Identification of patients eligible for discharge within 48 h of colorectal resection.

BACKGROUND: This study aimed to identify patients eligible for a 48-h stay after colorectal resection, to provide guidance for early discharge planning. METHODS: A bi-institutional retrospective cohort study was undertaken of consecutive patients undergoing major elective colorectal resection for benign or malignant pathology within a comprehensive enhanced recovery pathway between 2011 and 2017. Overall and severe (Clavien-Dindo grade IIIb or above) postoperative complication and readmission rates were compared between patients who were discharged within 48 h and those who had hospital stay of 48 h or more. Multinominal logistic regression analysis was performed to ascertain significant factors associated with a short hospital stay (less than 48 h). RESULTS: In total, 686 of 5122 patients (13·4 per cent) were discharged within 48 h. Independent factors favouring a short hospital stay were age below 60 years (odds ratio (OR) 1·34; P = 0·002), ASA grade less than III (OR 1·42; P = 0·003), restrictive fluid management (less than 3000 ml on day of surgery: OR 1·46; P < 0·001), duration of surgery less than 180 min (OR 1·89; P < 0·001), minimally invasive approach (OR 1·92; P < 0·001) and wound contamination grade below III (OR 4·50; P < 0·001), whereas cancer diagnosis (OR 0·55; P < 0·001) and malnutrition (BMI below 18 kg/m2 : OR 0·42; P = 0·008) decreased the likelihood of early discharge. Patients with a 48-h stay had fewer overall (10·8 per cent versus 30·6 per cent in those with a longer stay; P < 0·001) and fewer severe (2·6 versus 10·2 per cent respectively; P < 0·001) complications, and a lower readmission rate (9·0 versus 11·8 per cent; P = 0·035). CONCLUSION: Early discharge of selected patients is safe and does not increase postoperative morbidity or readmission rates. In these patients, outpatient colorectal surgery should be feasible on a large scale with logistical optimization.

ANTECEDENTES: Este estudio tuvo como objetivo identificar pacientes candidatos para una estancia hospitalaria de 48 horas tras resecciones colónicas, con el fin de proporcionar una guía de planificación del alta precoz. MÉTODOS: Estudio de cohortes retrospectivo de pacientes consecutivos sometidos a resección colorrectal electiva mayor por patología benigna o maligna en el marco de un programa integral de recuperación intensificada (enhanced recovery pathway, ERP), de dos hospitales entre 2011 y 2017. Se compararon las tasas de complicaciones postoperatorias globales y graves (Clavien ≥ IIIb) y de reingresos entre dos grupos (< 48 horas versus ≥ 48 horas de estancia hospitalaria). Se llevó a cabo una regresión logística multinominal de factores significativos (P < 0,05) asociados con una estancia corta (< 48 horas). RESULTADOS: En total, 686/5.122 pacientes (13,4%) fueron dados de alta dentro de las primeras 48 horas. Los factores independientes que propiciaron una estancia corta fueron la edad < 60 años (razón de oportunidades, odds ratio, OR 1,34, P = 0,002), puntuación < 3 de la American Society of Anesthesiologists (ASA) (OR 1,42, P = 0,003), manejo restrictivo del aporte de líquidos (< 3000 mL en el día de la cirugía: OR 1,46, P < 0,001), duración de la cirugía < 180 minutos (OR 1,89, P < 0,001), abordaje mínimamente invasivo (OR 1,92, P < 0,001) and tipo de herida clase < 3 (OR 4,5, P < 0,001), mientras que el diagnóstico de cáncer (OR 0,55, P < 0,001) y la malnutrición (IMC < 18 kg/m2 : OR 0,42, P = 0,008) disminuyeron la probabilidad de alta precoz. Los pacientes con una estancia de 48 horas tuvieron menos complicaciones globales (10,8% versus 30,6%, P < 0,001), menos complicaciones graves (2,6% versus 10,2%, P < 0,001) y una menor tasa de reingresos (9% versus 11,8%, P = 0,035). CONCLUSIÓN: El alta precoz en pacientes seleccionados es segura y no aumenta las tasas de morbilidad postoperatoria o de reingresos. En estos pacientes, la cirugía colorrectal ambulatoria debería ser viable a gran escala con una optimización de la logística.

