Adherence to enhanced recovery after surgery (ERAS) in older adults following colorectal resection.

INTRODUCTION: Enhanced recovery after surgery (ERAS) is an established pathway to improve short-term outcomes in colorectal surgery. It is unclear whether the efficacy, feasibility, and safety of the ERAS protocol are similar in older and younger patients. The study examined adherence to the ERAS protocol and identified factors leading to deviations in older patients. MATERIALS AND METHODS: Patients undergoing colorectal resection were prospectively included in the ERAS protocol between 2019 and 2022. The cohort was stratified according to age and ERAS adherence score. The patients were compared regarding clinical short-term follow-up (30 days). Univariate and multivariate analyses were performed using the statistical program R (version 4.1.2). RESULTS: During the study period, 414 patients were recruited, including 132 patients (31.9 %) aged ≥75 years. The cohort of older adults showed significantly higher American Society of Anesthesiologists (ASA) scores III/IV (57.8 % vs. 81.8 %; p < 0.001) and more frequently malignant diseases (45.9 % vs. 64.1 %; p < 0.001), but a lower body mass index (26.7 vs. 24.4; p < 0.001). Furthermore, older adults achieved significantly lower adherence to the ERAS protocol in the postoperative phase (84.6 % vs. 80.1 %; p = 0.003) and experienced a longer median length of hospital stay (6 vs. 8 days; p < 0.001). The differences identified were increased change of body weight on postoperative day 1, delayed removal of a urinary catheter, and shorter duration of mobilization on postoperative days 2 and 3 (p < 0.05). However, in the multivariate analysis, emergency and open surgery as well as severe complications, but not age, were elicited as independent predictive factors for lower adherence to the ERAS protocol postoperatively. DISCUSSION: Adherence to the postoperative ERAS requirements appears to be lower in older patients, although age alone was not an independent factor in our multivariate analysis and therefore not responsible for a lower adherence to the postoperative ERAS protocol after colorectal resection. This difference underlines the importance of interdisciplinary teamwork in daily practice to achieve optimal postoperative results, especially in older adults.

[Modern surgery for inflammatory bowel disease].

INTRODUCTION: Despite the advances in the medical management, especially biologics, there are still clear indications for operative management of IBD. For Crohn's disease, surgical therapy plays an important role after failure of medical management and for treatment of complications. In recent years, however, there has been a change in the treatment philosophy of patients with isolated involvement of the ileocecal region, and for selected patients, primary surgical resection appears to be an equivalent treatment alternative to therapy with biologics. In ulcerative colitis, surgery offers the only curative option. In severe acute colitis, surgery is indicated when conservative treatment is not effective and/or when there is a risk of colonic perforation. Indications for elective surgery are failure of conservative therapy and malignant transformation. The ileoanal J-pouch reconstruction is the standard procedure after restorative proctocolectomy with excellent functional long-term results. The increasing complexity of indications and minimally invasive surgical techniques, as well as the demanding perioperative treatment, led to an increasing specialization in the surgical treatment of IBD patients, with IBD-surgeons collaborating as a team with gastroenterologists to optimize the outcome of IBD-patients.

[Intussusception and Rectal Prolapse: A Common Cause for Defecation Disorders].

INTRODUCTION: A rectal prolapse is mainly a disease of the elderly population, occurring more frequently among women. The medical practitioner has an important role in the recognition and initiation of therapy for rectal prolapse. Appropriate therapy can have an important impact on symptom reduction and healthcare resources. Surgical therapy includes perineal or transabdominal surgery, with increasing use of minimally invasive techniques such as mesh rectopexy. This operation is indicated and feasible regardless of age. The management of the rectal prolapse in specialized pelvic floor centres with interdisciplinary expertise for diagnosis and therapy is recommended.

Herpes simplex virus colitis mimicking acute severe ulcerative colitis: a case report and review of the literature.

