Is ICG essential in all colorectal surgery? A 3-year experience in a single center: a cohort study.

INTRODUCTION AND OBJECTIVES: Indocyanine green (ICG) was introduced as a promising diagnostic tool to provide real-time assessment of intestinal vascularization. Nevertheless, it remains unclear whether ICG could reduce the rate of postoperative AL. The objective of this study is to assess its usefulness and to determine in which patients is most useful and would benefit the most from the use of ICG for intraoperative assessment of colon perfusion. METHODS: A retrospective cohort study was conducted in a single center, including all patients who underwent colorectal surgery with intestinal anastomosis between January 2017 and December 2020. The results of patients in whom ICG was used prior to bowel transection were compared with the results of the patients in whom this technique was not used. Propensity score matching (PSM) was employed to compare groups with and without ICG. RESULTS: A total of 785 patients who underwent colorectal surgery were included. The operations performed were right colectomies (35.0%), left colectomies (48.3%), and rectal resections (16.7%). ICG was used in 280 patients. The mean time since the infusion of ICG until detection of fluorescence in the colon wall was 26.9 ± 1.2 s. The section line was modified in 4 cases (1.4%) after ICG due to a lack of perfusion in the chosen section line. Globally, a non-statistically significant increase in anastomotic leak rate was observed in the group without ICG (9.3% vs. 7.5%; p = 0.38). The result of the PSM was a coefficient of 0.026 (CI - 0.014 to 0.065, p = 0.207). CONCLUSIONS: ICG is a safe and useful tool to assess the perfusion of the colon prior to performing the anastomosis in colorectal surgery. However, in our experience, it did not significantly lower the anastomotic leakage rate.

Stent as bridge to surgery decreases postoperative complications without worsening oncological outcomes: retrospective unicentric cohort study and stent placement protocol.

BACKGROUND: Even if the use of stent as bridge to surgery (BTS) for obstructive colon cancer was described long ago, there is still much controversy on their use. Patient recovery before surgery and colonic desobstruction are just some of the reasons to defend this management that can be found in several available articles. METHODS: This is a single-center, retrospective cohort study, including patients with obstructive colon cancer treated between 2010 and 2020. The primary aim of this study is to compare medium-term oncological outcomes (overall survival, disease-free survival) between stent as BTS and ES groups. The secondary aims are to compare perioperative results (in terms of approach, morbidity and mortality, and rate of anastomosis/stomas) between both groups and, within the BTS group, analyze whether there are any factors that may influence oncological outcomes. RESULTS: A total of 251 patients were included. Patients belonging to the BTS cohort presented a higher rate of laparoscopic approach, required less intensive care management, less reintervention, and less permanent stoma rate, when comparing with patients who underwent urgent surgery (US). There were not significant differences in terms of disease-free survival and overall survival between the two groups. Lymphovascular invasion negatively affected oncological results but was not related with stent placement. CONCLUSION: The stent as a bridge to surgery is a good alternative to urgent surgery, which leads to a decrease in postoperative morbidity and mortality without significantly worsening oncological outcomes.

Has the COVID-19 pandemic changed the clinical picture and tumour stage at the time of presentation of patients with colorectal cancer? A retrospective cohort study.

