Bowel preparation for elective colorectal resection: multi-treatment machine learning analysis on 6241 cases from a prospective Italian cohort.

BACKGROUND: Current evidence concerning bowel preparation before elective colorectal surgery is still controversial. This study aimed to compare the incidence of anastomotic leakage (AL), surgical site infections (SSIs), and overall morbidity (any adverse event, OM) after elective colorectal surgery using four different types of bowel preparation. METHODS: A prospective database gathered among 78 Italian surgical centers in two prospective studies, including 6241 patients who underwent elective colorectal resection with anastomosis for malignant or benign disease, was re-analyzed through a multi-treatment machine-learning model considering no bowel preparation (NBP; No. = 3742; 60.0%) as the reference treatment arm, compared to oral antibiotics alone (oA; No. = 406; 6.5%), mechanical bowel preparation alone (MBP; No. = 1486; 23.8%), or in combination with oAB (MoABP; No. = 607; 9.7%). Twenty covariates related to biometric data, surgical procedures, perioperative management, and hospital/center data potentially affecting outcomes were included and balanced into the model. The primary endpoints were AL, SSIs, and OM. All the results were reported as odds ratio (OR) with 95% confidence intervals (95% CI). RESULTS: Compared to NBP, MBP showed significantly higher AL risk (OR 1.82; 95% CI 1.23-2.71; p = .003) and OM risk (OR 1.38; 95% CI 1.10-1.72; p = .005), no significant differences for all the endpoints were recorded in the oA group, whereas MoABP showed a significantly reduced SSI risk (OR 0.45; 95% CI 0.25-0.79; p = .008). CONCLUSIONS: MoABP significantly reduced the SSI risk after elective colorectal surgery, therefore representing a valid alternative to NBP.

The Role of the Recovery Room in Improving Adherence During an Enhanced Recovery After Surgery (ERAS) Implementation Program for Colorectal Surgery: A Single-Center Retrospective Analysis.

PURPOSE: The purpose of thisstudy was to evaluate the clinical impact of the Recovery Room (RR) in an Enhanced Recovery After Surgery (ERAS) pathway in colorectal surgery. DESIGN: Single-center retrospective study. METHODS: From November 2019 until September 2021, a total of 149 consecutive patients that underwent to colon-rectal surgery were enrolled. The patients were divided into two study groups: RR Group if admitted to RR after surgery, and no-Recovery Room (NRR) Group if monitored directly on the ward, bypassing the RR. The postoperative ERAS items adherence was assessed in the two study groups. FINDINGS: Final analysis included 119 patients in the RR Group and 30 patients in NRR Group. Patients that started clear liquid oral intake within two hours postoperatively were 118 in the RR group and 19 in the NRR group (99.1% vs 63.3%, P < .001). A total of 98 patients and 18 patients were mobilized on day 0 in the RR group and in NRR group, respectively (84.4% vs 15.5%, P < .05). In the RR group, postoperative adherence to the ERAS protocol components was higher in comparison with the NRR group (P < .003); adherence to the all protocol components was also higher (P < .004). CONCLUSIONS: Among patients undergoing colorectal surgery admitted to RR after surgery, the RR nurse guaranteed effective patient assistance and ensured appropriate compliance to the postoperative ERAS items.

Management and 1-year outcomes of anastomotic leakage after elective colorectal surgery.

PURPOSE: To analyze different types of management and one-year outcomes of anastomotic leakage (AL) after elective colorectal resection. METHODS: All patients with anastomotic leakage after elective colorectal surgery with anastomosis (76/1,546; 4.9%), with the exclusion of cases with proximal diverting stoma, were followed-up for at least one year. Primary endpoints were as follows: composite outcome of one-year mortality and/or unplanned intensive care unit (ICU) admission and additional morbidity rates. Secondary endpoints were as follows: length of stay (LOS), one-year persistent stoma rate, and rate of return to intended oncologic therapy (RIOT). RESULTS: One-year mortality rate was 10.5% and unplanned ICU admission rate was 30.3%. Risk factors of the composite outcome included age (aOR = 1.08 per 1-year increase, p = 0.002) and anastomotic breakdown with end stoma at reoperation (aOR = 2.77, p = 0.007). Additional morbidity rate was 52.6%: risk factors included open versus laparoscopic reoperation (aOR = 4.38, p = 0.03) and ICU admission (aOR = 3.63, p = 0.05). Median (IQR) overall LOS was 20 days (14-26), higher in the subgroup of patients reoperated without stoma. At 1 year, a stoma persisted in 32.0% of patients, higher in the open (41.2%) versus laparoscopic (12.5%) reoperation group (p = 0.04). Only 4 out of 18 patients (22.2%) were able to RIOT. CONCLUSION: Mortality and/or unplanned ICU admission rates after AL are influenced by increasing age and by anastomotic breakdown at reoperation; additional morbidity rates are influenced by unplanned ICU admission and by laparoscopic approach to reoperation, the latter also reducing permanent stoma and failure to RIOT rates. TRIAL REGISTRATION: ClinicalTrials.gov # NCT03560180.