A 60-year-old female patient with longstanding left-sided ulcerative colitis presented with symptoms mimicking an acute flare and developed a colonic perforation shortly after starting steroid treatment. Following left hemicolectomy and Hartmann's procedure, rescue treatment with infliximab was started. Within a few days, the patient developed hepatic failure. Histology and immunohistochemistry of the specimen revealed extensive necrotizing herpes simplex virus colitis, and liver biopsy demonstrated herpes simplex virus hepatitis. Sixteen days after admission, the patient died from multiorgan failure. This compelling case of severe herpes simplex virus colitis raises awareness of a rare but potentially detrimental infection in patients with inflammatory bowel disease.

Evaluation of the Introduction of a Colorectal Bundle in Left Sided Colorectal Resections (EvaCol): Study Protocol of a Multicentre, Observational Trial.

Purpose: Overall complication and leak rates in colorectal surgery showed only minor improvements over the last years and remain still high. While the introduction of the WHO Safer Surgery Checklist has shown a reduction of overall operative mortality and morbidity in general surgery, only minor attempts have been made to improve outcomes by standardizing perioperative processes in colorectal surgery. Nevertheless, a number of singular interventions have been found reducing postoperative complications in colorectal surgery. The aim of the present study is to combine nine of these measures to a catalogue called colorectal bundle (CB). This will help to standardize pre-, intra-, and post-operative processes and therefore eventually reduce complication rates after colorectal surgery. Methods: The study will be performed among nine contributing hospitals in the extended north-western part of Switzerland. In the 6-month lasting control period the patients will be treated according to the local standard of each contributing hospital. After a short implementation phase all patients will be treated according to the CB for another 6 months. Afterwards complication rates before and after the implementation of the CB will be compared. Discussion: The overall complication rate in colorectal surgery is still high. The fact that only little progress has been made in recent years underlines the relevance of the current project. It has been shown for other areas of surgery that standardization is an effective measure of reducing postoperative complication rates. We hypothesize that the combination of effective, individual components into the CB can reduce the complication rate. Trial registration: Registered in ClinicalTrials.gov on 11/03/2020; NCT04550156. Highlights: Purpose: Overall complications in colorectal surgery remain still highStandardizing can reduce overall operative mortality and morbidityOnly minor attempts have been made to standardize perioperative processes in colorectal surgerySingular interventions have been found reducing postoperative complicationsThe aim is to combine nine of these measures to a colorectal bundle (CB)The CB will help to reduce complication rates after colorectal surgery Methods: The observational study will be performed among nine hospitals in SwitzerlandSix month the patients will be treated according to the local standardsAfterwards patients will be treated according to the CB for another six monthsComplication rates before and after the implementation of the CB will be compared Discussion: Only little progress has been made to reduce complication rate in colorectal surgeryStandardization is an effective measure of reducing complication ratesThe combination of effective, individual components into the CB can reduce the complication rate.

[Pancreatic cancer]. / Pankreaskarzinom.

Pancreatic cancer Abstract. Pancreatic cancer is the second most common cancer in the GI tract in Europe and North America and it is associated with a poor prognosis due to its aggressive tumor biology. Each year the number of deaths from pancreatic cancer is almost the same as the number of new cases diagnosed. Most of the pancreatic cancers develop from exocrine cells, while endocrine pancreatic cancers (i. e., neuroendocrine tumors or islet cell tumors) are uncommon. The term "pancreatic cancer" is typically used to refer to pancreatic adenocarcinoma, which will be the focus of this paper. Despite the introduction of multimodal therapy concepts, advanced surgical techniques, and increasing surgical specialization, overall survival in pancreatic cancer has not significantly improved. Early and complete surgical tumor resection remains the only curative option; however, this is rarely achieved, mainly due to the advanced stage at diagnosis. Adjuvant chemotherapy has become the gold standard after upfront resection. Neoadjuvant chemotherapy regimens, such as FOLFIRINOX, represent a valid option in order to achieve complete surgical tumor resection in more advanced cases. However, the overall uptake of this promising concept is very low.

Short- and long-term outcomes for primary anastomosis versus Hartmann's procedure in Hinchey III and IV diverticulitis: a multivariate logistic regression analysis of risk factors.