Introduction: Treatment of patients with Coronavirus Disease 2019 (COVID-19) has affected the management of patients with colorectal cancer (CRC). The aim of this study was to compare the diagnosis delay, symptoms, and stage of patients with CRC during the pandemic with a control cohort. Material and methods: Patients referred to the CRC multidisciplinary team between September 2019 and January 2020 (cohort 1, control group) were compared with those who presented between September 2020 and March 2021 (cohort 2, pandemic group). Results: 389 patients were included, 169 in cohort 1 and 220 in cohort 2. No differences were observed in the main characteristics of the patients. CRC screening and anaemia were the most common causes leading to the diagnosis of the tumour in cohort 1 and 2, respectively (p < 0.001). Diagnostic and therapeutic delay was longer in cohort 2 [6.4 (95% CI 5.8-6.9) vs. 4.8 (95% CI 4.3-5.3) months, p < 0.001]. More patients required non-elective treatment in the pandemic cohort (15.5% vs. 9.5%, p = 0.080). The tumour stage was more advanced in patients in cohort 2 [positive nodes in 52.3% vs. 36.7% (p = 0.002), and metastatic disease in 23.6% vs. 16.6% (p = 0.087)]. Conclusion: CRC patients in the pandemic cohort had a longer diagnostic and therapeutic delay and less patients were diagnosed because of CRC screening. In addition, patients with CRC during the pandemic needed non-elective treatment more frequently than patients in the control cohort, and their tumour stage tended to be more advanced.

Introducción: La pandemia de la enfermedad por coronavirus 2019 ha afectado al manejo de los pacientes con cáncer colorrectal (CCR). El objetivo de este estudio fue comparar el retraso diagnóstico, la sintomatología y el estadio de los pacientes con CCR durante la pandemia con una cohorte histórica. Material y métodos: Los pacientes valorados en el comité multidisciplinar de CCR entre septiembre de 2019 y enero de 2020 (cohorte 1) se compararon con los presentados entre septiembre de 2020 y marzo de 2021 (cohorte 2). Resultados: Trescientos ochenta y nueve pacientes fueron incluidos, 169 en la cohorte 1 y 220 en la cohorte 2. El cribado del CCR y la anemia fueron las causas que llevaron al diagnóstico en más pacientes en la cohorte 1 y 2, respectivamente (p < 0,001). El retraso diagnóstico y terapéutico fue mayor en la cohorte 2 (6,4 [IC 95%: 5,8-6,9] vs. 4,8 [IC 95%: 4,3-5,3] meses, p < 0,001). En la cohorte pandémica hubo más pacientes que requirieron tratamiento urgente (15,5% vs. 9,5%, p = 0,080). El estadio tumoral fue más avanzado en la cohorte 2 (ganglios positivos en el 52,3% vs. 36,7% [p = 0,002] y enfermedad metastásica en el 23,6% vs. 16,6% [p = 0,087]). Conclusión: Los pacientes con CCR en la cohorte pandémica tenían un retraso diagnóstico y terapéutico más largo, y menos pacientes fueron diagnosticados en el cribado de CCR. Además, los pacientes con CCR durante la pandemia necesitaron tratamiento urgente con más frecuencia y su estadio tumoral fue más avanzado.

Right laparoscopic pudendal release + neurostimulator prosthesis (LION procedure) in pudendal neuralgia.

AIM: Pudendal neuralgia is a highly disabling entity with complex diagnostic and controversial treatment results. Surgical neurolysis has been shown to be the most effective treatment. Sacral root neurostimulation or posterior tibial nerve stimulation are used to rescue patients who either have not responded to surgery or have worsened after an initial improvement. METHODS: Given the excellent visualization of the pudendal nerve during laparoscopic pudendal release, we propose to combine this procedure with neurostimulation, taking advantage of the possibility of in situ placement of the electrode. The abdominal cavity is accessed laparoscopically through four ports, and after identifying and releasing the pudendal nerve a neurostimulation electrode is placed next to the nerve and is connected to a generator located in a subcutaneous pocket. RESULTS: This procedure has been performed in one patient with a satisfactory result. CONCLUSIONS: Laparoscopic pudendal release with neurostimulator prosthesis is an experimental technique that can be promising for the treatment of pudendal neuralgia.

Prognostic impact of log odds of positive lymph nodes (LODDS) in the stratification of patients with rectal cancer.

