Intestinal Helminths Infections as Infrequent Cause of Emergency Abdominal Surgery: A Retrospective Study in a University Hospital over 20 Years.

INTRODUCTION: All organs of any organism can be affected by helminths. They can be seen in a broad spectrum, from simple infestations to extensive, life-threatening involvement. Symptomatology is usually of chronic latent course. However, sometimes the presentation is acute and requires urgent surgical intervention. MATERIAL AND METHODS: We conducted a retrospective observational prospective recruitment study of patients undergoing emergency surgery for helminth infection from January 2000 to December 2019 at a university hospital. Sociodemographic and analytical variables, variables related to the clinical process, and the diagnostic test were analysed. Variables related to the surgical procedure and postoperative complications were also analysed. RESULTS: A total of 36 patients required emergency surgery for their helminth infection, which represented 0.26% of emergency abdominal surgeries. The mean age was 34.91 ± 21.5 years, with a predominance of men (69.4%). Most patients presented with pain in the right iliac fossa (69.4%), followed by symptoms compatible with intestinal obstruction (19.4%). The most frequent surgical interventions were appendectomy (38.9%) followed bowel resection (33.3%) and ileocecal resection (11.1%). Enterobious vermicularis and Anisakis simplex both together accounted for 75% of the sample. Statistically significant differences were identified in age (p < 0.001), diagnostic test performed (p = 0.032), intraoperative clinical diagnosis (p = 0.005) and surgical treatment received (p < 0.001). CONCLUSION: The frequency of emergency surgeries for intestinal helminth parasitism is decreasing. However, the majority of these are E. vermicularis and Anisakis simplex, which have distinctly different clinical presentations. Identification and recognition by physicians continue to be necessary for further postoperative management and possible complications.

Outcomes of initially nonoperative management of diverticulitis with abscess formation in immunosuppressed patients. DIPLICAB study COLLABORATIVE group.

AIM: Management of diverticulitis with abscess formation in immunosuppressed patients (IMS) remains unclear. The main objective of the study was to assess short- and long-term outcomes between IMS and immunocompetent patients (IC). The secondary aim was to identify risk factors for emergency surgery. METHODS: A nationwide retrospective cohort study was performed at 29 Spanish referral centres between 2015-2019 including consecutive patients with first episode of diverticulitis classified as modified Hinchey Ib or II. IMS included immunosuppressive therapy, biologic therapy, malignant neoplasm with active chemotherapy and chronic steroid therapy. A multivariate analysis was performed to identify independent risk factors to emergency surgery in IMS. RESULTS: A total of 1395 patients were included; 118 IMS and 1277 IC. There were no significant differences in emergency surgery between IMS and IC (19.5% and 13.5%, p = 0.075) but IMS was associated with higher mortality (15.1% vs. 0.6%, p < 0.001). Similar recurrent episodes were found between IMS and IC (28% vs. 28.2%, p = 0.963). Following multivariate analysis, immunosuppressive treatment, p = 0.002; OR: 3.35 (1.57-7.15), free gas bubbles, p < 0.001; OR: 2.91 (2.01-4.21), Hinchey II, p = 0.002; OR: 1.88 (1.26-2.83), use of morphine, p < 0.001; OR: 3.08 (1.98-4.80), abscess size ≥5 cm, p = 0.001; OR: 1.97 (1.33-2.93) and leucocytosis at third day, p < 0.001; OR: 1.001 (1.001-1.002) were independently associated with emergency surgery in IMS. CONCLUSION: Nonoperative management in IMS has been shown to be safe with similar treatment failure than IC. IMS presented higher mortality in emergency surgery and similar rate of recurrent diverticulitis than IC. Identifying risk factors to emergency surgery may anticipate emergency surgery.

Fournier's gangrene and fecal diversion. When, in which patients, and what type should I perform?

