Fluorescence-based bowel anastomosis perfusion evaluation: results from the IHU-IRCAD-EAES EURO-FIGS registry.

BACKGROUND: Anastomotic leakage (AL) is one of the dreaded complications following surgery in the digestive tract. Near-infrared fluorescence (NIRF) imaging is a means to intraoperatively visualize anastomotic perfusion, facilitating fluorescence image-guided surgery (FIGS) with the purpose to reduce the incidence of AL. The aim of this study was to analyze the current practices and results of NIRF imaging of the anastomosis in digestive tract surgery through the EURO-FIGS registry. METHODS: Analysis of data prospectively collected by the registry members provided patient and procedural data along with the ICG dose, timing, and consequences of NIRF imaging. Among the included upper-GI, colorectal, and bariatric surgeries, subgroup analysis was performed to identify risk factors associated with complications. RESULTS: A total of 1240 patients were included in the study. The included patients, 74.8% of whom were operated on for cancer, originated from 8 European countries and 30 hospitals. A total of 54 surgeons performed the procedures. In 83.8% of cases, a pre-anastomotic ICG dose was administered, and in 60.1% of cases, a post-anastomotic ICG dose was administered. A significant difference (p < 0.001) was found in the ICG dose given in the four pathology groups registered (range: 0.013-0.89 mg/kg) and a significant (p < 0.001) negative correlation was found between the ICG dose and BMI. In 27.3% of the procedures, the choice of the anastomotic level was guided by means of NIRF imaging which means that in these cases NIRF imaging changed the level of anastomosis which was first decided based on visual findings in conventional white light imaging. In 98.7% of the procedures, the use of ICG partly or strongly provided a sense of confidence about the anastomosis. A total of 133 complications occurred, without any statistical significance in the incidence of complications in the anastomoses, whether they were ICG-guided or not. CONCLUSION: The EURO-FIGS registry provides an insight into the current clinical practice across Europe with respect to NIRF imaging of anastomotic perfusion during digestive tract surgery.

A simple in silico strategy identifies candidate biomarkers for the diagnosis of liver fibrosis in morbidly obese subjects.

BACKGROUND & AIMS: Non-alcoholic fatty liver disease (NAFLD) is a chronic liver disorder, tightly associated with obesity. The histological spectrum of the disease ranges from simple steatosis to steatohepatitis, with different stages of fibrosis, and fibrosis stage is the most significant predictor of mortality in NAFLD. Liver biopsy continues to be the gold standard for its diagnosis and reliable non-invasive diagnostic tools are unavailable. We investigated the accuracy of candidate proteins, identified by an in silico approach, as biomarkers for diagnosis of fibrosis. METHODS: Seventy-one morbidly obese (MO) subjects with biopsy-proven NAFLD were enrolled, and the cohort was subdivided according to minimal (F0/F1) or moderate (F2/F3) fibrosis. The plasmatic level of CD44 antigen (CD44), secreted protein acidic and rich in cysteine (SPARC), epidermal growth factor receptor (EGFR) and insulin-like growth factor 2 (IGF2) were determined by ELISA. Significant associations between plasmatic levels and histological fibrosis were determined by correlation analysis and the diagnostic accuracy by the area under receiver operating characteristic curves (AUROC). RESULTS: Eighty-two percentage of the subjects had F0/F1 and 18% with F2/F3 fibrosis. Plasmatic levels of IGF2, EGFR and their ratio (EGFR/IGF2) were associated with liver fibrosis, correlating inversely for IGF2 (P < .006) and directly (P < .018; P < .0001) for EGFR and EGFR/IGF2 respectively. The IGF2 marker had the best diagnostic accuracy for moderate fibrosis (AUROC 0.83), followed by EGFR/IGF2 ratio (AUROC 0.79) and EGFR (AUROC 0.71). CONCLUSIONS: Our study supports the potential utility of IGF2 and EGFR as non-invasive diagnostic biomarkers for liver fibrosis in morbidly obese subjects.

Modifiable and non-modifiable risk factors for surgical site infection after colorectal surgery: a single-center experience.

