avoided.

Subcapsular Hepatic Hematoma After Endoscopic Retrograde Cholangiopancreatography: A Case Report and Review of Literature

Endoscopic retrograde cholangiopancreatography (ERCP) is one of the most frequently performed procedures for the diagnosis and treatment of biliary-pancreatic diseases. ERCP-related complications total around 2.5% to 8%, with a mortality rate ranging from 0.5% to 1%. An exceptional ERCP complication is subcapsular hepatic hematoma, and few cases are reported worldwide.We present the case of a 52-year-old woman with a history of recurring upper abdominal pain and a clinical and ultrasonographic diagnosis of obstructive jaundice due to common bile duct stones. After 2 difficult endoscopic biliary procedures, common bile duct stones clearance was obtained. Post-ERCP course was symptomatic with upper abdominal pain and anemization with hemodynamic instability.CT scan demonstrated a 15 cm × 11 cm subcapsular hepatic hematoma filled with air and liquid on the surface of the right hepatic lobe. The patient was successfully treated with the embolization of a small branch of right hepatic artery angiographically identified as the cause of bleeding.Subcapsular hepatic hematoma after ERCP is a rare complication that must be taken into account in the differential diagnosis of symptomatic cases after ERCP. Its diagnosis is based on clinical and laboratory data and especially on imaging (ultrasound, CT, or MRI). Treatment is often conservative but, in some cases, embolization or percutaneous drainage or surgery may be necessary.

Prognostic evaluation of stage B colon cancer patients is improved by an adequate lymphadenectomy: results of a secondary analysis of a large scale adjuvant trial

OBJECTIVE

To determine if the extent of lymphadenectomy (number of recovered lymph nodes) was associated with long-term outcome in patients operated on for stage B and C colon cancer.

SUMMARY BACKGROUND DATA

Lymphatic spreading is the main prognostic indicator in colon cancer patients, although the optimal extent of lymphadenectomy and its prognostic impact are still unknown.

METHODS

In 3,648 patients (median follow-up 3.6 years) enrolled in two consecutive INTACC multicentric trials on adjuvant therapy for colon cancer, we studied the association of the number of recovered nodes with overall survival and relapse free survival by means of univariate and Cox regression analysis.

RESULTS

The worst overall survival was related to ages > 65 (risk ratio [RR] = 1.30), higher grading (RR = 1.96). Better overall survival was related to female gender (RR = 0.80) and to higher number of recovered nodes (8-12 nodes, RR = 0.46, 13-17 nodes, RR = 0.76, nodes > or = 18, RR = 0.79). The same pattern was observed for relapse free survival. Longer overall and relapse free survival were related to a higher number of recovered nodes with P =.034 and P =.003 respectively (stratified analysis for absence or presence of positive nodes). Stage B patients with fewer than 7 nodes in the specimen had both shorter overall survival (P =.0000) and relapse free survival (P =.0016) than the other B patients. Outcome of stage C patients was not related to the number of recovered nodes (P =.28 and 0.12 respectively). The interaction test between stage of disease and number of recovered nodes was statistically significant (P =.017).

CONCLUSIONS

Stage B patients with a small number of examined nodes may be understaged. Thus, these patients might be considered for adjuvant therapy because of their poorer life expectancy than other stage B patients. For stage C patients, the number of recovered nodes does not seem to affect long-term outcome.

Ischaemic necrotizing pancreatitis after cardiac surgery. A case report and review of the literature

Ischaemia is a rare but often lethal aetiology of pancreatitis. A 67-year-old man underwent aortocoronary by-pass. Postoperatively, he developed atrial fibrillation and possibly acute myocardial infarction. Later, he had acute pancreatitis and underwent laparotomy for purulent peritonitis due to a ruptured pancreatic abscess. Cholesterolosis was found but no gallstones. The postoperative period was heavily complicated and the patient eventually died due to multiorgan failure. The occurrence of ischaemic pancreatitis should be more readily suspected in patients with abdominal symptoms following surgery that induces ischaemia of the pancreas. It is possible that delay in diagnosis accounts for the high death rate of such postoperative complication.