INTRODUCTION: The use of the N category of the TNM staging system, lymph node ratio (LNR) and log odds of positive lymph nodes (LODDS) in predicting overall survival (OS) and disease-free survival (DFS) in patients with rectal cancer is still controversial. MATERIAL AND METHODS: A retrospective study of 445 patients with rectal cancer who underwent surgery between 2008 and 2017 in the University Complex Hospital of Vigo was performed. Patients were stratified according to number of lymph nodes examined (NLNE), N staging, LNR and LODDS. The analysis was performed using the log-rank test, Kaplan-Meier functions, Cox regression and ROC curves. RESULTS: Five-year OS and DFS were 73.7% and 62.5%, respectively. No statistically significant differences were observed depending on NLNE. Increased LNR and LODDS were associated with shorter OS and DFS, independently of NLNE. Multivariate analysis showed that N stage, LNR and LODDS were independently associated with OS and DFS; however, the LODDS system obtained the best area under the curve, with greater predictive capacity for OS (AUC: 0.679) and DFS (AUC: 0.711). CONCLUSION: LODDS and LNR give prognostic information that is not related to NLNE. LODDS provides better prognostic accuracy in patients with negative nodes than LNR and N stage.

Has the COVID-19 pandemic changed the clinical picture and tumour stage at the time of presentation of patients with colorectal cancer? A retrospective cohort study.

INTRODUCTION: Treatment of patients with Coronavirus Disease 2019 (COVID-19) has affected the management of patients with colorectal cancer (CRC). The aim of this study was to compare the diagnosis delay, symptoms, and stage of patients with CRC during the pandemic with a control cohort. MATERIAL AND METHODS: Patients referred to the CRC multidisciplinary team between September 2019 and January 2020 (cohort 1, control group) were compared with those who presented between September 2020 and March 2021 (cohort 2, pandemic group). RESULTS: 389 patients were included, 169 in cohort 1 and 220 in cohort 2. No differences were observed in the main characteristics of the patients. CRC screening and anaemia were the most common causes leading to the diagnosis of the tumour in cohort 1 and 2, respectively (p<0.001). Diagnostic and therapeutic delay was longer in cohort 2 [6.4 (95% CI 5.8-6.9) vs. 4.8 (95% CI 4.3-5.3) months, p<0.001]. More patients required non-elective treatment in the pandemic cohort (15.5% vs. 9.5%, p=0.080). The tumour stage was more advanced in patients in cohort 2 [positive nodes in 52.3% vs. 36.7% (p=0.002), and metastatic disease in 23.6% vs. 16.6% (p=0.087)]. CONCLUSION: CRC patients in the pandemic cohort had a longer diagnostic and therapeutic delay and less patients were diagnosed because of CRC screening. In addition, patients with CRC during the pandemic needed non-elective treatment more frequently than patients in the control cohort, and their tumour stage tended to be more advanced.

Ileoanal pouch-related fistulae: A systematic review with meta-analysis on incidence, treatment options and outcomes.

BACKGROUND: Ileoanal pouch related fistulae (PRF) are a complication of restorative proctocolectomy often requiring repeated surgical interventions and with a high risk of long-term recurrence and pouch failure. AIMS: To assess the incidence of PRF and to report on the outcomes of available surgical treatments. METHODS: A PRISMA-compliant systematic literature search for articles reporting on PRF in patients with inflammatory bowel diseases (IBD) or familial adenomatous polyposis (FAP) from 1985 to 2020. RESULTS: 34 studies comprising 770 patients with PRF after ileal-pouch anal anastomosis (IPAA) were included. Incidence of PRF was 1.5-12%. In IBD patients Crohn's Disease (CD) was responsible for one every four pouch-vaginal fistulae (PVF) (OR 24.7; p=0.001). The overall fistula recurrence was 49.4%; procedure-specific recurrence was: repeat IPAA (OR 42.1; GRADE +); transvaginal repair (OR 52.3; GRADE ++) and transanal ileal pouch advancement flap (OR 56.9; GRADE ++). The overall failure rate was 19%: pouch excision (OR 0.20; GRADE ++); persistence of diverting stoma (OR 0.13; GRADE +) and persistent fistula (OR 0.18; GRADE +). CONCLUSION: PVFs are more frequent compared to other types of PRF and are often associated to CD; surgical treatment has a risk of 50% recurrence. Repeat IPAA is the best surgical approach with a 42.1% recurrence rate.

