LekCheck: A Prospective Study to Identify Perioperative Modifiable Risk Factors for Anastomotic Leakage in Colorectal Surgery.

OBJECTIVE: To assess potentially modifiable perioperative risk factors for anastomotic leakage in adult patients undergoing colorectal surgery. SUMMARY BACKGROUND DATA: Colorectal anastomotic leakage (CAL) is the single most important denominator of postoperative outcome after colorectal surgery. To lower the risk of CAL, the current research focused on the association of potentially modifiable risk factors, both surgical and anesthesiological. METHODS: A consecutive series of adult patients undergoing colorectal surgery with primary anastomosis was enrolled from January 2016 to December 2018. Fourteen hospitals in Europe and Australia prospectively collected perioperative data by carrying out the LekCheck, a short checklist carried out in the operating theater as a time-out procedure just prior to the creation of the anastomosis to check perioperative values on 1) general condition 2) local perfusion and oxygenation, 3) contamination, and 4) surgery related factors. Univariate and multivariate logistic regression analysis were performed to identify perioperative potentially modifiable risk factors for CAL. RESULTS: There were 1562 patients included in this study. CAL was reported in 132 (8.5%) patients. Low preoperative hemoglobin (OR 5.40, P < 0.001), contamination of the operative field (OR 2.98, P < 0.001), hyperglycemia (OR 2.80, P = 0.003), duration of surgery of more than 3 hours (OR 1.86, P = 0.010), administration of vasopressors (OR 1.80, P = 0.010), inadequate timing of preoperative antibiotic prophylaxis (OR 1.62, P = 0.047), and application of epidural analgesia (OR, 1.81, P = 0. 014) were all associated with CAL. CONCLUSIONS: This study identified 7 perioperative potentially modifiable risk factors for CAL. The results enable the development of a multimodal and multidisciplinary strategy to create an optimal perioperative condition to finally lower CAL rates.

Preoperative endoscopic tattooing to mark the tumour site does not improve lymph node retrieval in colorectal cancer: a retrospective cohort study.

BACKGROUND: A direct correlation between number of lymph nodes retrieved and evaluated after a colectomy for colorectal cancer and survival of the patient has been reported, and consensus guidelines recommend to assess at least 12 lymph nodes for adequate staging. Many factors (i.e., patients' and tumour characteristics, surgeon, and pathologist) may influence the evaluation of the presence of neoplastic disease in lymph nodes as well as the total number of lymph nodes examined. Preoperative endoscopic tattooing to mark the site of the tumour has recently been suggested to facilitate the retrieval of lymph nodes in colorectal specimens. The aim of this study was to investigate its association with adequate lymphadenectomy (≥12 nodes) after colorectal resection for cancer. RESULTS: All patients undergoing elective colorectal resection for cancer between 2009 and 2011 at the S. Anna University Hospital in Ferrara, Italy (N = 250) were retrospectively divided into two cohorts according to whether ink tattooing to mark the tumour site was performed during preoperative colonoscopy. The two cohorts were comparable regarding age, gender, body mass index, tumour location and size, TNM staging, and DNA microsatellite instability-high status. No difference between the tattoo (N = 107) and control (N = 143) groups could be detected in the rate of adequate lymphadenectomies performed (78% vs. 79%, p = 0.40). All factors known to influence lymph nodes retrieval from colorectal specimen were specifically evaluated. Rectal and colonic cancers were analysed together and separately. Full adjusted logistic regression analysis in patients who underwent colonic resection showed that right hemicolectomy (OR 4.72; CI95% 1.09-20.36) was the only factor associated to adequate lymphadenectomy. No association between ink tattooing performed preoperatively to mark the site of the tumour and adequate lymphadenectomy after colorectal resection was found with logistic regression analysis. CONCLUSION: This study shows that preoperative ink tattooing utilized to mark the site of the tumour does not improve adequate lymphadenectomy and lymph nodes yield from colorectal cancer specimens. Further studies are therefore needed to determine if preoperative colonoscopic tattooing to mark the tumour site can refine staging.

