A new surgical technique: robotic intracorporeal Kono-S anastomosis in Crohn's - a safety and feasibility case series on short-term outcomes.

AIM: The Kono-S anastomosis was introduced as a possible solution to the high surgical recurrence rates in Crohn's disease. However, this technique is known to be challenging, which is why it was originally performed in an extracorporeal setting. The aim of this case series was to assess safety, in terms of intra-/postoperative complications, and feasibility, in terms of successful performance of anastomosis, of a robot-assisted intracorporeal Kono-S anastomosis. METHOD: This is a prospective single-centre consecutive case series. Patients were considered eligible if they were diagnosed with refractory Crohn's disease with significant bowel stenosis of the terminal ileum. All patients underwent robot-assisted intracorporeal Kono-S anastomosis. Perioperative care was provided according to the Enhanced Recovery After Surgery® protocol. Follow-up for postoperative complications was 30 days. RESULTS: Twenty patients were included, of whom 11 (55%) were men. The median age was 30 years [interquartile range (IQR) 22-51 years] and the median BMI was 25 kg/m2 (IQR 19-28 kg/m2). Intracorporeal Kono-S anastomosis was successfully performed in all cases. The median operating time was 155 min (IQR 144-176 min) and the median length of stay was 3 days (IQR 1-5 days). No conversions or 30-day mortality were observed. One patient experienced anastomotic leakage, which was treated with radiologically guided drainage. A total of three patients experienced postoperative complications in the first 30 days. CONCLUSION: Performance of intracorporeal robot-assisted Kono-S anastomosis seems safe and feasible in this case series for Crohn's disease. Since this is a first case series, further research is required to confirm results in a larger population-based cohort.

Blunt abdominal injury resulting in a belly full of candy after a motocross accident, a case report.

BACKGROUND: Blunt traumatic gastric perforations in children are rare. Delayed diagnosis will lead to abdominal contamination and may result in morbidity and even mortality. We present a case of an adolescent who sustained blunt abdominal injury in a motocross accident and presented with remarkable hyperdense spherical shaped structures on the computed tomography (CT). CASE PRESENTATION: A 15-year-old boy arrived at the emergency room with an acute abdomen after a motocross accident. A CT scan of the abdomen demonstrated free air and hyperdense round structures in the stomach, pelvic cavity and right paracolic gutter. During emergency laparotomy a traumatic gastric perforation was sutured, a splenic rupture was treated with a vicryl mesh and multiple spherical food scraps were removed from the abdomen. After surgery, the boy clarified that he had eaten a whole bag of colorful and spherical shaped candy just before the accident. CONCLUSIONS: Traumatic gastric rupture in children is rare but physicians should be aware of this diagnosis in case of blunt abdominal trauma with free air on the CT scan. Gastric contents, in this case candy, can present as hyperdense shaped structures in the abdominal cavity on the CT scan.

Five-Year Outcome of Self-Expanding Covered Stents for Superficial Femoral Artery Occlusive Disease and an Analysis of Factors Predicting Failure.

PURPOSE: To investigate the 5-year outcome of patients treated with self-expanding covered stents for superficial femoral artery (SFA) occlusive disease and identify parameters that could predict loss of primary patency. METHODS: In a dual-center study, 315 consecutive patients (mean age 69.0±10.1 years; 232 men) treated for SFA occlusive disease in 334 limbs with Viabahn self-expanding covered stents between 2001 and 2014 were retrospectively analyzed. Mean lesion length was 11.7±8.8 cm, and half of the lesions were classified as TASC II C/D. Five-year patency rates were calculated, and Cox regression analyses were performed to assess potential factors affecting patency. RESULTS: All-cause mortality at 5 years was 14.1%. Primary patency rates at 1, 3, and 5 years were 72.2%, 51.8%, and 47.6%, respectively, with secondary patency rates of 86.2%, 78.7%, and 77.5%. Parameters predicting loss of primary patency in a univariate analysis were covered stent diameter (p=0.001), the number of covered stents per lesion (p=0.015), and TASC II D classification (p=0.007). Covered stent diameter was the only parameter predicting loss of primary patency in the multivariate regression analysis (p=0.001), with 7-mm covered stents having superior performance. CONCLUSION: Five-year patency rates of self-expanding covered stents inserted for SFA occlusive disease are within an acceptable range. Covered stent diameter is the most relevant factor in predicting loss of primary patency, and thus, an adequate diameter of the distal landing site seems to be among the most important factors in the decision-making process. In smaller vessels, one should not use covered stents but venous conduits, as oversizing may be detrimental.