ICG fluorescence imaging in colorectal surgery: a snapshot from the ICRAL study group.

BACKGROUND: Fluorescence-guided visualization is a recently proposed technology in colorectal surgery. Possible uses include evaluating perfusion, navigating lymph nodes and searching for hepatic metastases and peritoneal spread. Despite the absence of high-level evidence, this technique has gained considerable popularity among colorectal surgeons due to its significant reliability, safety, ease of use and relatively low cost. However, the actual use of this technique in daily clinical practice has not been reported to date. METHODS: This survey was conducted on April 2020 among 44 centers dealing with colorectal diseases and participating in the Italian ColoRectal Anastomotic Leakage (iCral) study group. Surgeons were approximately equally divided based on geographical criteria from multiple Italian regions, with a large proportion based in public (89.1%) and nonacademic (75.7%) centers. They were invited to answer an online survey to snapshot their current behaviors regarding the use of fluorescence-guided visualization in colorectal surgery. Questions regarding technological availability, indications and techniques, personal approaches and feelings were collected in a 23-item questionnaire. RESULTS: Questionnaire replies were received from 37 institutions and partially answered by 8, as this latter group of centers do not implement fluorescence technology (21.6%). Out of the remaining 29 centers (78,4%), fluorescence is utilized in all laparoscopic colorectal resections by 72.4% of surgeons and only for selected cases by the remaining 27.6%, while 62.1% of respondents do not use fluorescence in open surgery (unless the perfusion is macroscopically uncertain with the naked eye, in which case 41.4% of them do). The survey also suggests that there is no agreement on dilution, dosing and timing, as many different practices are adopted based on personal judgment. Only approximately half of the surgeons reported a reduced leak rate with fluorescence perfusion assessment, but 65.5% of them strongly believe that this technique will become a minimum requirement for colorectal surgery in the future. CONCLUSION: The survey confirms that fluorescence is becoming a widely used technique in colorectal surgery. However, both the indications and methods still vary considerably; furthermore, the surgeons' perceptions of the results are insufficient to consider this technology essential. This survey emphasizes the need for further research to reach recommendations based on solid scientific evidence.

D1-plus vs D2 nodal dissection in gastric cancer: a propensity score matched comparison and review of published literature.

BACKGROUND: The results of D1-plus lymphadenectomy following gastric resection are seldom investigated. The aim of this study was to compare results of D1-plus vs D2 resections and to provide a literature review. METHODS: Patients who underwent upfront R0 gastrectomy for adenocarcinoma from 2000 to 2016 in three Institutions were selected using propensity scores and categorized according to lymphadenectomy. Statistical analyses were performed for the nodal harvest (LNH) and survival. Published literature comparing D1-plus and D2 was reviewed and analyzed according to PICO and PRISMA guidelines. RESULTS: Two matched groups of 93 D1-plus and 93 D2 resections were selected. LNH was significantly greater in D2 vs D1-plus dissections (mean 31.2 vs 27.2, p 0.04), however LNH distribution was similar. The cumulative incidence curves for overall survival, disease free and disease specific events did not report significant differences, however Cox regression analysis disclosed that total gastrectomies (HR 1.8; 95% 1.0-2.9), advanced stages (HR 5.9; 95% 3.4-10.3) and D1-plus nodal dissection (HR 2.1; 95% 1.26-3.50) independently correlated with disease free survival. Literature review including 297 D1-plus and 556 D2 lymphadenectomies documented LNH in favor of D2 sub-group (SMD -0.772; 95%CI -1.222- -0.322). CONCLUSION: D2 provided greater LNH than D1-plus dissections; prospective studies should aim to investigate long-term survival of D1-plus lymphadenectomy.