INTRODUCTION: Fournier's gangrene (FG) is a necrotizing fasciitis affecting the perineum and urogenital tissue. The mortality rate is high although early detection and aggressive debridement can reduce mortality by up to 16%. The prevalence of sequelae is very high and a colostomy is often necessary to control the perineal wound. MATERIAL AND METHODS: A retrospective study was carried out to recruit all patients operated on by the General Surgery and Urology Departments with a diagnosis of GF at the University Hospital over 22 years. Mortality, the Fournier gangrene severity index (FGSI), and fecal diversion (either surgical (colostomy) or straight (Flexi-seal)) are collected. RESULTS: A total of 149 patients met the inclusion criteria. FG's most frequent cause was a perianal abscess (107 patients-72%). Eighteen patients (12%) died of a specific cause of FG. Age (p = 0.014) and patients with an oncological history (p = 0.038) both were the only mortality risk factors for mortality according to logistic regression. Fifty patients required some form of fecal diversion in the postoperative period (32 colostomies and 18 Flexi-seal). Neither the use of postoperative fecal diversion (surgical or Flexi-seal) nor the timing of its use had any effect on postoperative mortality. CONCLUSIONS: One in eight patients died in the immediate postoperative period secondary to FG. Despite improved outcomes, 22% required a colostomy during admission. However, neither the performance of a colostomy nor the timing was associated with decreased FG-associated mortality. Non-invasive methods should be used first and surgical bowel diversion should be postponed as long as possible.

Anastomotic leak in colorectal cancer surgery: Contribution of gut microbiota and prediction approaches.

AIM: To monitor prospectively the occurrence of colorectal anastomotic leakage (CAL) in patients with colon cancer undergoing resectional surgery, characterizing the microbiota in both faeces and mucosal biopsies of anastomosis. In a second stage, we investigated the ability to predict CAL using machine learning models based on clinical data and microbiota composition. METHOD: A total of 111 patients were included, from whom a faecal sample was obtained, as well as biopsy samples from proximal and distal sites in the healthy margins of the tumour piece. The microorganisms present in the samples were investigated using microbial culture and 16S rDNA massive sequencing. Collagenase and protease production was determined, as well as the presence of genes responsible for expressing enzymes with these activities. Machine learning analyses were developed using clinical and microbiological data. RESULTS: The incidence of CAL was 9.0%, and CAL was associated with collagenase/protease-producing Enterococcus. Significant differences were found in the microbiota composition of proximal and distal biopsy samples, but not in faecal samples, among patients who developed CAL. Clinical predictors of CAL were 5-day C-reactive protein and heart disease, whereas 3-day C-reactive protein and diabetes were negative predictors. CONCLUSION: Biopsy samples from surgical margins, rather than faecal samples, are the most appropriate samples for exploring the contribution of the intestinal microbiota to CAL. Enterococci are only enriched in the anastomosis after surgery, and their collagenases and proteases are involved in the degradation of the anastomotic scar.

Diverticulitis with abscess formation: Outcomes of non-operative management and nomogram for predicting emergency surgery: The Diplicab Study Collaborative Group.

BACKGROUND: To assess short- and long-term outcomes from non-surgical management of diverticulitis with abscess formation and to develop a nomogram to predict emergency surgery. METHODS: This nationwide retrospective cohort study was performed in 29 Spanish referral centers, including patients with a first episode of a diverticular abscess (modified Hinchey Ib-II) from 2015 to 2019. Emergency surgery, complications, and recurrent episodes were analyzed. Regression analysis was used to assess risk factors, and a nomogram for emergency surgery was designed. RESULTS: Overall, 1,395 patients were included (1,078 Hinchey Ib and 317 Hinchey II). Most (1,184, 84.9%) patients were treated with antibiotics without percutaneous drainage, and 194 (13.90%) patients required emergency surgery during admission. Percutaneous drainage (208 patients) was associated with a lower risk of emergency surgery in patients with abscesses of ≥5 cm (19.9% vs 29.3%, P = .035; odds ratio 0.59 [0.37-0.96]). The multivariate analysis showed that immunosuppression treatment, C-reactive protein (odds ratio: 1.003; 1.001-1.005), free pneumoperitoneum (odds ratio: 3.01; 2.04-4.44), Hinchey II (odds ratio: 2.15; 1.42-3.26), abscess size 3 to 4.9 cm (odds ratio: 1.87; 1.06-3.29), abscess size ≥5 cm (odds ratio: 3.62; 2.08-6.32), and use of morphine (odds ratio: 3.68; 2.29-5.92) were associated with emergency surgery. A nomogram was developed with an area under the receiver operating characteristic curve of 0.81 (95% confidence interval: 0.77-0.85). CONCLUSION: Percutaneous drainage must be considered in abscesses ≥5 cm to reduce emergency surgery rates; however, there are insufficient data to recommend it in smaller abscesses. The use of the nomogram could help the surgeon develop a targeted approach.

Quality of life and outcomes after rubber band ligation for haemorrhoidal disease.