PURPOSE: Surgical site infection (SSI) is the most common complication of colorectal surgery, resulting in significant burden in terms of morbidity and length of hospital stay. The aims of this study were to establish the incidence of SSI in patients undergoing colorectal surgeries and to identify potentially modifiable risk factors to reduce overall SSI rates. METHODS: This retrospective study analyzed patients who underwent colorectal resection at our Department. Patients were identified using a prospective SSI database. Univariate and multivariate analyses were used to identify risk factors. RESULTS: A total of 687 patients were enrolled in the study and the overall SSI rate was 19.9% (137 patients). Superficial incisional surgical site infections (SSSIs) developed in 52 (7.6%) patients, deep incisional surgical site infections (DSSIs) developed in 15 (2.2%), and organ/space infections (OSIs) developed in 70 (10.1%). Univariate and multivariate analyses confirmed that age, diabetes, emergency surgery, and a high infection risk index are risk factors for SSI. CONCLUSIONS: There are some modifiable and non-modifiable risk factors for SSI. IRI and age are non-modifiable, whereas the timing of surgery and diabetes can be modulated by trying to defer some emergency procedures to elective ones and normalizing the glycemia of diabetic patients.

Sociodemographic and clinical changes in pediatric in-patient admissions for mental health emergencies during the COVID-19 pandemic: March 2020 to June 2021.

COVID-19 pandemic may affect children's mental health. Children <18 years in-patiently admitted for mental health emergencies between March 2020 and June 2021 were compared to those admitted in the same period of 2018-2019 in terms of sociodemographic and clinical characteristics. There were 49 admissions in the pre-pandemic period and 60 in the pandemic period (IRR: 1.22; 95% CI: 0.84-1.79), with the latter more likely to have a family history of psychiatric disorders, a personal history of physical disturbances, present with suicidal risk, and being diagnosed with an externalizing disorder. This study underscores the increased need for pediatric mental health services.

Peri-operative Morbidity of Nissen Sleeve Gastrectomy: Prospective Evaluation of a Cohort of 365 Patients, Beyond the Learning Curve.

PURPOSE: Over the last decade, an important interest was taken to prevent the reflux following sleeve. A new variant, Nissen-sleeve, was described with the purpose to prevent GERD and to decrease the occurrence of leak. The current study reports the preliminary results of a prospective trial. MATERIALS AND METHODS: All consecutive patients who underwent a Nissen-Sleeve between January 2018 and September 2020 were included. Baseline characteristics including age, gender, weight, body mass index (BMI), GERD symptoms, and treatment were evaluated after 1 year. Operative time, length of stay, complication, and reoperation data were also collected. RESULTS: Three hundred sixty-five consecutive patients decided to undergo Nissen-sleeve: 75% females with median age of 41.2 years (+ / - 14.1) and an average BMI of 41.6 kg/m2 (+ / - 5.4). There were 16 cases (4.4%) of early postoperative complications (< 30 days): six cases of acute wrap perforation (1.6%), intraabdominal bleeding for 5 patients (1.4%), one case of wrap dilatation (0.3%), one case of acute complete aphagia, one case of incarcerated umbilical hernia, and 2 cases (0.5%) of pulmonary atelectasis/pneumonia and one venous pulmonary embolism. We recorded the following complications: 16 patients (4.4%) mild dysphagia; 3 patients (0.8%) chronic dysphagia; and 2 cases of wrap perforation that have been diagnosed 8 and 9 months respectively, after the procedure due to the use of steroids not associated with PPI intake. The mean operative time was 83 min (46-125 min). The conversion and mortality rates were nil. CONCLUSION: Following the initial learning curve and additional technical modifications, the Nissen-Sleeve appears to be a safe surgical technique with an acceptable early postoperative complication rate. CLINICAL TRIAL REGISTRATION: NCT02310178.

Acute and complicated diverticulitis: are there significant differences between young and elderly patients?