Impact of laparoscopy on adherence to an enhanced recovery pathway and readiness for discharge in elective colorectal surgery: Results from the PeriOperative Italian Society registry.

INTRODUCTION: Previous studies reported that laparoscopic surgery (LPS) improved postoperative outcomes in patients undergoing colorectal surgery within an enhanced recovery program (ERP). However, the effect of minimally invasive surgery on each ERP item has not been clarified, yet. The aim of this study is to assess the impact of LPS on adherence to ERP items and recovery as measured by time to readiness for discharge (TRD). METHODS: Prospectively collected data entered in an electronic Italian registry specifically designed for ERP were reviewed. Patients undergoing elective colorectal surgery were divided into three groups: successful laparoscopy, conversion to open surgery, primary open surgery. Adherence to 19 ERP elements and postoperative outcomes were compared among groups. Multivariate regression analysis was used to identify whether LPS had an independent role to improve ERP adherence and postoperative outcomes. RESULTS: 714 patients (successful LPS 531, converted 42, open 141) underwent elective colorectal surgery within an ERP. Epidural analgesia was used in the 75.1% of open group patients versus 49.9% of LPS group patients (p = 0.012). After surgery, oral feeding recovery, i.v. fluids suspension, removal of both urinary and epidural catheters occurred earlier in the LPS group both in the overall series and in uneventful patients only. Mean TRD and length of hospital stay were significantly shorter in the LPS group (p < 0.001 for both). Overall morbidity rate was 18.7% in the LPS group versus 32.6% in the open group (p = 0.001). At multivariate analysis, LPS was significantly associated to an increased adherence to postoperative ERP items, a shorter TRD, and a reduced overall morbidity, whereas rectal surgery and new stoma formation impaired postoperative recovery. CONCLUSIONS: The present study showed that a successful laparoscopic procedure had an independent role to increase the adherence to postoperative ERP and to improve short-term postoperative outcome.

Enhanced Recovery Program in High-Risk Patients Undergoing Colorectal Surgery: Results from the PeriOperative Italian Society Registry.

BACKGROUND: Enhanced recovery after surgery (ERAS) pathways represent the optimal approach for patients undergoing colorectal surgery. Elderly or low physical status patients have been often excluded from ERAS pathways because considered at high risk. The aim of this study is to assess the adherence to ERAS protocol and its impact on short-term postoperative outcome in patients with different surgical risk undergoing elective colorectal resection. METHODS: Prospectively collected data entered in an electronic Italian registry specifically designed for ERAS were reviewed. Patients were divided into four groups according to age (70-year-old cutoff) and preoperative physical status as measured by the ASA grade (I-II vs. III-IV). Adherence to 18 ERAS elements and postoperative outcomes were compared between groups. Regression analysis was used to identify independent factors associated with improved outcomes. RESULTS: Eleven Italian hospitals reported data on 706 patients undergoing elective colorectal surgery within an ERAS protocol. Patients with low physical status had reduced adherence to preoperative carbohydrate loading, epidural analgesia, PONV prophylaxis, and early urinary catheter removal. No difference was found between groups for adherence to other perioperative elements. Major complications occurred in 37 (5.2 %) patients without significant differences among groups (p = 0.384). Median (IQR) time to readiness for discharge (TRD) was 4 (3-6) days, length of hospital stay (LOS) was 6 (4-7) days, and both were significantly shorter by only 1 day in the groups of younger patients (p < 0.001). At multivariate analysis, laparoscopy increased adherence to ERAS items and reduced TRD, LOS, and morbidity. A high ASA grade was significantly associated with lower adherence, whereas older age significantly prolonged TRD and LOS. CONCLUSION: ERAS pathway can be safely applied in elderly and low physical status patients yielding slight differences in postoperative morbidity and time to recover. Laparoscopy was independently associated with increased adherence to ERAS protocol and improved short-term postoperative outcome.

Oral Antibiotics Alone versus Oral Antibiotics Combined with Mechanical Bowel Preparation for Elective Colorectal Surgery: A Propensity Score-Matching Re-Analysis of the iCral 2 and 3 Prospective Cohorts.