Use of ileostomy versus colostomy as a bridge to surgery in left-sided obstructive colon cancer: retrospective cohort study.

BACKGROUND: Colorectal cancer causes the majority of large bowel obstructions and surgical resection remains the gold standard for curative treatment. There is evidence that a deviating stoma as a bridge to surgery can reduce postoperative mortality rate; however, the optimal stoma type is unclear. The aim of this study was to compare outcomes between ileostomy and colostomy as a bridge to surgery in left-sided obstructive colon cancer. METHODS: This was a national, retrospective population-based cohort study with 75 contributing hospitals. Patients with radiological left-sided obstructive colon cancer between 2009 and 2016, where a deviating stoma was used as a bridge to surgery, were included. Exclusion criteria were palliative treatment intent, perforation at presentation, emergency resection, and multivisceral resection. RESULTS: A total of 321 patients underwent a deviating stoma; 41 (12.7 per cent) ileostomies and 280 (87.2 per cent) colostomies. The ileostomy group had longer length of stay (median 13 (interquartile range (i.q.r.) 10-16) versus 9 (i.q.r. 6-14) days, P = 0.003) and more nutritional support during the bridging interval. Both groups showed similar complication rates in the bridging interval and after primary resection, including anastomotic leakage. Stoma reversal during resection was more common in the colostomy group (9 (22.0 per cent) versus 129 (46.1 per cent) for ileostomy and colostomy respectively, P = 0.006). CONCLUSION: This study demonstrated that patients having a colostomy as a bridge to surgery in left-sided obstructive colon cancer had a shorter length of stay and lower need for nutritional support. No difference in postoperative complications were found.

Prediction of Non-Response to Neoadjuvant Chemoradiotherapy in Esophageal Cancer Patients with 18F-FDG PET Radiomics Based Machine Learning Classification.

BACKGROUND: Approximately 26% of esophageal cancer (EC) patients do not respond to neoadjuvant chemoradiotherapy (nCRT), emphasizing the need for pre-treatment selection. The aim of this study was to predict non-response using a radiomic model on baseline 18F-FDG PET. METHODS: Retrospectively, 143 18F-FDG PET radiomic features were extracted from 199 EC patients (T1N1-3M0/T2-4aN0-3M0) treated between 2009 and 2019. Non-response (n = 57; 29%) was defined as Mandard Tumor Regression Grade 4-5 (n = 44; 22%) or interval progression (n = 13; 7%). Randomly, 139 patients (70%) were allocated to explore all combinations of 24 feature selection strategies and 6 classification methods towards the cross-validated average precision (AP). The predictive value of the best-performing model, i.e AP and area under the ROC curve analysis (AUC), was evaluated on an independent test subset of 60 patients (30%). RESULTS: The best performing model had an AP (mean ± SD) of 0.47 ± 0.06 on the training subset, achieved by a support vector machine classifier trained on five principal components of relevant clinical and radiomic features. The model was externally validated with an AP of 0.66 and an AUC of 0.67. CONCLUSION: In the present study, the best-performing model on pre-treatment 18F-FDG PET radiomics and clinical features had a small clinical benefit to identify non-responders to nCRT in EC.

The immediate impact of the coronavirus disease 2019 (COVID-19) pandemic on burn-out, work-engagement, and surgical training in the Netherlands.