AIM: The aim of our study was to assess if there were any differences in clinical presentation, management, and outcome, between younger and elderly patients with acute diverticulitis (AD). MATERIAL OF STUDY: 279 patients with diagnosis of AD treated at the General Surgery Department of Trieste from January 2007 to December 2015 were retrospectively examined and then followed for a minimum of 4 years. We divided patients in two categories: young ≤ 50 years and elderly > 50. Gender, American Society of Anesthesiologists status (ASA score), Hinchey's stage, type and timing of surgery, morbidity, length of hospital stay, recurrence, and overall mortality were retrospectively analyzed. RESULTS: There were 279 patients, 64 (22,9 %) were young and 215 (77,1%) were elderly. Female gender was more frequent in elderly cohort (150 pts 69,7 % F vs 65 pts 30,3 % M) than in the young (16 pts, 25% F vs 48 pts, 75% M), (p<0,001). Higher ASA scores were registered in elderly patients with statistically significant correlation with Hinchey's stage. 229 patients ( 82,07 %) received as initial treatment antibiotic therapy (conservative treatment), 50 (17,93 %) pts underwent EM-S, and 11 underwent to DEL-S. DISCUSSION: In our experience, none significant differences were recorded about Hinchey's stage, timing of surgery, morbidity, length of hospital stay, and recurrence; whereas, regarding the type of surgery (resection-anastomosis (R-A), Hartmann's procedures, and Lavage/Drainage) there were a significant difference (p=0,04). CONCLUSIONS: Hartmann's procedures have been effectuated more frequently in the elderly than in the young with recanalization in less than half of elderly. These data seems to confirm that there is no significant difference in incidence or the natural course of acute and complicated colonic diverticulitis among the young or the elderly. The best surgical treatment, with the least morbidity, may be resection with primary anastomosis. KEY WORDS: Diverticular Disease, Elderly Patients, Sigmoidectomy, Young Patients.

Changes in Gut Microbiota Composition after Bariatric Surgery: a New Balance to Decode.

BACKGROUND: Recently, the link between obesity and gut microbiota has become a focus for research. This study shed some light on the modification of postoperative gut microbial composition after bariatric surgery. METHODS: A prospective longitudinal study on healthy lean subjects and patients who underwent bariatric surgery (Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy) was carried out. Anthropometric and metabolic data, smoking, food preferences data, and stool samples were collected from lean subjects and from obese patients before and 3 and 6 months after surgery (T0, T3, and T6, respectively). RESULTS: We collected stool samples from 25 obese patients before surgery and 3 and 6 months thereafter and from 25 normal weight patients. After Roux-en-Y gastric bypass, Yokenella regensburgei (p < 0.05), Fusobacterium varium (p < 0.05), Veillonella dispar/atypica (p < 0.05), and Streptococcus australis/gordonii (p < 0.05) were transiently identified in the gut at T3. Roux-en-Y gastric bypass patients had a permanent increase in Akkermansia muciniphila (p < 0.05), which is associated with healthy metabolism, both at T3 and T6. There were no significant changes in gut microbiota in laparoscopic sleeve gastrectomy patients. CONCLUSIONS: In our study, Roux-en-Y gastric bypass induced major microbial differences and greater weight loss compared with laparoscopic sleeve gastrectomy. Analyzing the microbiota composition, a proliferation of potential pathogens and the onset of beneficial bacteria was observed. The effects of these bacteria on human health are still far from clear. Understanding the mechanisms of action of these bacteria could be the keystone in developing new therapeutic strategies for obesity.

Medically unexplained symptoms in the times of COVID-19 pandemic: A case-report.

In early 2020, a novel coronavirus (SARS-CoV-2) leading to a potentially fatal condition was discovered. Since then, the 2019 coronavirus disease (COVID-19) has spread worldwide becoming a pandemic. Beyond the risks strictly related to the infection, concerns have been expressed for the psychological impact that COVID-19 may have, especially on vulnerable individuals with pre-existing mental health conditions. Somatic symptom disorder (SSD) is characterized by a dysfunctional preoccupation with physical symptoms leading to excessive and unnecessary healthcare utilization. Despite being quite common, such condition remains underrecognized. We report a detailed clinical case of a 16 years old adolescent, who presented with a history suggestive of COVID-19 infection and associated psychological distress. Despite testing negative for the presence of SARS-CoV-2, his extreme and persisting health preoccupations required an inpatient admission to the Child and Adolescent Neuropsychiatric Unit. He responded rapidly to a low dose of antipsychotic and an antidepressant. Based on his medical history and current presentation, he received a diagnosis of SSD. When COVID-19-like symptoms occur, we highlight the importance of differentially diagnosing a possible exacerbation of a pre-existing SSD, triggered by fear of being infected. This may help preventing further burden to the healthcare system.

Level of pancreatic division and postoperative pancreatic fistula after distal pancreatectomy: A retrospective case-control study of 157 patients with non-pancreatic ductal adenocarcinoma lesions.