Evolución de la cirugía urgente en un servicio de cirugía general durante la pandemia de COVID-19 y comparación con una cohorte histórica.

BACKGROUND: Acute care surgery decreased during the first wave of the COVID-19 pandemic. OBJECTIVE: To study the evolution of acute care surgery and its relationship with the pandemic severity. METHOD: Retrospective cohort study which compared patients who underwent acute care surgery during the pandemic to a control group. RESULTS: A total of 660 patients were included (253 in the control group, 67 in the first-wave, 193 in the valley, and 147 in the second wave). The median daily number of acute care surgery procedures was 2 during the control period. This activity decreased during the first wave (1/day), increased during the valley (2/day), and didn't change in the second wave (2/day). Serious complications were more common during the first wave (22.4%). A negative linear correlation was found between the daily number of acute care surgery procedures, number of patients being admitted to the hospital each day and daily number of patients dying because of COVID-19. CONCLUSIONS: Acute care surgery was reduced during the first wave of the COVID-19 pandemic, increased during the valley, and returned to the pre-pandemic level during the second wave. Thus, acute care surgery was related to pandemic severity, with fewer surgeries being performed when the pandemic was more severe.

ANTECEDENTES: La cirugía urgente disminuyó durante la primera ola de la pandemia de COVID-19. OBJETIVO: Estudiar la evolución de la cirugía urgente y su relación con la gravedad de la pandemia. MÉTODO: Estudio de cohortes retrospectivo que compara los pacientes intervenidos de forma urgente durante la pandemia con un grupo control. RESULTADOS: Se incluyeron 660 pacientes (253 en el grupo control, 67 en primera ola de la pandemia, 193 en el periodo valle y 147 en la segunda ola). La mediana del número de cirugías urgentes fue de 2 (intervalo intercuartílico: 1-3) durante el periodo control, disminuyó durante la primera ola (1/día), aumentó durante el valle (2/día) y no se modificó en la segunda ola (2/día). Las complicaciones mayores fueron más comunes durante la primera ola (22.4%). Se encontró una correlación lineal negativa entre el número de procedimientos quirúrgicos urgentes diarios y el número de ingresos hospitalarios y fallecimientos diarios por COVID-19. CONCLUSIONES: La cirugía urgente se redujo durante la primera ola, aumentó durante el periodo valle y volvió a niveles prepandémicos durante la segunda ola. Además, la cirugía urgente se relaciona con la gravedad de la pandemia, ya que se realizaron menos cirugías urgentes durante el periodo de mayor gravedad de la pandemia.

Log odds of positive lymph nodes in colon cancer: a meaningful ratio-based lymph node classification system.

BACKGROUND: The log odds of positive lymph nodes (LODDS), defined as the log of the ratio between the numbers of positive and negative lymph nodes, has recently been proposed as a new prognostic index in surgical oncology. The aim of the present study was to investigate whether the LODDS system of lymph node classification was a more accurate prognostic tool than the tumor node metastasis (TNM) and lymph node ratio (LNR) classifications in colon cancer patients. MATERIALS AND METHODS: Clinicopathologic data from 258 colon cancer patients who had undergone surgical resection were reviewed. Lymph node parameters were categorized according to the Internation Union Against Cancer/American Joint Cancer Commission (UICC/AJCC) TNM staging system, the LNR (LNR0 with ratio ≤ 0.05, LNR1 with 0.05 < ratio ≤ 0.20, LNR2 with ratio > 0.20), and the log odds ratio (LODDS0 ≤ -1.36, -1.36 < LODDS1 ≤ -0.53, and LODDS2 > -0.53). RESULTS: The LODDS was able to identify patients who would have been included in different prognostic categories, according to both the TNM and LNR. In addition, LODDS was significantly related to the number of positive and negative lymph nodes, as well as the number of examined lymph nodes. In multivariate analysis, LODDS classification (LODDS0: HR 1; LODDS1: HR 3.687, p = 0.003; LODDS2: HR 9.440, p < 0.001) was identified as an independent prognostic factor. DISCUSSION: The LODDS system is a highly reliable staging system with strong predictive ability for patient outcome. Compared with other nodal staging systems, the prognostic power of LODDS is less influenced by the number of lymph nodes dissected and examined.