Single Anastomosis Jejuno-ileal (SAJI): a New Model of Malabsorptive Revisional Procedure for Insufficient Weight Loss or Weight Regain After Roux-en-Y Gastric Bypass.

BACKGROUND: In case of insufficient weight loss or weight regain or relapse of weight-related comorbidities after Roux-en-Y gastric bypass (RYGB), other procedures such as reduction of a large gastric pouch and stoma, lengthening of the Roux limb, conversion to sleeve gastrectomy and/or bilio-pancreatic diversion with duodenal switch have been advocated. Single anastomosis jejuno-ileal (SAJI) is a new revisional simple operation performed after RYGB failure which adds malabsorption to the previous gastric bypass. METHODS: SAJI includes a single jejuno-ileal anastomosis specifically joining the ileum 250-300 cm proximal to the ileo-caecal valve and the jejunum 30 cm below the gastro-jejunal anastomosis on the Roux limb of the previous RYGB. Thirty-one patients underwent SAJI for insufficient weight loss and/or weight regain after RYGB. The percent total weight loss (%TWL) after RYGB and before SAJI was 21.8 ± 7.8. All SAJI operations were performed laparoscopically. The SAJI mean operating time was 145 min. RESULTS: Regarding weight loss after SAJI, %TWL is 27.2 ± 7.4, 31.2 ± 6.4, 33.7 ± 5.9 and 32.9 ± 5.2 at 12, 24, 36 and 48 months, respectively. Our series recorded a low rate of peri-operative and medium-term complications with a low grade of severity (Clavien-Dindo classification grade). One patient required reoperation 36 days after SAJI for epigastrium incarcerated incisional hernia at the previous RYGB laparotomy site. Mortality was 0. Comorbidity reduction/resolution after SAJI is 83.2% for type 2 diabetes mellitus, 42.8% for arterial hypertension, 72.8% for dyslipidemia and 45.3% for OSA. CONCLUSIONS: Treatment of failed RYGB is challenging. SAJI is a less complicated, purely low invasive malabsorptive operation that should reach satisfactory %TWL and comorbidity reduction/resolution.

Use of fibrin glue in bariatric surgery: analysis of complications after laparoscopic sleeve gastrectomy on 450 consecutive patients.

Laparoscopic Sleeve Gastrectomy (LSG) is one of the most performed surgical procedures in bariatric surgery. Staple line leak and bleeding are by far the two most feared complications after LSG. In this study, we retrospectively compared the efficacy of Fibrin Glue in preventing staple line leak and bleeding. From September 2019 to January 2020, 450 obese patients underwent elective LSG and were placed into groups with Fibrin Glue reinforcement (Group A) or without Fibrin Glue reinforcement (Group B). Primary endpoints were postoperative staple line leak and bleeding; while, secondary endpoints were reintervention rate, total operative time and mortality. Mean Body Mass Index (BMI) was 45.4 ± 7.9 kg/m2 (range: 35.1-81.8). Mean age was 43.3 ± 11.8 years (range: 18-65). No intraoperative complications or conversion to laparotomy were reported. Mean operative time was comparable between the groups (48 ± 18 min in Group A vs 48 ± 14 min in Group B; p > 0.05). No decrease in overall postoperative complications was found in Group A (5.1% vs 7.0%; p > 0.05), but after stratification according to Clavien-Dindo classification, we found a higher rate of Grade II (0.0% vs 1.6%; p < 0.05) and Grade IIIb (0.0% vs 1%; p < 0.05) complications in group B. Our study showed that Fibrin Glue as a reinforcement method during LSG is a reliable tool, without affecting the operative time of surgery and mortality. A significant reduction in complications (Clavien-Dindo grade II and grade IIIb) was observed in patients undergoing LSG with Fibrin Glue.

Enhanced Recovery Program in Laparoscopic Colorectal Surgery: An Observational Controlled Trial.