BACKGROUND: Several studies have suggested that the level of pancreatic division during distal pancreatectomy (DP) has an impact on postoperative pancreatic fistula (POPF) occurrence. The purpose of this study was thus to investigate the level of pancreatic division as a potential risk factor for POPF after DP for non-pancreatic ductal adenocarcinoma lesions (non-PDAC) in the era of parenchyma-sparing resection. METHODS: Data from 217 patients requiring DP were collected in a prospectively maintained database from January 1997 to December 2017 and analyzed retrospectively. Only data from patients who underwent DP using a linear stapler for non-PDAC lesions were analyzed. The outcomes of DP with body/tail division (Body-Tail group) were compared to DP with neck division (Neck group). The primary outcome was POPF according to the 2016 ISGPF. RESULTS: Data from 157 patients who underwent DP using a linear stapler for non-PDAC lesions were included for analysis. Body-Tail (n = 53) and Neck (n = 104) groups were comparable concerning demographic data, period of treatment, BMI, ASA score, comorbidities, type of lesion, median lesion size, laparoscopic or open approach and spleen preservation rate. No differences were found in POPF (5.5 and 12.5%, p = 0.388) and new-onset pancreatogenic diabetes mellitus (22.5 vs. 20%; p = 0.439) in Body-Tail and Neck groups respectively. CONCLUSION: Clinically relevant POPF and postoperative diabetes do not appear to be affected by pancreatic division level. The intention to prevent POPF or pancreatogenic diabetes should not influence the decision on level of pancreatic division during DP.

Touch Imprinting Cytology may be useful in the intraoperative evaluation of the sentinel lymph node in melanoma.

PURPOSE: The aim of the study was to assess whether the reliability of Touch Imprinting Cytology (TIC) of Sentinel lymph node biopsy (SLNB) in skin melanoma patients allows intraoperative decisions regarding simultaneous radical lymphadenectomy to be made. Previous experiences have shown that the limit of TIC in extemporaneous diagnosis was represented by the minimal deposits of the tumor. Many current data seem to show that in this situation radical lymphadenectomy is no longer necessary, so we wondered if TIC could regain importance in the intraoperative management of these patients. METHODS: TIC results of Sentinel Lymph Nodes Biopsy (SLN) were compared with those of standard histopathological and immunohistochemical examinations. RESULTS: A total number of 110 SLN were detected from 50 melanoma patients.TIC revealed the presence of metastases only in 1 out of 13 melanoma-positive SLN (sensitivity 7.6%). There were no false-positive results of TIC (specificity 100%). The negative predictive value was 75.5%, the positive one 100% with a total diagnostic accuracy of 76%. CONCLUSIONS: TIC for SLNs is a reliable method, relatively fast and not very expensive. Although with a very high specificity, its sensitivity was very low, and almost exclusively limited to macro-metastases (>2mm). Furthermore, it was not possible to identify a subgroup of patients, based on the characteristics of the primary tumor, in which the method could have been more useful. Finally, even in positive cases, the method rarely reduced the need of a tactic in two stages, principally for the management of the operating room. KEY WORDS: Melanoma, Sentinel lymph node (SLN), Touch Imprinting Cytology (TIC).

Outcome of laparoscopic gastric bypass in obese and diabetic patients: when surgery fails.

BACKGROUND: The beneficial effects of bariatric surgery on diabetes and obesity have been widely demonstrated in the literature. The aim of our study was to evaluate the rate of failure of laparoscopic gastric bypass both in terms of weight loss and metabolic remission after one follow-up year. METHODS: A longitudinal, multicenter prospective study was carried out on 771 patients affected by pathological obesity. The following parameters were recorded for each patient before surgery: anthropometric, metabolic, social, smoking habits and previous failure of other bariatric procedures. After 1 follow-up year, final weight, final Body Mass Index (BMI), final percentage of lost excess body weight and percentage of lost BMI were evaluated. RESULTS: Statistical analysis showed a correlation between BMI>50 kg/m2, presence of metabolic syndrome, presence of diabetes, gastric pouch volume greater than 60 mL and failure of weight loss outcome. Statistical analysis of metabolic failure has recognized a high preoperative glycated hemoglobin percentage (HbA1c%) value as a statistically significant negative predictive factor. CONCLUSIONS: Bariatric Surgery is the most effective treatment for weight loss and metabolic improvement. However, in our study, surgery did not achieve the expected outcome in patients with specific metabolic, anthropometric and surgical characteristics (BMI>50 kg/m2, presence of metabolic syndrome, presence of T2DM with high preoperative HbA1c% level and gastric pouch volume greater than 60 mL).