PURPOSE: The main objective of this study was to assess the impact on quality of life after rubber band ligation (RBL) in patients with symptomatic grade II-III haemorrhoids who did not improve after 6 months of conservative treatment, using quality of life scores. METHODS: This was a prospective cohort observational study where patients with haemorrhoidal disease and indication for RBL were included between December 2019 and December 2020. RBL was offered as first-line treatment in this group. Patient´s quality of life was assessed by scores: HDSS (Hemorrhoidal Disease Symptom Score) and SHS (Short Health Scale).Secondary objectives were: to evaluate the rate of patients requiring one or more RBL procedures, to establish the overall success rate of RBL and to analyse complications. RESULTS: A total of 100 patients were finally included. Regarding the impact on quality of life after RBL, a significant reduction was found in the HDSS and SHS scores (p < 0.001). The main improvement was found in the first month and it was maintained until the sixth month. A high degree of satisfaction with the procedure was reported by 76% of patients. The overall success rate of banding was 89%. A 12% complication rate was detected, the most frequent complication was severe anal pain (58.3%) and self-limiting bleeding (41.7%). CONCLUSION: Rubber band ligation, as a treatment for symptomatic grade II-III haemorrhoids that do not respond to medical treatment, leads to a significant improvement in patients' symptoms and quality of life. It also has a high degree of satisfaction between patients.

Colorectal cancer: comparative analysis between two series of patients separated by more than three decades

Abstract Aim This study characterizes Colorectal Cancer (CRC) incidence in the University Hospital Ramon and Cajal, Madrid, and analyzes variations over time. It establishes risk groups, aiming to discover whether diagnosis can be determined in less advanced stages of disease. Method Evolutionary epidemiological study of genetic and environmental factors contributing to the development of CRC in this district that enables the comparison of two cohorts of patients separated by 37 years: G1 (patients of current group) and G2 (patients of historical group). The main risk variables gleaned retrospectively were analyzed and the statistical association between cohorts was determined. Results The mean age of patients increased significantly from 64 to 71 along with the incidence of ascending colon cancer. G1 scored higher than G2 for: the incidence of colon cancer in men, detection of adenomatous polyps (48.1%), percentage of resectability with curative intent (80.4%), and Dukes A stage (34.1%) (p < 0.001). Conclusion Biological aspects of CRC have been compared against its profile three decades earlier. We can confirm the existence of concrete changes in the manifestation and staging at the time of diagnosis or following earlier treatment. (AU)

An Immunologic Compatibility Testing Was Not Useful for Donor Selection in Fecal Microbiota Transplantation for Ulcerative Colitis.

Fecal microbiota transplantation (FMT) is an effective procedure against Clostridioides difficile infection (CDI), with promising but still suboptimal performance in other diseases, such as ulcerative colitis (UC). The recipient's mucosal immune response against the donor's microbiota could be relevant factor in the effectiveness of FMT. Our aim was to design and validate an individualized immune-based test to optimize the fecal donor selection for FMT. First, we performed an in vitro validation of the test by co-culturing lymphocytes obtained from the small intestine mucosa of organ donor cadavers (n=7) and microbe-associated molecular patterns (MAMPs) obtained from the feces of 19 healthy donors. The inflammatory response was determined by interleukin supernatant quantification using the Cytometric Bead Array kit (B&D). We then conducted a clinical pilot study with 4 patients with UC using immunocompetent cells extracted from rectal biopsies and MAMPs from 3 donor candidates. We employed the test results to guide donor selection for FMT, which was performed by colonoscopy followed by 4 booster instillations by enema in the following month. The microbiome engraftment was assessed by 16S rDNA massive sequencing in feces, and the patients were clinically followed-up for 16 weeks. The results demonstrated that IL-6, IL-8, and IL-1ß were the most variable markers, although we observed a general tolerance to the microbial insults. Clinical and colonoscopy remission of the patients with UC was not achieved after 16 weeks, although FMT provoked enrichment of the Bacteroidota phylum and Prevotella genus, with a decrease in the Actinobacteriota phylum and Agathobacter genus. The most relevant result was the lack of Akkermansia engraftment in UC. In summary, the clinical success of FMT in patients with UC appears not to be influenced by donor selection based on the explored recipient's local immunological response to FMT, suggesting that this approach would not be valid for FMT fecal donor optimization in such patients.

Surgical Wound Complications after Colorectal Surgery with Single-Use Negative-Pressure Wound Therapy Versus Surgical Dressing over Closed Incisions: A Randomized Controlled Trial.