PURPOSE: The management of perforated diverticulitis with generalized peritonitis is still controversial and no preferred standardized therapeutic approach has been determined. We compared surgical outcomes between Hartmann's procedure (HP) and primary anastomosis (PA) in patients with Hinchey III and IV perforated diverticulitis. METHODS: Multicenter retrospective analysis of 131 consecutive patients with Hinchey III and IV diverticulitis operated either with HP or PA from 2015 to 2018. Postoperative morbidity was compared after adjustment for known risk factors in a multivariate logistic regression. RESULTS: Sixty-six patients underwent HP, while PA was carried out in 65 patients, 35.8% of those were defunctioned. HP was more performed in older patients (74.6 vs. 61.2 years, p < .001), with Hinchey IV diverticulitis (37% vs. 7%, p < .001) and in patients with worse prognostic scores (P-POSSUM Physiology Score, p < .001, Charlson Comorbidity Index p < .001). Major morbidity and mortality were higher in HP compared to PA (30.3% vs. 9.2%, p = .002 and 10.6% vs. 0%, p = .007, respectively) with lower stoma reversal rate (43.9% vs. 86.9%, p < .001). In a multivariate logistic regression, PA was independently associated with lower postoperative morbidity and mortality (OR 0.24, 95% CI 0.06-0.96, p = .044). CONCLUSIONS: In comparison to PA, HP is associated with a higher morbidity, higher mortality, and a lower stoma reversal rate. Although a higher prevalence of risk factors in HP patients may explain these outcomes, a significant increase in morbidity and mortality persisted in a multivariate logistic regression analysis that was stratified for the identified risk factors.

[Surgical treatment of colorectal cancer]. / Chirurgische Behandlung des Kolon- und Rektumkarzinoms.

Surgical treatment of colorectal cancer Abstract. For the last two decades, colorectal surgery has been evolving driven by technical innovation, new findings in clinical trials and better understanding of the pathophysiology and biology of the tumours. Efforts to improve oncological outcomes led to a centralisation of care and nowadays surgery for colorectal cancer is mainly performed in certified high-volume centres. Standardised surgical techniques have been developed in order to facilitate training and improve oncological outcome. The introduction of total mesorectal excision (TME) resulted in a better postoperative outcome, reduced local recurrence rate and better overall survival for rectal cancer. Complete mesocolic excision (CME) was described as an attempt to standardise the operative technique for colon cancer and follows the same principles of the TME in order to improve the oncological outcome. In this approach, sharp precise dissection of the embryological planes allows the maintenance of integrity of the mesocolic envelope with its lymphatic drainage. However, CME has not yet been adopted universally by surgeons and data about long-term oncological outcome are awaited. One of the most substantial recent developments in the surgery of colon cancer is the implementation of minimally invasive approach. Randomised controlled trials demonstrated comparability of laparoscopic versus open surgery for colonic cancer. However, with the recent evidence, non-inferiority of the laparoscopic approach for TME could not be proven. Obtaining a clear circumferential resection margin especially in male patients with narrow pelvis is a major issue that has a direct impact on the local recurrence of rectal cancer. In an attempt to improve quality of the TME, new surgical techniques such as transanal total mesorectal excision and robotic surgery are now widely performed. However, oncological long-term data are lacking. Preservation of function and quality of life are factors which need to be addressed when counselling the patient with rectal cancer. Organ preservation with local excision for low-risk lesions is an appropriate approach for selected patients.

Patient-specific mental rehearsal with interactive visual aids: a path worth exploring?

