The use of indocyanine green fluorescence to define bowel microcirculation during laparoscopic surgery for acute small bowel obstruction.

AIM: Although there is growing evidence to support the feasibility of a minimally invasive approach for acute small bowel obstruction, the inability to adequately evaluate compromised bowel segments has been cited as a major limitation. The aim of this work is to report a novel application of extemporaneous indocyanine green (ICG) fluorescence to assess bowel viability where there is a concern for ischaemic damage. METHOD: After the cause of obstruction has been identified and resolved, and where there are dubious signs of bowel ischaemia present, fluorescent selective angiography is undertaken. The segment of bowel in question is observed under both normal and fluorescent light to assess local microcirculation. The adequacy of both the arterial supply and the venous drainage is thus appraised to define bowel viability. RESULTS: Among 71 patients who have undergone surgery for acute small bowel obstruction with a laparoscopic approach, seven received extemporaneous ICG fluorescence assessment of bowel viability. Different presentations with their relevant management are described. CONCLUSIONS: Selective use of intraoperative fluorescent angiography may overcome some of the intrinsic limitations of laparoscopy in assessing bowel viability during surgery for acute small bowel obstruction.

The impact of synchronous liver resection on the risk of anastomotic leakage following elective colorectal resection. A propensity score match analysis on behalf of the iCral study group.

INTRODUCTION: how best to manage patients with colorectal cancer and synchronous liver metastasis is still controversial, with specific concerns of increased risk of postoperative complications following combined resection. We aimed at analyzing the influence of combined liver resection on the risk of anastomotic leak (AL) following colorectal resection. METHODS: we reviewed the iCral prospectively maintained database to compare the relative risk of AL of patients undergoing colorectal resection for cancer to that of patients receiving simultaneous liver and colorectal resection for cancer with isolated hepatic metastases. The incidence of AL was the primary outcome of the analysis. Perioperative details and postoperative complications were also appraised. RESULTS: out of a total of 996 patients who underwent colorectal resection for cancer, 206 receiving isolated colorectal resection were compared with a matched group of 53 patients undergoing simultaneous liver and colorectal resection. Combined surgery had greater operative time and resulted in longer postoperative hospitalization compared to colorectal resection alone. The proportion of overall morbidity following combined resection was significantly higher than after isolated colorectal resection (56.6% vs. 37.9%, p = 0.021). Overall, the two groups of patients did not differ neither on the rate of major postoperative complications, nor in terms of AL (9.4% vs. 6.3%, p = 0.381). At specific multivariate analysis, the duration of surgery was the only risk factor independently associated with the likelihood of AL. CONCLUSIONS: combining hepatic with colorectal resection for the treatment of synchronous liver metastasis from colorectal cancer does not increase significantly the incidence of AL.

Complications and mortality in a cohort of patients undergoing emergency and elective surgery with perioperative SARS-CoV-2 infection: an Italian multicenter study. Teachings of Phase 1 to be brought in Phase 2 pandemic.

Since the beginning of the pandemic due to the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and its related disease, coronavirus disease 2019 (COVID-19), several articles reported negative outcomes in surgery of infected patients. Aim of this study is to report results of patients with COVID-19-positive swab, in the perioperative period after surgery. Data of COVID-19-positive patients undergoing emergent or oncological surgery, were collected in a retrospective, multicenter study, which involved 20 Italian institutions. Collected parameters were age, sex, body mass index, COVID-19-related symptoms, patients' comorbidities, surgical procedure, personal protection equipment (PPE) used in operating rooms, rate of postoperative infection among healthcare staff and complications, within 30-postoperative days. 68 patients, who underwent surgery, resulted COVID-19-positive in the perioperative period. Symptomatic patients were 63 (92.5%). Fever was the main symptom in 36 (52.9%) patients, followed by dyspnoea (26.5%) and cough (13.2%). We recorded 22 (32%) intensive care unit admissions, 23 (33.8%) postoperative pulmonary complications and 15 (22%) acute respiratory distress syndromes. As regards the ten postoperative deaths (14.7%), 6 cases were related to surgical complications. One surgeon, one scrub nurse and two circulating nurses were infected after surgery due to the lack of specific PPE. We reported less surgery-related pulmonary complications and mortality in Sars-CoV-2-infected patients, than in literature. Emergent and oncological surgery should not be postponed, but it is mandatory to use full PPE, and to adopt preoperative screenings and strategies that mitigate the detrimental effect of pulmonary complications, mostly responsible for mortality.

Kono-S anastomosis after intestinal resection for Crohn's disease.

BACKGROUND: Kono-S anastomosis was described for the first time in 2011 and it showed a lower surgical recurrence rate in patients with Crohn's disease when compared to the standard technique. The aim of this review is to assess the safety and effectiveness of this surgical procedure by analyzing the data existing in the literature. MATERIALS AND METHODS: Pubmed, EMBASE and Scopus databases were used as data sources for a systematic comprehensive search of all studies where Kono-S anastomosis was performed in patients with Crohn's disease. Perioperative data and clinical outcomes were measured. RESULTS: Five studies described the use of Kono technique to restore intestinal continuity. Postoperative complications rates seem to be acceptable, with the exception of one case regarding the surgical site infection and bowel obstruction rates of one of the studies compared to the others. Surgical recurrence rate ranges from 0 to 3.4% with significant differences between Kono-S anastomosis and other techniques in the only two existing comparative studies. CONCLUSION: Kono's anastomosis seems to be a safe procedure with encouraging results on the reduction of the need for reoperation due to relapse, but the few existing studies do not allow to draw final conclusions. Further comparative, randomized studies, with appropriate sample size, follow up and endoscopic evaluation are necessary to establish the real benefits in the use of this hand-sewn antimesenteric anastomosis compared to a stapled wide lumen side-to-side anastomosis.