Intragastric Balloon Device: Weight Loss and Satisfaction Degree.

BACKGROUND: An intragastric balloon is a non-surgical device enhancing a sensation of early satiety and reducing food intake. The aim of this study is to analyze the results in terms of weight loss and patient satisfaction undergoing intragastric balloon implantation. METHODS: Air-filled and water-filled devices were used. All patients were participated in strict follow-up programs. Weight, body mass index (BMI), total body weight loss (TWL), percentage of excess weight loss (EWL), and satisfaction degree were taken into account. RESULTS: Eighty-one patients completed a 6-month period with a device in place; 72 of them were then contacted for a follow-up at 12.3 ± 2.4 months post-removal. During treatment period, in 76 cases (93.8 %), a statistically significant reduction in weight was observed. A statistically meaningful linear correlation between a 3-month EWL (or TWL) and a 6-month EWL (or TWL) was found. At the end of endoscopic treatment, a significant link between baseline BMI and EWL >20 % was found. Sixty-three percent of the patients were not satisfied with the procedure, did not deem useful to change their diet, and refused to perform it again. CONCLUSIONS: In our study, at device removal and 1 year thereafter, a statistically significant reduction in weight was observed. Most of the patients were found to have a weight loss more than the cut-off of 20 %. The weight reached at the third month appears to be predictive of the effectiveness of endoscopic treatment. Data showed an overall dissatisfaction with procedure.

Preoperative Predictive Factors of Successful Weight Loss and Glycaemic Control 1 Year After Gastric Bypass for Morbid Obesity.

BACKGROUND: Gastric bypass (GBP) is one of the most effective surgical procedures to treat morbid obesity and the related comorbidities. This study aimed at identifying preoperative predictors of successful weight loss and type 2 diabetes mellitus (T2DM) remission 1 year after GBP. METHODS: Prospective longitudinal study of 771 patients who underwent GBP was performed at four Italian centres between November 2011 and May 2013 with 1-year follow-up. Preoperative anthropometric, metabolic and social parameters, the surgical technique and the previous failed bariatric procedures were analyzed. Weight, the body mass index (BMI), the percentage of excess weight lost (% EWL), the percentage of excess BMI lost (% BMIL) and glycated haemoglobin (HbA1c) were recorded at follow-up. RESULTS: Univariate and multivariate analysis showed that BMI <50 kg/m(2) (p = 0.006) and dyslipidaemia (p = 0.05) were predictive factors of successful weight loss. Multivariate analysis of surgical technique showed significant weight loss in patients with a small gastric pouch (p < 0.001); the lengths of alimentary and biliary loops showed no statistical significance. All diabetic patients had a significant reduction of HbA1c (p < 0.001) after surgery. BMI ≥ 50 kg/m(2) (p = 0.02) and low level of preoperative HbA1c (p < 0.01) were independent risk factors of T2DM remission after surgery. CONCLUSIONS: This study provides a useful tool for making more accurate predictions of best results in terms of weight loss and metabolic improvement.

Primary hyperparathyroidism in older people: surgical treatment with minimally invasive approaches and outcome.

Introduction. Elderly patients with primary hyperparathyroidism (pHPT) are often not referred to surgery because of their associated comorbidities that may increase surgical risk. The aim of the study was to review indications and results of minimally invasive approach parathyroidectomy in elderly patients to evaluate its impact on outcome. Materials and Methods. All patients of 70 years of age or older undergoing minimally approach parathyroidectomy at our Department from May 2005 to May 2011 were reviewed. Data collected included patients demographic information, biochemical pathology, time elapsed from pHPT diagnosis to surgical intervention, operative findings, complications, and results of postoperative biochemical studies. Results and Discussion. 37 patients were analysed. The average length of stay was 2.8 days. 11 patients were discharged within 24 hours after their operation. Morbidity included 6 transient symptomatic postoperative hypocalcemias while one patient developed a transient laryngeal nerve palsy. Time elapsed from pHPT diagnosis to first surgical visit evidences that the elderly patients were referred after their disease had progressed. Conclusions. Our data show that minimally invasive approach to parathyroid surgery seems to be safe and curative also in elderly patients with few associated risks because of combination of modern preoperative imaging, advances in surgical technique, and advances in anesthesia care.