The evidence regarding the role of oral antibiotics alone (oA) or combined with mechanical bowel preparation (MoABP) for elective colorectal surgery remains controversial. A prospective database of 8359 colorectal resections gathered over a 32-month period from 78 Italian surgical units (the iCral 2 and 3 studies), reporting patient-, disease-, and procedure-related variables together with 60-day adverse events, was re-analyzed to identify a subgroup of 1013 cases (12.1%) that received either oA or MoABP. This dataset was analyzed using a 1:1 propensity score-matching model including 20 covariates. Two well-balanced groups of 243 patients each were obtained: group A (oA) and group B (MoABP). The primary endpoints were anastomotic leakage (AL) and surgical site infection (SSI) rates. Group A vs. group B showed a significantly higher AL risk [14 (5.8%) vs. 6 (2.5%) events; OR: 3.77; 95%CI: 1.22-11.67; p = 0.021], while no significant difference was recorded between the two groups regarding SSIs. These results strongly support the use of MoABP for elective colorectal resections.

Intraoperative left-sided colorectal anastomotic testing in clinical practice: a multi-treatment machine-learning analysis of the iCral3 prospective cohort.

BACKGROUND: Current evidence about intraoperative anastomotic testing after left-sided colorectal resections is still controversial. The aim of this study was to analyze the impact of Indocyanine Green fluorescent angiography (ICG-FA) and air-leak test (ALT) over standard assessment on anastomotic leakage (AL) rates according to surgeon's perception of anastomosis perfusion and/or integrity in clinical practice. METHODS: A database of 2061 patients who underwent left-sided colorectal resections was selected from patients enrolled in a prospective multicenter study. It was retrospectively analyzed through a multi-treatment machine-learning model considering standard visual assessment (NW; No. = 899; 43.6%) as the reference treatment arm, compared to ICG-FA alone (WP; No. = 409; 19.8%), ALT alone (WI; No. = 420; 20.4%) or both (WPI; No. = 333; 16.2%). Twenty-four covariates potentially affecting the outcomes were included and balanced into the model within the subgroups. The primary endpoint was AL, the secondary endpoints were overall morbidity (OM), major morbidity (MM), reoperation for AL, and mortality. All the results were reported as odds ratio (OR) with 95% confidence intervals (95%CI). RESULTS: The WPI subgroup showed significantly higher AL risk (OR 1.91; 95% CI 1.02-3.59; p 0.043), MM risk (OR 2.35; 95% CI 1.39-3.97; p 0.001), and reoperation for AL risk (OR 2.44; 95% CI 1.12-5.31; p 0.025). No other significant differences were recorded. CONCLUSIONS: This study showed that the surgeons' perception of both anastomotic perfusion and integrity (WPI subgroup) was associated to a significantly higher risk of AL and related morbidity, notwithstanding the extensive use of both ICG-FA and ALT testing.

Colonic Resection, Stoma, or Self-expanding Metal Stents for Obstructive Left Colon Cancer: the CROSCO-1 study protocol.

BACKGROUND: Colorectal cancer (CRC) is one of the most common cancers worldwide. There are several causes of a mechanical left bowel obstructive but CRC accounts for approximately 50% of cases and in 10-30% of whom it is the presenting syndrome. In most cases, the left colon is involved. At present, the range of therapeutic alternatives in the management of obstructive left CRC in emergency conditions (primary resection vs. staged resection with applied self-expanding metallic stents) is broad, whereas internationally validated clinical recommendations in each condition are still lacking. This enormous variability affects the scientific evidence on both the immediate and long-term surgical and oncological outcomes. METHODS: CROSCO-1 (Colonic Resection, Stoma or Self-expanding Metal Stents for Obstructive Left Colon Cancer) study is a national, multi-center, prospective observational study intending to compare the clinical results of all these therapeutic regimens in a cohort of patients treated for obstructive left-sided CRC. RESULTS: The primary aim of the CROSCO-1 study is the 1-year stoma rate of patients undergoing primary emergency surgical resection (Hartmann procedure or primary resection and anastomosis) compared with patients undergoing staged resection. Secondary outcomes are 30-day and 90-day major morbidity and mortality, 1-year quality of life and the timing of chemotherapy initiation in the two groups. Future CROSCO studies will follow in which, instead, we will evaluate the long-term oncological outcomes of the two treatment strategies. CONCLUSIONS: The results of a large prospective cohort study which will analyze what really happens in the common clinical practice of managing patients with obstructive left CRC will have the aim of understanding which is the best strategy in terms of surgical and oncological outcomes. Indeed, the CROSCO-1 study will analyze the early surgical outcomes for patients with obstructed left CRC. Future CROSCO studies will follow in which, instead, we will evaluate the long-term oncological outcomes of the two treatment strategies.