Inflammatory Bowel Diseases Benefit from Enhanced Recovery After Surgery [ERAS] Protocol: A Systematic Review with Practical Implications.

BACKGROUND: Enhanced Recovery After Surgery [ERAS] is widely adopted in patients undergoing colorectal surgery, with demonstrated benefits. Few studies have assessed the feasibility, safety, and effectiveness of ERAS in patients with inflammatory bowel diseases [IBD]. The aim of this study was to investigate the current adoption and outcomes of ERAS in IBD. METHODS: This PRISMA-compliant systematic review of the literature included all articles reporting on adult patients with IBD who underwent colorectal surgery within an ERAS pathway. PubMed/MEDLINE, Cochrane Library, and Web of Science were searched. Endpoints included ERAS adoption, perioperative outcomes, and ERAS items more consistently reported, with associated evidence levels [EL] [PROSPERO CRD42021238653]. RESULTS: Out of 217 studies, 16 totalling 2347 patients were included. The median number of patients treated was 50.5. Malnutrition and anaemia optimisation were only included as ERAS items in six and four articles, respectively. Most of the studies included the following items: drinking clear fluids until 2 h before the surgery, fluid restriction, nausea prophylaxis, early feeding, and early mobilisation. Only two studies included postoperative stoma-team and IBD-team evaluation before discharge. Highest EL were observed for ileocaecal Crohn's disease resection [EL2]. Median in-hospital stay was 5.2 [2.9-10.7] days. Surgical site infections and anastomotic leaks ranged between 3.1-23.5% and 0-3.4%, respectively. Complications occurred in 5.7-48%, and mortality did not exceed 1%. CONCLUSIONS: Evidence on ERAS in IBD is lacking, but this group of patients might benefit from consistent adoption of the pathway. Future studies should define if IBD-specific ERAS pathways and selection criteria are needed.

Ischemic colitis. Does right colon location mean worst prognosis?

INTRODUCTION: Most patients with ischemic colitis have a favourable evolution; nevertheless, the location in the right colon has been associated with a worse prognosis. The purpose of this study is to compare the clinical presentation and results of right colon ischemic colitis (CICD) with ischemic colitis of other colonic segments (non-CIDC). METHODS: Retrospective, observational study of patients admitted to our hospital with ischemic colitis between 1993 and 2014, identified through a computerized search of ICD9 codes. They were divided into 2 groups: CICD and non-CICD. Comorbidities, clinical presentation, need for surgery, and mortality were compared. Multivariate analysis was performed using logistic regression adjusting for age and sex. Statistical significance was established at a value of P < 0.05. RESULTS: A total of 204 patients were identified, 61 (30%) with CICD; 61% of CICD patients required surgery compared to 22% of non-CICD patients (P < 0.001). Differences in post-surgical mortality (32% vs 55%) and overall mortality (20% vs 15%) were not statistically significant. CICD patients had more commonly unfavourable outcomes than non-CICD patients (61% vs 25%, P < 0.001). The odds ratio (OR) for surgery was 5.28 and 4.47 for unfavourable outcomes for patients with CICD. CONCLUSIONS: CICD patients have a worse prognosis than non-CICD patients, 5 times more likely to need surgery and 4 times more likely to have unfavourable outcomes.