BACKGROUND: Surgeons of today are faced with unprecedented challenges; necessitating a novel approach to pre-operative preparation which takes into account the specific tests each case poses. In this study, we examine patient-specific mental rehearsal for pre-surgical practice and assess whether this method has an additional effect when compared to generic mental rehearsal. METHODS: Sixteen medical students were trained how to perform a simulated laparoscopic cholecystectomy (SLC). After baseline assessments, they were randomised to two equal groups and asked to complete three SLCs involving different anatomical variants. Prior to each procedure, Group A practiced mental rehearsal with the use of a pre-prepared checklist and Group B mental rehearsal with the checklist combined with virtual models matching the anatomical variations of the SLCs. The performance of the two groups was compared using simulator provided metrics and competency assessment tool (CAT) scoring by two blinded assessors. RESULTS: The participants performed equally well when presented with a "straight-forward" anatomy [Group A vs. Group B-time sec: 445.5 vs. 496 p = 0.64-NOM: 437 vs. 413 p = 0.88-PL cm: 1317 vs. 1059 p = 0.32-per: 0.5 vs. 0 p = 0.22-NCB: 0 vs. 0 p = 0.71-DVS: 0 vs. 0 p = 0.2]; however, Group B performed significantly better [Group A vs. B Total CAT score-Short Cystic Duct (SCD): 20.5 vs. 26.31 p = 0.02 η 2 = 0.32-Double cystic Artery (DA): 24.75 vs. 30.5 p = 0.03 η 2 = 0.28] and committed less errors (Damage to Vital Structures-DVS, SCD: 4 vs. 0 p = 0.03 η 2=0.34, DA: 0 vs. 1 p = 0.02 η 2 = 0.22). in the cases with more challenging anatomies. CONCLUSION: These results suggest that patient-specific preparation with the combination of anatomical models and mental rehearsal may increase operative quality of complex procedures.

[Changes in indications for surgery in the management of diverticulitis]. / Primum et super omnium: nihil nocere Operationsindikation im Wandel bei Divertikulitis.

Diverticulitis is a common disease in western countries and its incidence is increasing especially among young patients. Colonic diverticulosis, incidentally diagnosed by endoscopy or CT-scanning, has no immediate clinical consequences. Progression to diverticulitis develops in only 4 % of cases. In the last decades management of diverticular disease evolved and expectative treatment and less invasive techniques have gained importance. Elective resection has traditionally been advised after a second episode of diverticulitis or after a first episode if the patient was less than 50 years of age or complicated disease occurred. Recent changes in understanding the natural history of diverticular disease have substantially modified treatment paradigms. Elective resection in case of recurrent diverticular disease should be performed on a individual basis and in cases with complications like intestinal obstruction or fistulas. Primary anastomosis is an option even in emergency surgery due to colonic perforation, while diverting operations are indicated for selected patient groups with a high risk profile. Several prospective studies showed good results for laparoscopic drainage and lavage in the setting of perforated diverticulitis with generalized peritonitis, though this concept needs to be controlled with randomized clinical trials before application into the daily practice. This article should provide a short overview of trends in the surgical treatment of diverticulitis, help to understand the natural history of the disease and thereby explain the currently lower frequency of surgical interventions for diverticulitis.

Spatial and temporal patterns of bone formation in ectopically pre-fabricated, autologous cell-based engineered bone flaps in rabbits.

Biological substitutes for autologous bone flaps could be generated by combining flap pre-fabrication and bone tissue engineering concepts. Here, we investigated the pattern of neotissue formation within large pre-fabricated engineered bone flaps in rabbits. Bone marrow stromal cells from 12 New Zealand White rabbits were expanded and uniformly seeded in porous hydroxyapatite scaffolds (tapered cylinders, 10-20 mm diameter, 30 mm height) using a perfusion bioreactor. Autologous cell-scaffold constructs were wrapped in a panniculus carnosus flap, covered by a semipermeable membrane and ectopically implanted. Histological analysis, substantiated by magnetic resonance imaging (MRI) and micro-computerized tomography scans, indicated three distinct zones: an outer one, including bone tissue; a middle zone, formed by fibrous connective tissue; and a central zone, essentially necrotic. The depths of connective tissue and of bone ingrowth were consistent at different construct diameters and significantly increased from respectively 3.1+/-0.7 mm and 1.0+/-0.4 mm at 8 weeks to 3.7+/-0.6 mm and 1.4+/-0.6 mm at 12 weeks. Bone formation was found at a maximum depth of 1.8 mm after 12 weeks. Our findings indicate the feasibility of ectopic pre-fabrication of large cell-based engineered bone flaps and prompt for the implementation of strategies to improve construct vascularization, in order to possibly accelerate bone formation towards the core of the grafts.