Mechanical bowel preparation in elective colorectal surgery: a propensity score-matched analysis of the Italian colorectal anastomotic leakage (iCral) study group prospective cohorts.

Retrospective evaluation of the effects of mechanical bowel preparation (MBP) on data derived from two prospective open-label observational multicenter studies in Italy regarding elective colorectal surgery. MBP for elective colorectal surgery remains a controversial issue with contrasting recommendations in current guidelines. The Italian ColoRectal Anastomotic Leakage (iCral) study group, therefore, decided to estimate the effects of no MBP (treatment variable) versus MBP for elective colorectal surgery. A total of 8359 patients who underwent colorectal resection with anastomosis were enrolled in two consecutive prospective studies in 78 surgical centers in Italy from January 2019 to September 2021. A retrospective PSMA was performed on 5455 (65.3%) cases after the application of explicit exclusion criteria to eliminate confounders. The primary endpoints were anastomotic leakage (AL) and surgical site infections (SSI) rates; the secondary endpoints included SSI subgroups, overall and major morbidity, reoperation, and mortality rates. Overall length of postoperative hospital stay (LOS) was also considered. Two well-balanced groups of 1125 patients each were generated: group A (No MBP, true population of interest), and group B (MBP, control population), performing a PSMA considering 21 covariates. Group A vs. group B resulted significantly associated with a lower risk of AL [42 (3.5%) vs. 73 (6.0%) events; OR 0.57; 95% CI 0.38-0.84; p = 0.005]. No difference was recorded between the two groups for SSI [73 (6.0%) vs. 85 (7.0%) events; OR 0.88; 95% CI 0.63-1.22; p = 0.441]. Regarding the secondary endpoints, no MBP resulted significantly associated with a lower risk of reoperation and LOS > 6 days. This study confirms that no MBP before elective colorectal surgery is significantly associated with a lower risk of AL, reoperation rate, and LOS < 6 days when compared with MBP.

Abdominal drainage after elective colorectal surgery: propensity score-matched retrospective analysis of an Italian cohort.

BACKGROUND: In Italy, surgeons continue to drain the abdominal cavity in more than 50 per cent of patients after colorectal resection. The aim of this study was to evaluate the impact of abdominal drain placement on early adverse events in patients undergoing elective colorectal surgery. METHODS: A database was retrospectively analysed through a 1:1 propensity score-matching model including 21 covariates. The primary endpoint was the postoperative duration of stay, and the secondary endpoints were surgical site infections, infectious morbidity rate defined as surgical site infections plus pulmonary infections plus urinary infections, anastomotic leakage, overall morbidity rate, major morbidity rate, reoperation and mortality rates. The results of multiple logistic regression analyses were presented as odds ratios (OR) and 95 per cent c.i. RESULTS: A total of 6157 patients were analysed to produce two well-balanced groups of 1802 patients: group (A), no abdominal drain(s) and group (B), abdominal drain(s). Group A versus group B showed a significantly lower risk of postoperative duration of stay >6 days (OR 0.60; 95 per cent c.i. 0.51-0.70; P < 0.001). A mean postoperative duration of stay difference of 0.86 days was detected between groups. No difference was recorded between the two groups for all the other endpoints. CONCLUSION: This study confirms that placement of abdominal drain(s) after elective colorectal surgery is associated with a non-clinically significant longer (0.86 days) postoperative duration of stay but has no impact on any other secondary outcomes, confirming that abdominal drains should not be used routinely in colorectal surgery.

Intracorporeal versus extracorporeal anastomosis after laparoscopic right hemicolectomy for cancer: a systematic review and meta-analysis.