Pathologic stage of ypT0N+ rectal cancers following neo-adjuvant treatment: clinical interpretation of an orphan status.

Approximately 20% of locally advanced rectal cancers treated with neoadjuvant therapy achieve a pathologic complete response, but approximately 10% of them present residual nodal metastases (ypT0N+). We aimed this research to compare the survival rates of ypT0/ypTisN+ and stage 3a rectal cancer patients. A large multicenter study recently investigated ypT0/ypTis rectal cancers treated between 2005 and 2015 in Italy and Spain. ypT0/ypTisN+ were selected and compared with stage 3a rectal cancers treated at the same institutions with upfront surgery (ySICO group). Additionally, the SEER database was searched for patients with stage 3a rectal cancers treated with surgery in the same years. Overall survival (OS), disease-free survival (DFS), and disease-specific survival (DSS) were analyzed using Kaplan-Meier curves and random survival forest analysis (RSF). The ySICO study population consisted of 19 ypT0/2ypTisN+ (mean follow-up 41.8 months) and 72 Stage 3a patients (mean follow-up 56.9 months). These subgroups were comparable, but stage 3a patients were treated more frequently with adjuvant therapy (90.5% vs 61.9%, p 0.0001). No significant differences were reported between the ySICO subgroups for the OS, DFS, and DSS curves. When the 1213 SEER patients were added to Stage 3a, the RFS model failed to differentiate OS between groups that presented identical survival. Root analysis showed that adjuvant therapy was the only variable differentiating OS and DSS in the ySICO population. These findings suggest that ypT0/ypTisN+ and stage 3a rectal cancers could be ranked together based on their similar outcomes and pathologic assessment, and they stress the importance of adjuvant therapy in patients presenting with residual nodal metastases.

Upfront surgery versus self-expanding metallic stent as bridge to surgery in left-sided colonic cancer obstruction: A multicenter observational study.

BACKGROUND: Oncological outcomes of self-expanding metallic stent used as a bridge to surgery in potential curative patients with left-sided colonic cancer obstruction remain unclear. The aim of this study was to investigate perioperative and mid-term oncological outcomes of 2 of the currently most commonly performed treatments in left-sided colonic cancer obstruction. METHODS: This is a retrospective multicenter study including patients with left-sided colonic cancer obstruction treated with curative intent between 2013 and 2017. The presence of metastasis at diagnosis was an exclusion criterion. The primary outcome was to evaluate the noninferiority, in terms of overall survival, of bridge to surgery strategy compared with emergency colonic resection. The secondary outcomes were perioperative morbimortality, disease free survival, local recurrence, and distant recurrence. RESULTS: A total of 564 patients were included, 320 in the emergency colonic resection group and 244 in the bridge to surgery group. Twenty-seven patients of the bridge-to-surgery group needed urgent operation. Postoperative morbidity rates were statistically higher in the emergency colonic resection group (odds ratio [95% confidence interval] 0.37 [0.24-0.55], P < .001). There was no difference in 90-day mortality between groups (odds ratio [95% confidence interval] 0.85 [0.36-1.99], P = .702). The median follow-up was 3.80 years (2.29-4.92). The results show the noninferiority of bridge to surgery versus emergency colonic resection in terms of overall survival (hazard ratio [95% confidence interval) 0.78 [0.56-1.07], P = .127). There were no differences in disease free survival, distant recurrence, and local recurrence rates between bridge to surgery and emergency colonic resection groups. CONCLUSION: Self-expanding metallic stent as bridge to surgery might not lead to a negative impact on the long-term prognosis of the tumor compared with emergency colonic resection in expert hands and selected patients.

Anatomy, Physiology and Pathophysiology of Haemorrhoids.