Background: Most of the evidence for enhanced recovery programs (ERPs) in colorectal surgery relies on nonrandomized studies with control groups either historical or operated on at different facilities. The aim of this study was to investigate ERP in coeval groups admitted in different wards at the same hospital. Materials and Methods: A prospective cohort of consecutive patients (n = 100) undergoing elective laparoscopic colorectal resection completing a standardized ERP (ERP group) was compared with patients (n = 100) operated with traditional perioperative care in the same period at the same institution (non-ERP group). The two groups were located in separate wards and shared the same anesthesiologists. The exclusion criteria were: >80 years old, American Society of Anesthesia (ASA) IV, metastatic disease, and inflammatory bowel disease. The primary outcome was hospital length of stay (LoS), used as a proxy of functional recovery. Secondary outcomes included: postoperative complications, readmission rate, mortality, and protocol adherence. Results: The ERP group protocol adherence was 81%. The LoS was significantly reduced in the ERP group (4 versus 7 days). The number of 30-day postoperative complications was lower in the ERP group (P < .001). No increase was found in 30-day readmission or mortality. Conventional perioperative protocol was the only predictor of any postoperative complication and, together with male sex and age 65-74 years old, was the only factor associated with prolonged LoS. Conclusion: Implementing a colorectal ERP is feasible, safe, and efficient for functional recovery, but high protocol adherence is needed. Following traditional perioperative care is associated with more postoperative complications and prolonged LoS.

COVID-19 and Obesity: Is Bariatric Surgery Protective? Retrospective Analysis on 2145 Patients Undergone Bariatric-Metabolic Surgery from High Volume Center in Italy (Lombardy).

INTRODUCTION: On February 20, 2020, a severe case of pneumonia due to SARS-CoV-2 was diagnosed in northern Italy (Lombardy). Some studies have identified obesity as a risk factor for severe disease in patients with COVID-19. The purpose of this study was to investigate the incidence of SARS-CoV-2 infection and its severity in patients who have undergone bariatric surgery. MATERIAL AND METHODS: During the lockdown period (until May 2020), we contacted operated patients by phone and social networks (e.g., Facebook) to maintain constant contact with them; in addition, we gave the patients a dedicated phone number at which to call us for emergencies. We produced telemedicine and educational videos for obese and bariatric patients, and we submitted a questionnaire to patients who had undergone bariatric surgery in the past. RESULTS: A total of 2145 patients (313 male; 1832 female) replied to the questionnaire. Mean presurgical BMI: 44.5 ± 6.8 kg/m2. Mean age: 44.0 ± 10.0 year. Mean BMI after surgery: 29.3 ± 5.5 kg/m2 (p < 0.05). From February to May 2020, 8.4% of patients reported that they suffered from at least one symptom among those identified as related to SARS-CoV-2 infection. Thirteen patients (0.6%) tested positive for COVID-19. Six patients (0.3%) were admitted to the COVID Department, and 2 patients (0.1%) were admitted to the ICU. CONCLUSIONS: Although the reported rates of symptoms and fever were high, only 0.6% of patients tested positive for COVID-19. Among more than 2000 patients who underwent bariatric surgery analyzed in this study, only 0.1% needed ICU admission.

A rare case of ileo-ileal intussusception due to a bleeding lipomatous mass treated by laparoscopic ileal resection.

INTRODUCTION: Adult intussusception is a rare cause of bowel obstruction with atypical presentation. It can be associated with primary or secondary intestinal tumors and, rarely, with lipomatous masses. CASE REPORT: We report the case of a 69-year old man presenting with a history of gastrointestinal bleeding and anemia. Upper and lower endoscopies were negative for bleeding. On abdominal contrast enhanced computerized tomography (CT) scan, a trans-omental hernia in the right lower abdominal quadrant was diagnosed with no active bleeding or evidence of tumor. On exploratory laparoscopy we detected an ileo-ileal intussusception caused by a submucosal mass in the distal ileum, which was reduced and we then performed a segmental resection of the involved small bowel tract. The patient fully recovered by postoperative day 3 when he was discharged home. Final pathology confirmed an ileal lipoma. CONCLUSION: Ileal intussusception caused by lipoma is a rare condition, which can be diagnosed with endoscopy, barium enema, and abdominal ultrasound or CT scanning, but preoperative diagnosis may be difficult. The treatment of choice is the reduction of the intussusception and the resection (laparoscopic or open) of the involved tract. KEY WORDS: Intussusception, Lipoma, Ileum, Laparoscopy, Bleeding.