PURPOSE: The aim of this systematic review was to compare intracorporeal (IA) versus extracorporeal anastomosis (EA) after laparoscopic right hemicolectomy for cancer. METHODS: The meta-analysis was conducted following all aspects of the Cochrane Handbook for systematic reviews and Preferred Reporting Items for Systematic Reviews and Meta-analysis statement. Studies published from 2009 to 2012 that compare IA and EA after laparoscopic right hemicolectomy were identified. The included non-randomized studies were assessed for their methodological quality using the revised and modified grading system of the Scottish Intercollegiate Guidelines Network. Intraoperative, early postoperative, and postoperative recovery outcomes were compared using weighted mean differences and odds ratios. RESULTS: Five non-randomized controlled trials published between 2009 and 2011, comprising 425 patients, were included in this analysis. IA was associated with significant faster bowel movement, faster first flatus, shorter time to solid diet, decreased use of analgesics, and shorter duration of the hospital stay. No differences were observed for nasogastric tube reintroduction rate, operative time, incision length, number of nodes harvested, intraoperative complications, mortality, non-surgical site complications, surgical site complications (anastomotic leakage, anastomotic bleeding, wound infection, ileus), reintervention, and readmission rate. CONCLUSIONS: Even when the limitations are taken into account due to the observational nature of the included studies, the results suggest that the IA after laparoscopic right hemicolectomy for cancer results in better postoperative recovery outcomes, such as shorter hospital stay, faster bowel movement recovery, faster first flatus, faster time to solid diet, and lesser analgesic usage.

Fast-track colorectal surgery: protocol adherence influences postoperative outcomes.

PURPOSE: This single-center prospective cohort study, conducted outside of a clinical trial, tried to identify the importance of each fast-track surgery procedure and protocol adherence level on clinical outcomes after colorectal surgery. METHODS: From a prospectively maintained database, 606 patients who underwent elective laparoscopic or open colorectal resection within a well established fast-track surgery (FT) protocol, between 2005 and 2011, were identified. Univariate and multivariate analysis were performed to assess the relationship between each FT procedure with an adherence rate <100 % and the outcome variables (length of stay-LOS, 30-day morbidity and readmission rate). Patients were divided into four adherence level groups to FT procedures-100 %, 85-95 %,70-80 %, and <65 %. Each adherence group was compared with the other groups to evaluate differences in clinical outcome variables. RESULTS: Group comparisons revealed that higher levels of FT protocol adherence corresponded to significantly improved LOS and morbidity rates. Readmission rates were only significantly different between the full fast-track pathway and the less implemented groups. Multivariate analyses revealed that the fast removal of bladder catheter positively influenced length of stay (p < 0.0001) and 30-day morbidity (p < 0.0001). Laparoscopy surgery, no drain positioning and enforced mobilization improved LOS (p = 0.027, p < 0.0001, p = 0.002, respectively). Early solid feeding improved LOS (p < 0.0001), morbidity (p < 0.0001) and readmission rate (p = 0.011). CONCLUSION: Postoperative outcomes after colorectal surgery are directly proportional to FT protocol adherence. The early removal of the bladder catheter and early postoperative solid feeding independently influenced the length of hospital stay and 30-day morbidity rates.

Laparoscopic surgery improves postoperative outcomes in high-risk patients with colorectal cancer.

BACKGROUND: Patients with significant comorbidities often are denied laparoscopic colorectal resections, because they are thought to be too "high-risk." This study was designed to examine the feasibility and safety of laparoscopic colorectal resections in high-risk colorectal cancer patients and to compare them with a similar cohort of patients undergoing open resections in the same time period. METHODS: This was a single-center, prospective, cohort study conducted at a high-volume, nonuniversity, tertiary care hospital. From a database of 616 patients submitted to elective colorectal surgery for cancer within a fast-track protocol (January 2005 to November 2011), 188 patients who met at least one minor (age >80 years and body mass index (BMI) >30 m/kg(2)) and one major (cardiac, pulmonary, renal or liver disease, diabetes mellitus) criterion were classified as high-risk. Differences in baseline characteristics, intraoperative outcomes, and short-term (30-day) postoperative outcomes, as well as the pathology findings and the readmission and reoperation rates, were compared between the open and laparoscopic cohorts in both high- and low-risk groups and between high- and low-risk groups. RESULTS: During the study period, 68 high-risk patients underwent laparoscopic resections and 120 had open surgeries. A shorter length of postoperative stay (6 vs. 9 days, p < 0.0001) and fewer postoperative nonsurgical complications (4 % vs. 19 %, p = 0.003) were observed among the laparoscopic group. Postoperative major (p = 0.774) and minor complications (p = 0.3) and reoperations (p = 0.196) were similar between the two groups, and a significantly lower rate of mortality (1.5 vs. 7.5 %, p = 0.038) was observed in the laparoscopic group than in the open group. CONCLUSIONS: Laparoscopic colorectal resection can be safely performed on "high-risk" surgical patients with better results than a similar group of high-risk patients undergoing open colon resections.

