Cost saving in implementing ERAS protocol in emergency abdominal surgery.

INTRODUCTION: ERAS (Enhanced Recovery After Surgery) protocol is now proposed as the standard of care in elective major abdominal surgery. Implementation of the ERAS protocol in emergency setting has been proposed but his economic impact has not been investigated. Aim of this study was to evaluate the cost saving of implementing ERAS in abdominal emergency surgery in a single institution. METHODS: A group of 80 consecutive patients treated by ERAS protocol for gastrointestinal emergency surgery in 2021 was compared with an analogue group of 75 consecutive patients treated by the same surgery the year before implementation of ERAS protocol. Adhesion to postoperative items, length of stay, morbidity and mortality were recorded. Cost saving analysis was performed. RESULTS: 50% Adhesion to postoperative items was reached on day 2 in the ERAS group in mean. Laparoscopic approach was 40 vs 12% in ERAS and control group respectively (p ,002). Length of stay was shorter in ERAS group by 3 days (9 vs 12 days p ,002). Morbidity and mortality rate were similar in both groups. The ERAS group had a mean cost saving of 1022,78 € per patient. CONCLUSIONS: ERAS protocol implementation in the abdominal emergency setting is cost effective resulting in a significant shorter length of stay and cost saving per patient.

Pancreatic fistula: interventional radiological treatment by collection. Jejunal loop internal drainage.

Pancreaticoduodenectomy is a major surgical procedure associated with various and important complications, often difficult to be managed. Pancreatic fistula is due to leakage of pancreatic juice in the abdominal cavity and is the main and most frequent complication after pancreatic surgery. The treatment of pancreatic fistula may change according to degree. Interventional radiology (IR) can offer powerful minimally invasive alternatives in managing pancreatic fistulas. We report the case of a patient affected by ampullar adenocarcinoma who underwent pancreaticoduodenectomy. Surgery was complicated by high-flow pancreatic fistula treated conservatively with CT guided percutaneous transhepatic drainage. Due to persistent leak of pancreatic fluid the abdominal effusion was drained percutaneously in the jejunal loop by Interventional radiology. KEY WORDS: Pancreatic fistula, Jejunal loop internal drainage, Radiological treatment.

Implementing Enhanced Perioperative Care in Emergency General Surgery: A Prospective Multicenter Observational Study.

INTRODUCTION: ERAS pathway has been proposed as the standard of care in elective abdominal surgery. Guidelines on ERAS in emergency surgery have been recently published; however, few evidences are still available in the literature. The aim of this study was to evaluate the feasibility of an enhanced recovery protocol in a large cohort of patients undergoing emergency surgery and to identify possible factors impacting postoperative protocol compliance. METHODS: This is a prospective multicenter observational study including patients who underwent major emergency general surgery for either intra-abdominal infection or intestinal obstruction. The primary endpoint of the study is the adherence to ERAS postoperative protocol. Secondary endpoints are 30-day mortality and morbidity rates, and length of hospital stay. RESULTS: A total of 589 patients were enrolled in the study, 256 (43.5%) of them underwent intestinal resection with anastomosis. Major complications occurred in 92 (15.6%) patients and 30-day mortality was 6.3%. Median adherence occurred on postoperative day (POD) 1 for naso-gastric tube removal, on POD 2 for mobilization and urinary catheter removal, and on POD 3 for oral intake and i.v. fluid suspension. Laparoscopy was significantly associated with adherence to postoperative protocol, whereas operative fluid infusion > 12 mL/Kg/h, preoperative hyperglycemia, presence of a drain, duration of surgery and major complications showed a negative association. CONCLUSIONS: The present study supports that an enhanced recovery protocol in emergency surgery is feasible and safe. Laparoscopy was associated with an earlier recovery, whereas preoperative hyperglycemia, fluid overload, and abdominal drain were associated with a delayed recovery.