BACKGROUND: Global studies indicate that surgical site infections (SSIs) are a major healthcare challenge within hospitals and can have a profound impact on patient quality of life and healthcare costs. Closed-incision negative-pressure therapy (ciNPT) has been reported to provide positive clinical benefits for patients with various incisions, including those following colorectal surgeries. METHODS: Investigators performed a prospective, randomized, multicenter trial to evaluate complications of surgical incisions in patients who received a ciNPT dressing versus a conventional surgical dressing (control) over their closed incision following colorectal surgery. The incidence of SSI was determined at 7, 15, and 30 days postsurgery. RESULTS: A total of 148 patients participated in the study. Results showed that the SSI rate on day 7 was lower in the ciNPT group versus the control group (10/75 [13.3%] vs 17/73 [23.3%]), but this difference was not statistically significant. On day 15, the SSI rate was 12/75 (16.0%) in the ciNPT group versus 21/73 (28.8%) in the control group; however, this difference was only marginally statistically significant (P = .0621). At 1 month, the SSI rate remained lower in the ciNPT group (13/75 [17.3%] vs 21/73 [28.8%], P = .0983) compared with the control group. CONCLUSIONS: Future studies with larger population sizes are necessary to determine the impact of ciNPT on patients' incisions after colorectal surgery.

Watch and wait approach in rectal cancer: Current controversies and future directions.

According to the main international clinical guidelines, the recommended treatment for locally-advanced rectal cancer is neoadjuvant chemoradiotherapy followed by surgery. However, doubts have been raised about the appropriate definition of clinical complete response (cCR) after neoadjuvant therapy and the role of surgery in patients who achieve a cCR. Surgical resection is associated with significant morbidity and decreased quality of life (QoL), which is especially relevant given the favourable prognosis in this patient subset. Accordingly, there has been a growing interest in alternative approaches with less morbidity, including the organ-preserving watch and wait strategy, in which surgery is omitted in patients who have achieved a cCR. These patients are managed with a specific follow-up protocol to ensure adequate cancer control, including the early identification of recurrent disease. However, there are several open questions about this strategy, including patient selection, the clinical and radiological criteria to accurately determine cCR, the duration of neoadjuvant treatment, the role of dose intensification (chemotherapy and/or radiotherapy), optimal follow-up protocols, and the future perspectives of this approach. In the present review, we summarize the available evidence on the watch and wait strategy in this clinical scenario, including ongoing clinical trials, QoL in these patients, and the controversies surrounding this treatment approach.

Medullary colorectal carcinoma. Do we really know it?

Medullary carcinoma (MC) is a recently described subtype of mismatch repair deficient (MMRd) colorectal carcinoma (CRC) which, despite being poorly differentiated by traditional morphological criteria, has been reported to have a good prognosis. By the moment, there is a handful reports about its clinical and pathological features, without agreement between results obtained.

Role of negative pressure wound therapy in the prevention of surgical site infection in colorectal surgery. / Papel de la terapia presión negativa en la prevención de infección del sitio quirúrgico en cirugía colorrectal.

BACKGROUND: Surgical site infection (SSI) is one of the most frequent complications in colorectal surgery. It is diagnosed in 10 - 20% of colorectal procedures. Negative Pressure Wound Therapy (NPWT) has shown efficacy in the treatment of chronic and traumatic wounds, wound dehiscence, flaps and grafts. The main objective of this study is to assess NPWT in the prevention of SSI in colorectal surgery. Hospital stay reduction and SSI risk factors are secondary objectives. METHODS: We present a prospective case-control study including 80 patients after a colorectal diagnosis and surgical procedure (elective and non-elective) in 2017. Forty patients were treated with prevention NPWT for one week. Forty patients were treated according to the standard postoperative surgical wound care protocol. RESULTS: No significant differences were found in demographic variables, comorbidities, surgical approach, elective or non-elective surgery, mechanical bowel preparation and surgical procedure. Three patients has SSI in the NPWT group (8%) (95%CI 0 - 17.5). Ten patients presented SSI in the control group (25%) (95%CI 12.5 - 37.5) (p=0.034); OR 0.7 (95%CI 0.006-0.964). Hospital stay in the NPWT group was 8 days versus 12 days in the non-NPWT group (p=0.22). In the multivariate analysis, mechanical bowel preparation was found to be the only risk factor for SSI (p=0.047; OR: 0.8, CI 0.45-0.93). CONCLUSIONS: NPWT is a useful SSI prevention treatment in colorectal surgery.

Spontaneous liver rupture secondary to distal right hepatic artery microaneurysms in a patient admitted due to Staphylococcus aureus pneumonia.