BACKGROUND: Haemorrhoidal Disease (HD) is a frequent anal disorder and one of the most common findings identified at the colorectal clinic. This article aims to provide an overview of the anatomy, physiology and pathophysiology of haemorrhoids and haemorrhoidal disease. INTRODUCTION: Internal haemorrhoids are vascular cushions located in the anal canal, above the dentate line and covered by columnar epithelium. They contribute to the faecal continence and the sensitivity of the anal canal. The enlargement and/or sliding of haemorrhoidal tissue produce symptoms and complications, the so-called haemorrhoidal disease. METHODS: A systematic research was realized, looking at the best evidence in literature, searching PubMed, Embase, Cochrane library and the most renowed textbooks of colorectal surgery from January 1980 to January 2020. RESULT: Aetiology and pathophysiology of HD are still controversial, but multifactorial. Disruption of stromal scaffolding, enlargement of vascular component, elevated anal pressure and rectal redundancy represent key events in the development and complications of the disease. Local inflammation may also play a role. Goligher's classification remains the most widely used. Thorough patient history and examination are paramount to diagnose HD, excluding other anal or colonic pathologies. CONCLUSION: Several aspects of etiopathogenesis and pathophysiology remain controversial. Further studies are needed to obtain a better understanding of the disease.

Evolution of Surgical Management of Hemorrhoidal Disease: An Historical Overview.

Hemorrhoidal disease (HD) is the symptomatic enlargement and/or distal displacement of the normal hemorrhoidal cushions and is one of the most frequent diseases in colorectal surgery. Several surgical or office-based therapies are currently available, with the aim of being a more tailored approach. This article aimed to elucidate the historical evolution of surgical therapy for HD from ancient times, highlighting the crucial steps, controversies, and pioneers in the field. In contrast with the previous literature on the topic that is often updated to the 1990s, with the introduction of stapled hemorrhoidopexy and transanal hemorrhoidal dearterialization, this article describes all new surgical and office-based treatments introduced in the first 20 years of the 2000s.

Ischemic colitis. Does right colon location mean worst prognosis? / Colitis isquémica. ¿La localización en el colon derecho tiene peor pronóstico?

INTRODUCTION: Most patients with ischemic colitis have a favourable evolution; nevertheless, the location in the right colon has been associated with a worse prognosis. The purpose of this study is to compare the clinical presentation and results of right colon ischemic colitis (CICD) with ischemic colitis of other colonic segments (non-CIDC). METHODS: Retrospective, observational study of patients admitted to our hospital with ischemic colitis between 1993 and 2014, identified through a computerized search of the ICD9 codes. They were divided into 2groups: CICD and non-CICD. Comorbidities, clinical presentation, need for surgery, and mortality were compared. Multivariate analysis was performed using logistic regression adjusting for age and sex. Statistical significance was established at a value of P <0.05. RESULTS: A total of 204 patients were identified, 61 (30%) with CICD; 61% of CICD patients required surgery compared to 22% of non-CICD patients (P <0.001). Post-surgical mortality (32 vs. 55%) and overall mortality (20 vs. 15%) differences were not statistically significant. CICD patients had more commonly unfavourable outcomes than non-CICD patients (61 vs. 25%, P <0.001). The odds ratio (OR) for surgery was 5.28 and 4.47 for unfavourable outcomes for patients with CICD. CONCLUSIONS: CICD patients have a worse prognosis than non-CICD patients, 5 times more likely to need surgery and 4 times more likely to have unfavourable outcomes.

Deadlock of proctologic practice in Italy during COVID-19 pandemic: a national report from ProctoLock2020.