Laparoscopic versus open transverse-incision right hemicolectomy: a retrospective comparison study.

BACKGROUND: The optimal surgical approach to right colon cancer is still under debate. The aim of the present study was to compare the short- and long-term outcomes of laparoscopic and transverse-incision open approaches to right hemicolectomy for colon cancer. METHODS: Data on 99 adult patients with right-side colon cancer undergoing either laparoscopic or open transverse-incision right hemicolectomy at two different university hospitals, between January 2013 and December 2016, were retrospectively reviewed. Data concerning patients' characteristics, operative details and post-operative recovery were retrieved from prospective databases and analysed. RESULTS: Forty-nine subjects were operated on laparoscopically, while 50 through an open transverse incision. Operating time was significantly longer in the laparoscopic group compared with the open group (182 versus 105 min; P < 0.01). Patients treated laparoscopically had a shorter time to first bowel movement, while time to resume a normal diet and post-operative length of hospital stay were comparable in between groups. The median number of lymph nodes harvested was higher in the laparoscopic group (25.6 versus 18.6; P < 0.01), but no significant difference in overall survival between groups was detected. At long-term follow-up, the incidence of incisional hernia was higher in the laparoscopic group as compared to the open group (24.5% versus 0%; P = 0.0002). CONCLUSION: Our results show that laparoscopic right hemicolectomy when compared to the transverse-incision open procedure may guarantee the same oncological radicality, but short-term functional benefits are still unclear. Randomized control studies are warranted to better clarify the comparison of these two approaches for right-sided colon cancers.

Prevalência de Blastocystis sp. em moradores de uma comunidade quilombola na região pantaneira do estado de Mato Grosso / Prevalence of Blastocystis sp. in inhabitants of a quilombola community in the pantanal region of Mato Grosso state / Prevalencia de Blastocystis sp. en habitantes de una comunidad quilombola de la región del pantanal del estado de Mato Grosso

Introdução: Blastocystis sp. é o parasito mais comum encontrado nos estudos de prevalência de parasitas intestinais em diferentes populações. Objetivo: determinar a prevalência do parasita intestinal Blastocystis sp. em moradores da comunidade quilombola Distrito Nossa Senhora Aparecida do Chumbo localizada em uma área rural do Município de Poconé-MT. Método: Trata-se de um estudo epidemiológico descritivo e quantitativo que determinou a prevalência do parasita intestinal Blastocystis sp. que ocorreu nos meses de dezembro de 2021 a maio de 2022. A amostra final foi composta por 114 participantes. Na identificação das formas evolutivas dos parasitas intestinais nas amostras fecais foi empregado o método de Hoffman. As amostras foram analisadas com auxílio do microscópio óptico e as lâminas foram coradas com lugol, para identificação das formas evolutivas dos parasitos. Para análise descritiva foi realizado a frequência absoluta e percentual. Foram realizados cálculos para determinar a prevalência total de parasitos intestinais e a prevalência por tipo de parasitas. Resultados: A prevalência total foi de 75%, deste a maior ocorrência foi apresentada por Blastocystis sp. Conclusão: Sugerimos, que a alta prevalência deste parasito que tem por via de contaminação fecal- oral, esteja associada à falta de um saneamento adequado, bem como ao acesso da água de qualidade.