Laparoscopic surgery for colorectal cancer

Despite the widespread use of laparoscopic techniques in many fields, in the realm of malignant diseases, a great concern has been raised regarding safety, efficacy, and long-term results. The authors report their experience of 163 patients operated on for colorectal malignancies by minimally invasive access. The conversion rate (20.4%), morbidity (15.1%), and null mortality compare well with other studies published worldwide. The postoperative outcome was characterized by a prompt return to activity (1.3 days) and of bowel movements (2.9 days), while length of stay and an adequate oral resumption were comparable to those of open surgery. Peritoneal lavage did not show tumor cells disseminated during the operative maneuvers. The distance of tumor from resection margins and the number of lymph nodes harvested with the operative specimen did not vary from those obtained in open surgery. Two patients (1.2%) recurred at the mini-laparotomy and port sites, but, in both cases, the traumatic manipulation of the cancer specimen was probably responsible for the event. After a mean follow-up of over 3 years, 34 patients died of neoplastic recurrence, and 17 are alive with disease relapse. The laparoscopic approach to colectomy has not yet gained an unquestioned place in the experience of the colorectal surgeon. However, if sound surgical method and judgement are used to minimize local recurrences, and if a better preservation of postoperative immune function proves to be of clinical significance in the long term, laparoscopic colectomy may prove to be a safe and less stressful approach to colon resection.

A difficult early diagnosis of pancreatic body neoplasia

The Authors report the case of a 60-year-old man, V.A., a smoker with type II diabetes and cholelithiasis. One month after the onset of symptoms in March 1995, his clinical picture led us to suspect a pancreatic adenocarcinoma. Only 110 days after the initial discovery of a high CA 19-9, following the failure of numerous techniques and the solution of various problems of differential diagnosis, the first unclear X-ray image of a suspected pancreatic neoplasia was obtained. A new computed tomography scan and a further increase in CA 19-9 later confirmed the diagnosis. Duodenopancreatectomy with splenectomy for adenocarcinoma was performed. The thread connecting 150 days of clinical history is CA 19-9, which acted as an ideal marker. It enabled a clinical "rarity" (pancreatic neoplasia in its initial stages) to be diagnosed and it increased as the neoplasia developed. After surgical removal of the tumor, the marker is now returning to normal levels and will be used to monitor the post-operative phase, when any increase in level could mean a recrudescence of the disease.

[Gallbladder and common bile duct calculi: treatment with laparoscopy vs laparotomy. Costs and benefits]

The cost-benefit ratio of laparoscopy vs laparotomy was evaluated comparing 2 groups of patients: 500 operated using traditional laparotomy and 500 operated via laparoscopy. The first parameter considered was the average hospital stay, which was 8.4 days (min. 3, max. 22 days) in group I (laparotomy) (Fig. 1) against 4 days (min. 2, max. 13 days) in group II (laparoscopy). Even more interesting were the results related to the average postoperative hospital stay: 5 days for laparotomy, 2 days for laparoscopy. Currently, 90% of patients submitted to laparoscopic cholecystectomy is discharged in the first postoperative day. The cost of the surgical procedure is 1,100,000 It. Lit. for laparotomic cholecystectomy and 2,130,000 It. Lit. for laparoscopic cholecystectomy. However, considering the cost of the daily hospital stay and adding the cost of the surgical procedure we already save 50% with the laparoscopic method. Furthermore, if we consider the time occurring between patients' discharge and return to work a 50% reduction of the postoperative recovery time is obtained. The conclusions of the Authors are the following: Laparoscopic cholecystectomy performed by skilled surgeons presents an incidence of complications comparable to traditional cholecystectomy. The operating time is almost the same for both methods. Operative costs are higher for the laparoscopic technique. Postoperative hospital stay is drastically reduced with the laparoscopic procedure. Return to work is assured in a shorter time after laparoscopy.