Gains and limitations of a connected tracking solution in the perioperative follow-up of colorectal surgery patients.

AIM: The means to target shorter hospital stay include information technology strategies to improve communication between caregivers and patients in order to limit potentially avoidable readmissions. The aim of the present study was to analyse the benefits and limitations of a smartphone-based connected tracking solution in the perioperative follow-up of colorectal surgery patients. METHOD: This was a retrospective monocentric cohort study of consecutive patients after colorectal surgery between February and December 2018. The mobile health application included information delivery and daily structured questionnaires on a personalized patient electronic profile, before the hospital stay and for 7 days post-discharge. The medical team answered automatic alerts in real time. RESULTS: A total of 93 eligible patients were approached and 36 had to be excluded (26 no smartphone, five no email, five not French speaking). Among the potential users, 50 (88%) engaged in an mHealth app and seven refused. Of these 50 patients, seven dropped out. Of the remaining 43 patients, the app detected 12 adverse events, and 10 (83%) were handled through the app. Healthcare providers responded to patient-generated alerts after a median time of 90 min (range 9-448 min). Patients' mean satisfaction level was 4 ± 0.97 out of 5. CONCLUSION: In total, 88% of smartphone-equipped patients showed a willingness to engage in mHealth. Reasons for exclusion were the absence of connection tools and a language barrier. Patients who responded to the survey were satisfied with the solution and 83% of post-discharge adverse events were solved through the app, avoiding emergency consultations.

Training in colorectal surgery in Europe and 20 years of the European Board of Surgical Qualification coloproctology examination.

AIM: Training in colorectal surgery across Europe is not yet standardized. The European Board of Surgical Qualification (EBSQ) coloproctology examination has been held annually since 1998. The aims of this study were to illustrate the current situation of coloproctology specialization in Europe and to analyse the EBSQ examinations held over the last 20 years. METHOD: A survey, focused on current training and education in colorectal surgery in Europe, was conducted among all national representatives of the European Society of Coloproctology (ESCP) in 2018. Candidate demographics (1998-2018) and the results of the EBSQ examination (2007-2018) were analysed. RESULTS: In Europe, there are currently 26 national colorectal societies, 27 national annual colorectal meetings, 16 national specialized training programmes and 13 national colorectal fellowships. Six countries have board certification in colorectal surgery and five a dedicated examination. During the last 20 years, 475 candidates from 29 countries, of whom 88 (19%) were women, passed the EBSQ examination. The pass rate was higher in younger applicants (< 42 years, P = 0.01). The success rate was higher for candidates with academic experience (more than five publications or presentations) and with an academic title (thesis) (P = 0.01). CONCLUSION: Colorectal surgical training is still not standardized in Europe, although efforts have been made to recognize colorectal surgery as an independent speciality. The number of holders of the EBSQ Diploma has increased over the years, demonstrating the acceptance of the examination among European surgeons. Young candidates with an academic profile are the most successful.

Receiver operating characteristic analysis to determine optimal fluid management during open colorectal surgery.

AIM: The present study aimed to analyse fluid management and to define optimal fluid-related thresholds for elective open colorectal surgery. METHOD: A retrospective analysis was made of all consecutive elective open colorectal resections performed in our tertiary centre between May 2011 and May 2017. The main outcomes were postoperative complications [overall (I-V) and severe (IIIB-V) according to the Clavien classification], respiratory complications and postoperative ileus (POI). Critical thresholds regarding perioperative fluid management and postoperative weight gain were identified by using receiver operator characteristic (ROC) analysis. Independent risk factors for overall complications were identified by multivariable logistic regression analysis. RESULTS: Of 121 patients who had open operations, 84 (69%) had some complication and 26 (21%) had severe complications. Respiratory complications and POI occurred in 15 (12%) and 46 patients (38%), respectively. The thresholds for intravenous fluids were 3.5 l at postoperative day (POD) 0 [area under ROC curve (AUROC) 0.7 for any 0.69 for respiratory complications] and 3.5 kg weight gain at POD 2 (AUROC 0.82 for respiratory complications). Multivariable analysis revealed weight gain of > 3.5 kg at POD 2 (OR 5.9; 95% CI 1.3-16.6) as a significant risk factor for overall complications. Acute kidney injury was observed in five patients (4%), three (5%) in the group with > 3.5 l at POD 0 and two (3%) in the group with < 3.5 l at POD 0 (P = 0.64). Creatinine increase was transitory and all patients regained baseline levels before discharge. CONCLUSION: A weight gain of > 3.5 kg at POD 2 has been identified as the critical threshold for overall and respiratory complications and prolonged length of stay after open elective colorectal surgery.