Impact of lockdown on emergency general surgery during first 2020 COVID-19 outbreak.

PURPOSE: To evaluate and analyze the impact of lockdown strategy due to coronavirus disease 2019 (COVID-19) on emergency general surgery (EGS) in the Milan area at the beginning of pandemic outbreak. METHODS: A survey was distributed to 14 different hospitals of the Milan area to analyze the variation of EGS procedures. Each hospital reported the number of EGS procedures in the same time frame comparing 2019 and 2020. The survey revealed that the number of patients during the COVID-19 pandemic outbreak in 2020 was reduced by 19% when compared with 2019. The decrease was statistically significant only for abdominal wall surgery. Interestingly, in 2020, there was an increase of three procedures: surgical intervention for acute mesenteric ischemia (p = 0.002), drainage of perianal abscesses (p = 0.000285), and cholecystostomy for acute cholecystitis (p = 0.08). CONCLUSIONS: During the first COVID-19 pandemic wave in the metropolitan area of Milan, the number of patients operated for emergency diseases decreased by around 19%. We believe that this decrease is related either to the fear of the population to ask for emergency department (ED) consultation and to a shift towards a more non-operative management in the surgeons 'decision making' process. The increase of acute mesenteric ischaemia and perianal abscess might be related to the modification of dietary habits and reduction of physical activity related to the lockdown.

The decrease of non-complicated acute appendicitis and the negative appendectomy rate during pandemic.

BACKGROUND: During pandemic, admissions for surgical emergencies dropped down dramatically. Also acute appendicitis decreased. The aim of the present study was to evaluate the change in volume and clinical presentation of patients with acute appendicitis during pandemic and the variation in treatment. METHODS: This is a retrospective study of patients admitted in 11 Italian hospital for acute appendicitis during the lockdown period (March-April 2020) compared with the same period of the previous 2 years (2018-2019). The number and the rate of complicated and non-complicated acute appendicitis were recorded and compared between the two study periods; non-operative vs operative treatment and negative appendectomy rate were also recorded. RESULTS: The study included 532 patients, 112 in the study period and 420 in the control period; Hospital admission for acute appendicitis dropped by 46% (OR 0.516 95% CI 0.411-0.648 p < 0.001) during the 2020 lockdown. The number of complicated acute appendicitis did not change (- 18%, OR 0.763 95% CI 0.517-1.124 p = 0.1719), whereas the number of non-complicated acute appendicitis significantly decreased (- 56%, OR 0.424 95% CI 0.319-0.564 p < 0.001). Non-operative treatment rate remained similar (12.1% vs. 11.6% p = 0.434). The negative appendectomy rate also significantly decreased (6.1% vs. 17.3%, p = 0.006). CONCLUSIONS: The present study found a significant reduction of both admissions for non-complicated acute appendicitis and negative appendectomy rate during the pandemic period. Conversely, admissions for complicated acute appendicitis did not change. TRIAL REGISTRATION: NCT04649996.

The role of E-cadherin expression in the treatment of western undifferentiated early gastric cancer: Can a biological factor predict lymph node metastasis?