Spontaneous liver rupture is an uncommon and life-threatening condition often associated with high mortality rate. The most common causes are preeclampsia and HELLP syndrome during pregnancy, liver tumours and overdosing of anticoagulant therapy, however, hepatic rupture in the absence of underlying pathology is an extremely rare occurrence. Treatment can include observation, embolization, hepatic artery ligation, hepatic lobectomy, hematoma evacuation and packing, and even liver transplantation has been described.

The long-term recurrence rate and survival of obstructive left-sided colon cancer patients: a stent as a bridge to surgery.

BACKGROUND: a colonic stent as a bridge to elective surgery for left-sided malignant colonic obstruction is an alternative to the classical treatment. The aim of our study was to evaluate the recurrence rate as well as the morbidity and mortality of this treatment. PATIENTS AND METHODS: patients admitted to the Emergency Department with left-sided malignant colonic obstruction between June 2006 and January 2014 were analyzed in a retrospective observational study. Patients who underwent self-expanding metallic stent placement via endoscopy as a bridge to surgery were included. The observation period was performed until May 2017. RESULTS: fifty-three patients were treated with a colonic stent as a bridge to surgery; nine patients died during the postoperative period. The deceased patients were more frequently male (100% in the deceased vs 62% in the non-deceased, p = 0.02), with a more advanced age (81.4 ± 5.1 vs 71.6 ± 10.8, p < 0.001), lower hemoglobin levels on admission (12.9 vs 13.6 p < 0.001), a greater number of leukocytes (12,918 vs 9,437, p < 0.001) and greater coagulopathy (INR 1.6 vs 1, p < 0.001). Eight patients had a distant relapse with a median disease-free survival of 19.1 months. The variables were compared according to the appearance of distant disease and the mean age was lower in patients with a recurrence (65.9 ± 11.3 vs 74.9 ± 9.9, p < 0.001). CONCLUSIONS: the results of the use of a stent as a bridge to curative surgery in patients with obstructive left colon cancer in our hospital is comparable to previous studies.

Superior mesenteric artery syndrome: an uncommon cause of intestinal obstruction.

Superior mesenteric artery syndrome, also Wilkie's syndrome, is an uncommon cause of upper intestinal obstruction. It includes compression of the third duodenal portion by the aorta and the overlying superior mesenteric artery when the angle formed by these two structures becomes smaller. It may result from significant weight loss or abdominal trauma, or may have a congenital origin. Treatment for most cases is conservative.

Previous Exposure to the Fish Parasite Anisakis as a Potential Risk Factor for Gastric or Colon Adenocarcinoma.

Anisakiasis is a global disease caused by consumption of raw or lightly cooked fish contaminated with L3 Anisakis spp. larvae. High rates of parasitization of fish worldwide make Anisakis a serious health hazard. In fact, anisakiasis is a growing disease in countries such as Spain, Italy, and Japan, where consumption of raw/marinated fish is high. Some parasitic infections have been recognized as a causative factor for human cancer. Suggested mechanisms include chronic inflammation elicited by the parasite, and a possible tumorigenic effect from certain parasitic secretions. Anisakis can produce persistent local inflammation and granuloma, and larvae have been incidentally found in gastrointestinal (GI) tumors. Our aim was to discover possible differences in the prevalence of unnoticed or asymptomatic previous Anisakis infection in GI cancer patients compared with healthy individuals. Serum levels of specific antibodies against Anisakis antigens were used as a reliable marker of previous contact with their larvae. Ninety-four participants without a previous history of Anisakis infection were prospectively allocated into 1 of 2 groups: 47 patients with GI cancer and 47 controls. Specific IgE, IgA1, and IgG1 against the Anisakis recombinant antigens Ani s 1, Ani s 5, Ani s 9, and Ani s 10 were determined by an ELISA assay. The ratio of positivity to sIgA1, rAni s 1, or rAni s 5 was significantly higher in the cancer patients than in the controls (38.30% vs 6.38%, P < 0.001) and (42.55% vs 10.64%, P < 0.001, respectively). When disaggregated by type of tumor, the patients with gastric cancer showed a higher proportion of positive results for sIgA1 to rAni s 1 (P < 0.001), whereas a higher proportion of colon cancer patients were shown to be positive for sIgA1 to both rAni s 1 (P < 0.05) and rAni s 5 (P < 0.01). Earlier Anisakis infection might be a risk factor for the development of stomach or colon cancer.