Resection with primary anastomosis vs nonrestorative resection for perforated diverticulitis with peritonitis: a systematic review and meta-analysis.

AIM: It is still controversial whether the optimal operation for perforated diverticulitis with peritonitis is primary anastomosis (PRA) or nonrestorative resection (NRR). The aim of this systematic review and meta-analysis was to evaluate mortality and morbidity rates following emergency resection for perforated diverticulitis with peritonitis and ostomy reversal, as well as ostomy nonreversal rates. METHOD: The Pubmed, EMBASE, Cochrane Library, MEDLINE via Ovid, CINAHL and Web of Science databases were systematically searched. Mortality was the primary end-point. A subgroup meta-analysis of randomized controlled trials was performed in addition to a meta-analysis of all eligible studies. Odds ratios (ORs) and mean difference (MD) were calculated for dichotomous and continuous outcomes, respectively. RESULTS: Seventeen studies, including three randomized controlled trials (RCTs), involving 1016 patients (392 PRA vs 624 NRR) were included. Overall, mortality was significantly lower in patients with PRA compared with patients with NRR [OR (95% CI) = 0.38 (0.24, 0.60), P < 0.0001]. Organ/space surgical site infection (SSI) [OR (95% CI) = 0.25 (0.10, 0.63), P = 0.003], reoperation [OR (95% CI) = 0.48 (0.25, 0.91), P = 0.02] and ostomy nonreversal rates [OR (95% CI) = 0.27 (0.09, 0.84), P = 0.02] were significantly decreased in PRA. In the RCTs, the mortality rate did not differ [OR (95% CI) = 0.46 (0.15, 1.38), P = 0.17]. The mean operating time for PRA was significantly longer than for NRR [MD (95% CI) = 19.96 (7.40, 32.52), P = 0.002]. Organ/space SSI [OR (95% CI) = 0.28 (0.09, 0.82), P = 0.02] was lower after PRA. Ostomy nonreversal rates were lower after PRA. The difference was not statistically significant [OR (95% CI) = 0.26 (0.06, 1.11), P = 0.07]. However, it was clinically significant [number needed to treat/harm (95% CI) = 5 (3.1, 8.9)]. CONCLUSION: This meta-analysis found that organ/space SSI rates as well as ostomy nonreversal rates were decreased in PRA at the cost of prolonging the operating time.

Application of an enhanced recovery pathway for ileostomy closure: a case-control trial with surprising results.

BACKGROUND: Enhanced recovery after surgery (ERAS) protocols have been widely validated in colorectal surgery; however, few data exist on loop ileostomy closure. The aim of this study was to compare clinical outcomes before and after introduction of ERAS for loop ileostomy closure. METHODS: Data on outcomes after loop ileostomy closure were retrospectively collected before ERAS was applied at our department (control group). These results were compared to results of patients undergoing loop ileostomy closure within the original colorectal ERAS pathway (ERAS 1 group); after analysis of these results, adaptations were made to the ERAS pathway regarding the postoperative diet, and this second category of patients was analyzed (ERAS 2 group). RESULTS: Forty-eight patients in the control group were compared to 46 ERAS 1 and 69 ERAS 2 patients. First stool was significantly faster in ERAS 2 group versus control and ERAS 1 group [median 1 (range 1-2) days vs 2 (2-3) days p value 0.01]. The incidence of vomiting increased from 26% in the control group to 45% in ERAS 1 group, and then decreased to 29% in the ERAS 2 group (p value 0.41). Length of stay was significantly shorter during the ERAS 2 protocol: median 4 (range 3-6) days versus 5 (4-8) days in the control group (p value < 0.01). CONCLUSIONS: After application of the 'colorectal' ERAS pathway to loop ileostomy closure, results were initially not improved. Minor corrections were sufficient to avoid increased incidence of vomiting and to allow for reduced hospital stay. Uncritical extrapolation of an ERAS colorectal protocol to other types of surgery should be monitored and needs audit for corrections.