Introduction: Blastocystis sp. is the most common parasite found in studies of intestinal parasite prevalence in different populations. Objective: To determine the prevalence of the intestinal parasite Blastocystis sp. in residents of the quilombola community of Distrito Nossa Senhora Aparecida do Chumbo located in a rural area of the Municipality of Poconé-MT. Method: This is a descriptive and quantitative epidemiological study that determined the prevalence of the intestinal parasite Blastocystis sp. that occurred in the months from December 2021 to May 2022. The final sample consisted of 114 participants. The Hoffman method was used to identify the evolutionary forms of the intestinal parasites in the fecal samples. The samples were analyzed with the aid of an optical microscope and the slides were stained with lugol to identify the evolutive forms of the parasites. For descriptive analysis, absolute and percentage frequency was performed. Calculations were performed to determine the total prevalence of intestinal parasites and the prevalence by type of parasites. Results: The total prevalence was 75%, of this the highest occurrence was presented by Blastocystis sp. Conclusion: We suggest, that the high prevalence of this parasite that has a fecal-oral contamination route, is associated with the lack of proper sanitation, as well as access to quality water.

Introducción: Blastocystis sp. es el parásito más común encontrado en estudios de prevalencia de parásitos intestinales en diferentes poblaciones. Objetivo: Determinar la prevalencia del parásito intestinal Blastocystis sp. en residentes de la comunidad quilombola del Distrito Nossa Senhora Aparecida do Chumbo localizada en una zona rural del Municipio de Poconé-MT. Método: Se trata de un estudio epidemiológico descriptivo y cuantitativo que determinó la prevalencia del parásito intestinal Blastocystis sp. ocurrida en los meses de diciembre de 2021 a mayo de 2022. La muestra final estuvo compuesta por 114 participantes. Se utilizó el método Hoffman para identificar las formas evolutivas de los parásitos intestinales en las muestras fecales. Las muestras se analizaron con la ayuda de un microscopio óptico y los portaobjetos se tiñeron con lugol para identificar las formas evolutivas de los parásitos. Para el análisis descriptivo se calcularon las frecuencias absolutas y porcentuales. Se realizaron cálculos para determinar la prevalencia total de parásitos intestinales y la prevalencia por tipo de parásitos. Resultados: La prevalencia total fue de 75%, de esta la mayor ocurrencia la presentó Blastocystis sp. Conclusión: Sugerimos, que la alta prevalencia de este parásito que tiene por vía de contaminación fecal-oral, está asociada a la falta de saneamiento adecuado, así como al acceso a agua de calidad.

Impact of a colorectal enhanced recovery program implementation on clinical outcomes and institutional costs: A prospective cohort study with retrospective control.

BACKGROUND: The enhanced recovery program for perioperative care of the surgical patient reduces postoperative metabolic response and organ dysfunction, accelerating functional recovery. The aim of this study was to determine the impact on postoperative recovery and cost-effectiveness of implementing a colorectal enhanced recovery program in an Italian academic centre. MATERIALS AND METHODS: A prospective series of consecutive patients (N = 100) undergoing elective colorectal resection completing a standardized enhanced recovery program in 2013-2015 (ERP group) was compared to patients (N = 100) operated at the same institution in 2010-2011 (Pre-ERP group) before introducing the program. The exclusion criteria were: >80 years old, ASA score of IV, a stage IV TNM, and diagnosis of inflammatory bowel disease. The primary outcome was hospital length of stay which was used as a proxy of functional recovery. Secondary outcomes included: postoperative complications, 30-day readmission and mortality, protocol adherence, nursing workload, cost-effectiveness, and factors predicting prolonged hospital stay. The ERP group patient satisfaction was also evaluated. RESULTS: Hospital stay was significantly reduced in the ERP versus the Pre-ERP group (4 versus 8 days) as well as nursing workload, with no increase in postoperative complications, 30-day readmission or mortality. ERP group protocol adherence (81%) and patient satisfaction were high. Conventional perioperative protocol was the only independent predictor of prolonged hospital stay. Total mean direct costs per patient were significantly higher in the Pre-ERP versus the ERP group (6796.76 versus 5339.05 euros). CONCLUSIONS: Implementing a colorectal enhanced recovery program is feasible, efficient for functional recovery and hospital stay reduction, safe, and cost-effective. High patient satisfaction and nursing workload reduction may also be expected, but high protocol adherence is necessary.