The use of endoscopic techniques to cure small sized, well differentiated early gastric cancer has been adopted worldwide. In the Eastern world, endoscopic resection is being increasingly utilized to treat small undifferentiated early gastric cancer according to the extended criteria proposed by the Japanese Gastric Cancer Associations. However, studies in the Western world reported in these tumors a rate of nodal metastasis ranging between 5% and 20%, that is higher of those observed in Eastern counterparts. A tool to predict the risk of nodal dissemination would be of great use to guide treatment toward endoscopic resection. In our study, we propose E-cadherin expression as a biological factor to predict lymph node involvement. We retrospectively reviewed the E-cadherin (E-cad) expression profile of all histological specimens of undifferentiated early gastric cancer from two Oncologic Departments and compared it with several tumor characteristics. A total of 39 patients with early gastric cancer met the inclusion criteria, of which 16 (41%) pT1a, and 23 (58.9%) pT1b SM1. Thirty-two patients (82%) underwent subtotal gastrectomy, whereas total gastrectomy was performed in only seven cases (17.9%). Patients were divided into two groups: low E-cad expression (E-cad 0/1+, 10 patients) and high E-cad expression (E-cad 2+/3+, 29 patients) according to the immunohistochemical assay (ICH). On univariate analysis, we found an association between low E-cad expression and low grading tumor (p = 0.019), pure undifferentiated histotype (PU-type) (p = 0.014), and lymph node involvement (N+) (p < 0.001). The association between low E-cad expression and lymph node metastasis was confirmed by multivariate analysis (OR = 14.5, 95% CI 3.46-60.76, p < 0.001). The loss of expression of E-cad may be a simple biological factor to predict lymph nodes metastasis in patients with undifferentiated early gastric cancer. Additional larger prospective studies are necessary to confirm these findings.

COVID-19 Epidemic in the Middle Province of Northern Italy: Impact, Logistics, and Strategy in the First Line Hospital.

The novel coronavirus (COVID-19) began in China in early December 2019 and rapidly has spread to many countries around the globe, with the number of confirmed cases increasing every day. An epidemic has been recorded since February 20 in a middle province in Northern Italy (Lodi province, in the low Po Valley). The first line hospital had to redesign its logistical and departmental structure to respond to the influx of COVID-19-positive patients who needed hospitalization. Logistical and structural strategies were guided by the crisis unit, managing in 8 days from the beginning of the epidemic to prepare the hospital to be ready to welcome more than 200 COVID-19-positive patients with different ventilatory requirements, keeping clean emergency access lines, and restoring surgical interventions and deferred urgent, routine activity.

Paediatric gastric trichobezoar: the Rapunzel syndrome A report of two cases.

Rapunzel syndrome is a rare case of bowel obstruction resulting from hair ingestion (Trichobezoar). The obstruction can occur in any level of intestinal tract, but usually the stomach is primary involved. This syndrome is usually reported in patients affected by Trichotillomania or Pica syndrome, an obsessive-compulsive disorder that are characterized by an irresistible need to eat body hairs or non-digestible substances 1. When bowel obstruction occurs, it may be treated conservatively, but sometimes surgery is required. We reported two cases of Rapunzel Syndrome in two pediatric patients with different clinical presentation. Both patients were initially treated conservatively but eventually they underwent surgery. KEY WORDS: Bowel obstruction, Rapunzel syndrome, Trichobezoar.

Operative and long-term results after one-stage surgery for obstructing colonic cancer.

BACKGROUND/AIMS: To analyze retrospectively the operative results and five-year survival after single-stage resection and primary anastomosis for right- or left-sided colonic malignant obstruction. METHODOLOGY: From 1994 to 2002, 83 patients with acute obstruction due to primary cancer underwent a one-stage procedure, 36 (43.3%) for cancer of the right and 47 (56.7%) of the left colon. Of the 47 patients with left acute obstruction, 45 were treated with intraoperative colonic on-table lavage for decompression and wash-out before resection and anastomosis. Long-term survival was compared with the outcome of 369 patients with colonic cancer without obstruction 144 (39%) right and 225 (61%) left. RESULTS: Overall operative morbidity and mortality were 25.3% and 6%, respectively. Overall anastomotic leakage rate was 6%. Kaplan-Meier curves showed five-year survival rates poorer for patients operated on for obstructing malignancy than those observed for patients without obstruction (p=0.0001, Log-Rank test), obstructing malignancy was associated with more advanced age (p<0.0005) and staging of the cancer. CONCLUSIONS: One-stage resection and primary anastomosis can be applied to the majority of patients with malignant colonic obstruction and it allows achieving excellent operative results. Obstructing colonic cancer proved to be associated to a worse long-term survival.