Organ preservation in rectal cancer: a synopsis of current guidelines.

BACKGROUND: The high morbidity associated with radical resection for rectal cancer is an incentive for surgeons to adopt strategies aimed at organ preservation, particularly for early disease. There are a number of different approaches to achieve this. In this study we have collated current national and international guidelines to produce a synopsis to support this changing practice. METHODS: The databases PubMed, Embase, Trip database, national guideline clearinghouse, BMJ Best practice were interrogated. Guidelines published before 2010 were excluded. The AGREE-II tool was used for quality assessment. RESULTS: 24 guidelines were drawn from 2278 potential publications. A consensus exists for local excision for "low risk" T1 rectal cancer but there is no agreement how to stratify the risk of treatment failure. There is a low level of agreement for rectal preservation for more advanced disease but when mentioned is recommended for unfit patients or in th context of a clinical trial. Guidelines are inconsistent with respect to surveillance in node negative disease and after, complete response to chemoradiotherapy CONCLUSION: According to current guidelines and consensus statements organ preservation for rectal cancer beyond low risk T1, is still considered experimental and only indicated in patients unsuitable for radical surgery.. Follow up strategies and cN0 staging deserve attention and highlight the need for high quality clinical trials. This article is protected by copyright. All rights reserved.

Obstructed defaecation syndrome: European consensus guidelines on the surgical management.

Clinical decision-making in the treatment of patients with obstructed defaecation remains controversial and no international guidelines have been provided so far. This study reports a consensus among European opinion leaders on the management of obstructed defaecation in different possible clinical scenarios.

Systematic review of evidence and consensus on perianal fistula: an analysis of national and international guidelines.

AIM: Treatment of perianal fistula has evolved with the introduction of new techniques and biologicals in Crohn's disease (CD). Several guidelines are available worldwide, but many recommendations are controversial or lack high-quality evidence. The aim of this work was to provide an overview of the current available national and international guidelines for perianal fistula and to analyse areas of consensus and areas of conflicting recommendations, thereby identifying topics and questions for future research. METHOD: MEDLINE, EMBASE and PubMed were systematically searched for guidelines on perianal fistula. Inclusion was limited to papers in English less than 10 years old. The included topics were classified as having consensus (unanimous recommendations in at least two-thirds of the guidelines) or controversy (fewer than three guidelines commenting on the topic or no consensus) between guidelines. The highest level of evidence was scored as sufficient (level 3a or higher of the Oxford Centre for Evidence-based Medicine Levels of Evidence 2009, http://www.cebm.net/oxford-centre-evidence-based-medicine-levels-evidence-march-2009/) or insufficient. RESULTS: Twelve guidelines were included and topics with recommendations were compared. Overall, consensus was present in 15 topics, whereas six topics were rated as controversial. Evidence levels varied from strong to lack of evidence. CONCLUSION: Evidence on the diagnosis and treatment of perianal fistulae (cryptoglandular or related to CD) ranged from nonexistent to strong, regardless of consensus. The most relevant research questions were identified and proposed as topics for future research.

Delaying surgery to perform CT scans for suspected appendicitis decreases the rate of negative appendectomies without increasing the rate of perforation nor postoperative complications.