Blood Transfusions and Adverse Events after Colorectal Surgery: A Propensity-Score-Matched Analysis of a Hen-Egg Issue.

Blood transfusions are considered a risk factor for adverse outcomes after colorectal surgery. However, it is still unclear if they are the cause (the hen) or the consequence (the egg) of adverse events. A prospective database of 4529 colorectal resections gathered over a 12-month period in 76 Italian surgical units (the iCral3 study), reporting patient-, disease-, and procedure-related variables, together with 60-day adverse events, was retrospectively analyzed identifying a subgroup of 304 cases (6.7%) that received intra- and/or postoperative blood transfusions (IPBTs). The endpoints considered were overall and major morbidity (OM and MM, respectively), anastomotic leakage (AL), and mortality (M) rates. After the exclusion of 336 patients who underwent neo-adjuvant treatments, 4193 (92.6%) cases were analyzed through a 1:1 propensity score matching model including 22 covariates. Two well-balanced groups of 275 patients each were obtained: group A, presence of IPBT, and group B, absence of IPBT. Group A vs. group B showed a significantly higher risk of overall morbidity (154 (56%) vs. 84 (31%) events; OR 3.07; 95%CI 2.13-4.43; p = 0.001), major morbidity (59 (21%) vs. 13 (4.7%) events; OR 6.06; 95%CI 3.17-11.6; p = 0.001), and anastomotic leakage (31 (11.3%) vs. 8 (2.9%) events; OR 4.72; 95%CI 2.09-10.66; p = 0.0002). No significant difference was recorded between the two groups concerning the risk of mortality. The original subpopulation of 304 patients that received IPBT was further analyzed considering three variables: appropriateness of BT according to liberal transfusion thresholds, BT following any hemorrhagic and/or major adverse event, and major adverse event following BT without any previous hemorrhagic adverse event. Inappropriate BT was administered in more than a quarter of cases, without any significant influence on any endpoint. The majority of BT was administered after a hemorrhagic or a major adverse event, with significantly higher rates of MM and AL. Finally, a major adverse event followed BT in a minority (4.3%) of cases, with significantly higher MM, AL, and M rates. In conclusion, although the majority of IPBT was administered with the consequence of hemorrhage and/or major adverse events (the egg), after adjustment accounting for 22 covariates, IPBT still resulted in a definite source of a higher risk of major morbidity and anastomotic leakage rates after colorectal surgery (the hen), calling urgent attention to the implementation of patient blood management programs.

Three-row versus two-row circular staplers for left-sided colorectal anastomosis: a propensity score-matched analysis of the iCral 2 and 3 prospective cohorts.

BACKGROUND: Since most anastomoses after left-sided colorectal resections are performed with a circular stapler, any technological change in stapling devices may influence the incidence of anastomotic adverse events. The aim of the present study was to analyze the effect of a three-row circular stapler on anastomotic leakage and related morbidity after left-sided colorectal resections. MATERIALS AND METHODS: A circular stapled anastomosis was performed in 4255 (50.9%) out of 8359 patients enrolled in two prospective multicenter studies in Italy, and, after exclusion criteria to reduce heterogeneity, 2799 (65.8%) cases were retrospectively analyzed through a 1:1 propensity score-matching model including 20 covariates relative to patient characteristics, to surgery and to perioperative management. Two well-balanced groups of 425 patients each were obtained: group (A) - true population of interest, anastomosis performed with a three-row circular stapler; group (B) - control population, anastomosis performed with a two-row circular stapler. The target of inferences was the average treatment effect in the treated (ATT). The primary endpoints were overall and major anastomotic leakage and overall anastomotic bleeding; the secondary endpoints were overall and major morbidity and mortality rates. The results of multiple logistic regression analyses for the outcomes, including the 20 covariates selected for matching, were presented as odds ratios (OR) and 95% confidence intervals (95% CI). RESULTS: Group A versus group B showed a significantly lower risk of overall anastomotic leakage (2.1 vs. 6.1%; OR 0.33; 95% CI 0.15-0.73; P =0.006), major anastomotic leakage (2.1 vs. 5.2%; OR 0.39; 95% CI 0.17-0.87; P =0.022), and major morbidity (3.5 vs. 6.6% events; OR 0.47; 95% CI 0.24-0.91; P =0.026). CONCLUSION: The use of three-row circular staplers independently reduced the risk of anastomotic leakage and related morbidity after left-sided colorectal resection. Twenty-five patients were required to avoid one leakage.