BACKGROUND: The coronavirus disease 2019 pandemic led to major changes in health care and education options for all health care employees. The aim of this study is to achieve insight into coronavirus disease-care participation of surgical residents in the Netherlands, the impact of coronavirus disease 2019 on the experienced quality of surgical training, and the influence on Burn-out and Work Engagement compared with the non-coronavirus disease 2019 period in January 2020. METHODS: In this study, we have conducted 2 digital surveys immediately before and 2 months after the start of the coronavirus disease 2019 pandemic. We surveyed a validated Dutch questionnaire 'Utrecht Burn-out Scale,' derived from the Maslach Burn-out Inventory, and also collected the 'Utrecht Work Engagement Scale' measuring work engagement. Additionally, we describe the coronavirus disease-care participation of surgical residents, the impact on how they experienced the quality of their surgical training, and the influence on 'Burn-out and Work Engagement' compared with the pre-coronavirus disease 2019 period for surgical residents in the Netherlands. RESULTS: In January 2020, a total of 317 residents completed the online survey, and in April 2020, a total of 313 residents completed the online survey. Of the responders, 48.6%, in April, participated in coronavirus disease-care in both the coronavirus disease ward as well as the coronavirus disease intensive care unit. Residents experienced that the coronavirus disease 2019 influenced their surgical training in 85.2% of responders. In only 5% of the residents did the pandemic not affect the exposure to surgical training in the operating theater. More burn-out symptoms were noted amongst coronavirus disease ward deployed residents versus no coronavirus disease ward deployment, (16.0% vs 7.6%, P = .06). The Work-Engagement questionnaire showed a significantly lower work engagement score of 4.2 for residents who were deployed in a coronavirus disease-care intensive care unit versus a score of 4.6 for residents scheduled in a coronavirus disease ward (P = .02). CONCLUSION: This study shows a significant impact of the first months of the coronavirus disease 2019 pandemic on the Dutch surgical trainee program, with a major redistribution of residents with a decrease of surgical exposure and education. We emphasize the need for adequate guidance of all surgical residents and potentially lengthening the surgical training program.

Intestinal obstruction caused by pericecal internal herniation.

Intestinal obstruction caused by pericecal internal herniation are rare and only described in a few cases. This case describes an 80-year-old man presented with acute abdominal pain, nausea and vomiting, with no prior surgical history. Computed tomography was performed and showed a closed loop short bowel obstruction in the right lower quadrant and ascites. Laparoscopy revealed pericecal internal hernia. This is a viscous protrusion through a defect in the peritoneal cavity. Current operative treatment modalities include minimally invasive surgery. Laparoscopic repair of internal herniation is possible and feasible in experienced hands. It must be included in the differential diagnoses of every patient who presents with abdominal pain. When diagnosed act quick and thorough and expeditiously. Treatment preference should be a laparoscopic procedure.

Malignant Transformation of an HNF1a-Inactivated Hepatocellular Adenoma to Hepatocellular Carcinoma.

Hepatocellular adenomas (HCA) are rare benign tumors of the liver, occurring predominantly in females using oral contraceptives. Our case describes a 66-year-old woman presenting with a palpable mass in her upper abdomen. Contrast-enhanced computed tomography and magnetic resonance imaging showed a large exophytic mass protruding from the caudal border of liver segments IV and V, without visible metastases. Laparoscopic resection of the tumor and gallbladder was performed. Histopathological examination showed a hepatocellular carcinoma with areas of HNF1a-HCA (H-HCA). This case shows that malignant transformation is possible in H-HCA. We present our preoperative decision-making process, as well as the role of imaging techniques in this rare case.