PURPOSE: Negative appendectomies are costly and are embedded with unnecessary risks for the patients. A careful indication for surgery seems mandatory even more so, since conservative therapy emerges as a potential alternative to surgery. The aims of this population-based study were to analyze whether radiological examinations for suspected appendicitis decreased the rate of negative appendectomies without increasing the rate of perforation or worsening postoperative outcomes. METHOD: This study is a retrospective analysis of a prospective population-based database. The data collection included preoperative investigations and intraoperative and postoperative outcomes. RESULTS: Based on 2559 patients, the rate of negative appendectomies decreased significantly with the use of CT scan as compared to clinical evaluation only (9.3 vs 5 %, p = 0.019), whereas ultrasonography alone was not able to decrease this rate (9.3 vs 6.2 %, p = 0.074). Delaying surgery for radiological investigation did not increase the rate of perforation (18.1 vs 19.2 %; adjusted odds ratio (OR) 1.01; 0.8-1.3; p = 0.899). Postoperative complications (surgical reintervention, postoperative wound infection, postoperative hematoma, postoperative intra-abdominal abscess, postoperative ileus) were all comparable. CONCLUSION: In this population-based study, CT scan was the only radiological modality that significantly reduced the rate of negative appendectomy. The delay induced by such additional imaging did not increase perforation nor complication rates. Abdominal CT scans for suspected appendicitis should therefore be more frequently used if clinical findings are unconclusive.

A new stomaplasty ring (Koring™) to prevent parastomal hernia: an observational multicenter Swiss study.

BACKGROUND: Parastomal hernias (PSH) are one of the most frequent complications of enterostomies with a non-negligible complication rate and a significant socioeconomic effect. Therefore, preventing PSH by placing a mesh at the time of primary surgery has been advocated. The aim of our study was to evaluate the safety and feasibility of the new stomaplasty ring [Koring™, (Koring GmbH, Basel, Switzerland)] and investigate the reason why surgeons are reluctant to take preventive measures. METHODS: A multicenter observational study was conducted on 30 patients between December 2013 and January 2015. In permanent end colostomies and end ileostomies, the Koring™ was implanted. The primary outcome was the 30-day morbidity (infection and other stoma-related complications). Secondary endpoints were the technical feasibility and the time needed to fix the ring. In addition, an online survey of 107 surgeons was performed. RESULTS: Twenty-seven patients received permanent end colostomies, and three received end ileostomies. No stoma-related complication was detected within the first 30 days post-operatively. The Koring™ ring was evaluated by the surgeons as easy and very easy to implant in more than half of the patients. Average additional operating time for ring implantation was 19 min. CONCLUSIONS: Koring™ implantation at the time of creating the stoma is safe, easy and only adds minimally operating time. A long-term follow-up as well as a randomized controlled study is needed to evaluate the impact of the Koring™ on PSH prevention. The ease and rapidity with which Koring™ can be implanted may help surgeons to overcome their apprehension of using a preventative device.

Results of the Gore Bio-A fistula plug implantation in the treatment of anal fistula: a multicentre study.

BACKGROUND: The aim of this prospective study was to determine the efficiency of the Gore Bio-A synthetic plug in the treatment of anal fistulas. METHODS: A synthetic bioabsorbable anal fistula plug was implanted in 60 patients. All fistulas were transsphincteric and cryptoglandular in origin. RESULTS: The healing rate after 1 year of follow-up was 52 % (31 out of 60 patients). No patient was lost to follow-up. The treatment had no effect on the incontinence score. The plug dislodgement rate was 10 % (6 out of 60 patients). Thirty-four per cent of the patients (16 out of 47) required reoperation. The average operating time was 32 ± 10.2 min, and the average length of hospital stay was 3.3 ± 1.8 days. CONCLUSIONS: Synthetic plugs may be an alternative to bioprosthetic fistula plugs in the treatment of transsphincteric anal fistulas. This method might have better success rates than treatment with bioprosthetic fistula plugs.

Transanal minimal invasive surgery for rectal lesions: should the defect be closed?

AIM: Transanal minimal invasive surgery (TAMIS) of rectal lesions is increasingly being used, but the technique is not yet standardized. The aims of this study were to evaluate peri-operative complications and long-term functional outcome of the technique and to analyse whether or not the rectal defect needs to be closed. METHOD: Consecutive patients undergoing TAMIS using the SILS port (Covidien) and standard laparoscopic instruments were studied. RESULTS: Seventy-five patients (68% male) of mean age 67 (± 15) years underwent single-port transanal surgery at three different centres for 37 benign lesions and 38 low-risk cancers located at a mean of 6.4 ± 2.3 cm from the anal verge. The median operating time was 77 (25-245) min including a median time for resection of 36 (15-75) min and for closure of the rectal defect of 38 (9-105) min. The defect was closed in 53% using interrupted (75%) or a running suture (25%). Intra-operative complications occurred in six (8%) patients and postoperative morbidity was 19% with only one patient requiring reoperation for Grade IIIb local infection. There was no difference in the incidence of complications whether the rectal defect was closed or left open. Patients were discharged after 3.4 (1-21) days. At a median follow-up of 12.8 (2-29) months, the continence was normal (Vaizey score of 1.5; 0-16). CONCLUSION: Transanal rectal resection can be safely and efficiently performed by means of a SILS port and standard laparoscopic instruments. The rectal defect may be left open and at 1 year continence is not compromised.