The multidisciplinary audit in enhanced recovery after surgery (ERAS) colorectal surgery: experience in a single Italian center.

BACKGROUND: Current literature underlines the role of periodical feed-back to improve Enhanced Recovery After Surgery (ERAS) path adherence during implementation program. The aim of this retrospective study was to evaluate the clinical impact of an audit program in an ERAS path. METHODS: All elective patients submitted to elective colorectal surgery from November 2018 to January 2020 in our Institution were considered. The sample was divided into two study groups: group 1, including patients enrolled in the first sixth months of ERAS program until the first audit; group 2, patients enrolled in a time period of a six months after the first audit. RESULTS: The final analysis included 46 patients in group 1 and 64 in group 2. Group 2 showed a higher ASA Score (P<0.03), a higher prevalence of right hemicolectomy, and a lower prevalence of left hemicolectomy and anterior rectum resection (RAR) (P<0.016). Group 2 also had a lower prevalence of anastomotic leakage (AL) (P<0.004). Intraoperative normothermia (T>36 C°) in this group was achieved in a larger number of patients in comparison with group 1 (39% vs. 19.5%) (P<0.01). Group 2 experienced a higher average body temperature at admission in recovery room (RR) when compared to Group 1 (35.8 vs. 35.1 C°, P<0.01). CONCLUSIONS: Audit program may represent a useful tool to promote advantageous changes in clinical practice and to favor a better compliance to ERAS program.

Primary Tumour Treatment in Stage 4 Colorectal Cancer with Unresectable Liver and Lung Metastases and No Peritoneal Carcinomatosis-Current Trends and Attitudes in the Absence of Clear Guidelines.

BACKGROUND: The treatment of the primary tumour in colorectal cancer with unresectable liver and/or lung metastases but no peritoneal carcinomatosis is still a matter of debate. In the absence of clear evidence and guidelines, our survey was aimed at obtaining a snapshot of the current attitudes and the rationales for the choice of offering resection of the primary tumour (RPT) despite the presence of untreatable metastases. METHODS: An online survey was administered to medical professionals worldwide. The survey had three sections: (1) demographics of the respondent, (2) case scenarios and (3) general questions. For each respondent, an "elective resection score" and an "emergency resection score" were calculated as a percentage of the times he or she would offer RPT in the elective and in the emergency case scenarios. They were correlated to independent variables such as age, type of affiliation and specific workload. RESULTS: Most respondents would offer palliative chemotherapy as the first choice in elective scenarios, while a more aggressive approach with RPT would be reserved for younger patients with good performance status and in emergency situations. Respondents younger than 50 years old and those with a specific workload of fewer than 40 cases of colorectal cancer per year tend to be more conservative. CONCLUSIONS: In the absence of clear guidelines and evidence, there is a lack of consensus on the treatment of the primary tumour in case of colon cancer with unresectable liver and/or lung metastases and no peritoneal carcinomatosis. Palliative chemotherapy seems to be the first option, but more consistent evidence is needed to guide this choice.

Implementation Strategies for Preventing Healthcare-Associated Infections across the Surgical Pathway: An Italian Multisociety Document.

Healthcare-associated infections (HAIs) result in significant patient morbidity and can prolong the duration of the hospital stay, causing high supplementary costs in addition to those already sustained due to the patient's underlying disease. Moreover, bacteria are becoming increasingly resistant to antibiotics, making HAI prevention even more important nowadays. The public health consequences of antimicrobial resistance should be constrained by prevention and control actions, which must be a priority for all health systems of the world at all levels of care. As many HAIs are preventable, they may be considered an important indicator of the quality of patient care and represent an important patient safety issue in healthcare. To share implementation strategies for preventing HAIs in the surgical setting and in all healthcare facilities, an Italian multi-society document was published online in November 2022. This article represents an evidence-based summary of the document.