Twenty-four hours stay after colorectal surgery: a systematic review

Introduction: The introduction of Enhanced Recovery After Surgery led to increasing twenty-four hours discharge pathways, for example in laparoscopic cholecystectomy and bariatric surgery. However, implementation in colorectal surgery still must set off. This systematic review assesses safety and feasibility of twenty-four hours discharge in colorectal surgery in terms of readmission and complications in current literature. Secondary outcome was identification of factors associated with success of twenty-four hours discharge. Methods: Pubmed and EMBASE databases were searched to identify studies investigating twenty-four hours discharge in colorectal surgery, without restriction of study type. Search strategy included keywords relating to ambulatory management and colorectal surgery. Studies were scored according to MINORS score. Results: Thirteen studies were included in this systematic review, consisting of six prospective and seven retrospective studies. Number of participants of the included prospective studies ranged from 5 to 157. Median success of discharge was 96% in the twenty-four hours discharge group. All prospective studies showed similar readmission and complication rates between twenty-four hours discharge and conventional postoperative management. Factors associated with success of twenty-four hours discharge were low ASA classification, younger age, minimally invasive approach, and relatively shorter operation time. Conclusions: Twenty-four hours discharge in colorectal surgery seems feasible and safe, based on retro- and prospective studies. Careful selection of patients and establishment of a clear and adequate protocol are key items to assure safety and feasibility. Results should be interpreted with caution, due to heterogeneity. To confirm results, an adequately powered prospective randomized study is needed. (AU)

Two versus five days of antibiotics after appendectomy for complex acute appendicitis (APPIC): study protocol for a randomized controlled trial.

BACKGROUND: Acute appendicitis is one of the most common indications for emergency surgery. In patients with a complex appendicitis, prolonged antibiotic prophylaxis is recommended after appendectomy. There is no consensus regarding the optimum duration of antibiotics. Guidelines propose 3 to 7 days of treatment, but shorter courses may be as effective in the prevention of infectious complications. At the same time, the global issue of increasing antimicrobial resistance urges for optimization of antibiotic strategies. The aim of this study is to determine whether a short course (48 h) of postoperative antibiotics is non-inferior to current standard practice of 5 days. METHODS: Patients of 8 years and older undergoing appendectomy for acute complex appendicitis - defined as a gangrenous and/or perforated appendicitis or appendicitis in presence of an abscess - are eligible for inclusion. Immunocompromised or pregnant patients are excluded, as well as patients with a contraindication to the study antibiotics. In total, 1066 patients will be randomly allocated in a 1:1 ratio to the experimental treatment arm (48 h of postoperative intravenously administered (IV) antibiotics) or the control arm (5 days of postoperative IV antibiotics). After discharge from the hospital, patients participate in a productivity-cost-questionnaire at 4 weeks and a standardized telephone follow-up at 90 days after appendectomy. The primary outcome is a composite endpoint of infectious complications, including intra-abdominal abscess (IAA) and surgical site infection (SSI), and mortality within 90 days after appendectomy. Secondary outcomes include IAA, SSI, restart of antibiotics, length of hospital stay (LOS), reoperation, percutaneous drainage, readmission rate, and cost-effectiveness. The non-inferiority margin for the difference in the primary endpoint rate is set at 7.5% (one-sided test at ɑ 0.025). Both per-protocol and intention-to-treat analyses will be performed. DISCUSSION: This trial will provide evidence on whether 48 h of postoperative antibiotics is non-inferior to a standard course of 5 days of antibiotics. If non-inferiority is established, longer intravenous administration following appendectomy for complex appendicitis can be abandoned, and guidelines need to be adjusted accordingly. TRIAL REGISTRATION: Dutch Trial Register, NTR6128 . Registered on 20 December 2016.

A traumatic superficial temporal artery aneurysm after a bicycle accident.

A male cyclist presented with a swelling on the forehead. Six weeks before, he fell of his bike and smashed his head on the ground while wearing a helmet. A smooth lump of 1 cm had evolved on the temporal side of his forehead in a few weeks. Duplex ultrasonography demonstrated a dilated vessel with a minor defect in the luminal wall. Surgical exploration revealed an aneurysm of the superficial temporal artery (STA). The aneurysm was surgically removed and the patient recovered uneventfully. Owing to its superficial course, the STA is vulnerable to blunt head trauma. Traumatic aneurysms of the STA should be a differential diagnostic consideration in patients with a history of trauma and a swelling on their head.