Proctology is one of the surgical specialties that suffered the most during COVID-19 pandemic. Using data from a cross-sectional worldwide web survey, we aimed to snapshot the current status of proctologic practice in Italy with differences between three macro areas (North, Centre, South). Specialists affiliated to renowned scientific societies with an interest in coloproctology were invited to join a 27-item survey. Predictive power of respondents' and hospitals' demographics on the change of status of surgical activities was calculated. The study was registered at ClinicalTrials.gov (NCT04392245). Of 299 respondents from Italy, 94 (40%) practiced in the North, 60 (25%) in the Centrer and 82 (35%) in the South and Islands. The majority were men (79%), at consultant level (70%), with a mean age of 46.5 years, practicing in academic hospitals (39%), where a dedicated proctologist was readily available (68%). Southern respondents were more at risk of infection compared to those from the Center (OR, 3.30; 95%CI 1.46; 7.47, P = 0.004), as were males (OR, 2.64; 95%CI 1.09; 6.37, P = 0.031) and those who routinely tested patients prior to surgery (OR, 3.02; 95%CI 1.39; 6.53, P = 0.005). The likelihood of ongoing surgical practice was higher in the South (OR 1.36, 95%CI 0.75; 2.46, P = 0.304) and in centers that were not fully dedicated to COVID-19 care (OR 4.00, 95%CI 1.88; 8.50, P < 0.001). The results of this survey highlight important factors contributing to the deadlock of proctologic practice in Italy and may inform the development of future management strategies.

Is Norton Score a useful tool for identifying high-risk patients prior to emergency surgery?

BACKGROUND: Emergency surgery in elderly patients is associated with high mortality rates. Various scoring systems may be valuable in predicting mortality and morbidity rates. It has been suggested that the Norton Score (NS) could be used to quantify frailty. We hypothesized that NS could be a useful tool for identifying high-risk patients before emergency/urgent surgeries. METHODS: A retrospective study was conducted in the Department of Surgery at Kaplan Medical Center, Rehovot, Israel. INCLUSION CRITERIA: age ≥50 years, American Society of Anesthesiologists (ASA) physical status score ≥3 and urgent/emergency laparotomy. A total of 400 patients were identified, and 150 (37.5%) matched the inclusion criteria. RESULTS: A total of 150 patients with ASA scores of 3-5 and who underwent emergent/urgent laparotomy from 1 January 2011 through 31 January 2013 were included. Mean age was 77 ± 9.7 years. The mortality rate at 1 month was 44% (66 patients) and at 1 year was 54.7% (82 patients). A higher ASA score was significantly associated with mortality (P < 0.001). Survivors had lower frailty scores and presented significantly higher preoperative NS (Modified Frailty Index 2.45 versus 3.06, P < 0.05; NS 16.09 versus 12.94, P < 0.01). Preoperative NS was the most significant variable that predicted poor patient prognosis (odds ratio 0.84; 95% confidence interval 0.73-0.96). For ASA 3 and ASA 4, the grade of daily personal independence in activities showed a positive correlation with survival (P < 0.001). CONCLUSION: NS can be a very useful and quick tool to evaluate surgical risk in emergency surgery. Our study supports the use of NS in the perioperative evaluation prior to emergency surgery.

Efficacy of rectus muscle fragment welding in the control of presacral venous bleeding.

BACKGROUND: The incidence of presacral venous bleeding during rectal resection is low, but this complication can be severe and even lethal. Occasionally, the traditional methods - such as pelvic gauze packing and the use of metallic thumbtacks - are not effective. When combined with their complications and difficulties, these failures have resulted in numerous creative procedures with which to control this complication. In 1994, the indirect electrocoagulation method, which is performed via a fragment of the rectus abdominis muscle of the abdomen, was introduced to control presacral venous bleeding. METHODS: From January 2002 to December 2015, five of 872 patients with rectal cancer and one patient with rectal metastasis of gastric cancer developed presacral venous bleeding, and this technique was used in every case. RESULTS: Haemostasis was permanent in all cases. There were no complications such as infection or rebleeding. CONCLUSION: In our experience, indirect electrocoagulation via a fragment of the rectus abdominis muscle of the abdomen is a rapid, easily executed and effective method for controlling presacral venous bleeding during rectal resection.