Rectal enema is an alternative to full mechanical bowel preparation for primary rectal cancer surgery.

AIM: According to the French GRECCAR III randomized trial, full mechanical bowel preparation (MBP) for rectal surgery decreases the rate of postoperative morbidity, in particular postoperative infectious complications, but MBP is not well tolerated by the patient. The aim of the present study was to determine whether a preoperative rectal enema (RE) might be an alternative to MBP. METHODS: An analysis was performed of 96 matched cohort patients undergoing rectal resection with primary anastomosis and protective ileostomy at two different university teaching hospitals, whose rectal cancer management was comparable except for the choice of preoperative bowel preparation (MBP or RE). Prospective databases were retrospectively analysed. RESULTS: Patients were well matched for age, gender, body mass index and Charlson index. The surgical approach and cancer characteristics (level above anal verge, stage and use of neoadjuvant therapy) were comparable between the two groups. Anastomotic leakage occurred in 10% of patients having MBP and in 8% having RE (P = 1.00). Pelvic abscess formation (6% vs 2%, P = 0.63) and wound infection (8% vs 15%, P = 0.55) were also comparable. Extra-abdominal infection (13% vs 13%, P = 1.00) and non-infectious abdominal complications such as ileus and bleeding (27% and 31%, P = 0.83) were not significantly different. Overall morbidity was comparable in the two groups (50% vs 54%, P = 0.83). CONCLUSION: A simple RE before rectal surgery seems not to be associated with more postoperative infectious complications nor a higher overall morbidity than MBP.

An outcome and cost analysis of anal fistula plug insertion vs endorectal advancement flap for complex anal fistulae.

AIM: The study aimed to compare the rate of success and cost of anal fistula plug (AFP) insertion and endorectal advancement flap (ERAF) for anal fistula. METHOD: Patients receiving an AFP or ERAF for a complex single fistula tract, defined as involving more than a third of the longitudinal length of of the anal sphincter, were registered in a prospective database. A regression analysis was performed of factors predicting recurrence and contributing to cost. RESULTS: Seventy-one patients (AFP 31, ERAF 40) were analysed. Twelve (39%) recurrences occurred in the AFP and 17 (43%) in the ERAF group (P = 1.00). The median length of stay was 1.23 and 2.0 days (P < 0.001), respectively, and the mean cost of treatment was €5439 ± €2629 and €7957 ± €5905 (P = 0.021), respectively. On multivariable analysis, postoperative complications, underlying inflammatory bowel disease and fistula recurring after previous treatment were independent predictors of de novo recurrence. It also showed that length of hospital stay ≤ 1 day to be the most significant independent contributor to lower cost (P = 0.023). CONCLUSION: Anal fistula plug and ERAF were equally effective in treating fistula-in-ano, but AFP has a mean cost saving of €2518 per procedure compared with ERAF. The higher cost for ERAF is due to a longer median length of stay.

[Acute sigmoid diverticulitis: toward a more and more conservative treatment]. / Diverticulites sigmoïdiennes aiguës: vers un traitement de plus en plus conservateur.

Acute diverticulitis of the colon is a frequent pathology especially among elderly people and people of Caucasian origin. The prevalence is higher among sedentary people and in people with low-fiber diet. Its diagnosis is mainly based on computed tomography (CT) that allows guiding the therapeutic management. Over the last few years the treatment of acute diverticulitis has passably changed with in particular an evolution toward a restriction of the elective and emergency surgery indications and a reduction of the antiobiotherapy and hospitalization number. This article reviews the epidemiology, the diagnostic tools, and the management of this frequent digestive pathology.