Diverticulitis with abscess formation: Outcomes of non-operative management and nomogram for predicting emergency surgery: The Diplicab Study Collaborative Group.

BACKGROUND: To assess short- and long-term outcomes from non-surgical management of diverticulitis with abscess formation and to develop a nomogram to predict emergency surgery. METHODS: This nationwide retrospective cohort study was performed in 29 Spanish referral centers, including patients with a first episode of a diverticular abscess (modified Hinchey Ib-II) from 2015 to 2019. Emergency surgery, complications, and recurrent episodes were analyzed. Regression analysis was used to assess risk factors, and a nomogram for emergency surgery was designed. RESULTS: Overall, 1,395 patients were included (1,078 Hinchey Ib and 317 Hinchey II). Most (1,184, 84.9%) patients were treated with antibiotics without percutaneous drainage, and 194 (13.90%) patients required emergency surgery during admission. Percutaneous drainage (208 patients) was associated with a lower risk of emergency surgery in patients with abscesses of ≥5 cm (19.9% vs 29.3%, P = .035; odds ratio 0.59 [0.37-0.96]). The multivariate analysis showed that immunosuppression treatment, C-reactive protein (odds ratio: 1.003; 1.001-1.005), free pneumoperitoneum (odds ratio: 3.01; 2.04-4.44), Hinchey II (odds ratio: 2.15; 1.42-3.26), abscess size 3 to 4.9 cm (odds ratio: 1.87; 1.06-3.29), abscess size ≥5 cm (odds ratio: 3.62; 2.08-6.32), and use of morphine (odds ratio: 3.68; 2.29-5.92) were associated with emergency surgery. A nomogram was developed with an area under the receiver operating characteristic curve of 0.81 (95% confidence interval: 0.77-0.85). CONCLUSION: Percutaneous drainage must be considered in abscesses ≥5 cm to reduce emergency surgery rates; however, there are insufficient data to recommend it in smaller abscesses. The use of the nomogram could help the surgeon develop a targeted approach.

Neuroendocrine tumor associate with inflammatory bowel disease: two cases report.

INTRODUCTION: Patients with inflammatory bowel disease (IBD) have a higher risk of developing gastrointestinal tumors, the adenocarcinoma is the most frequently associated, and neuroendocrine tumor (NET) the most rare. CLINICAL CASES: We present two patients, one with Crohn's disease and the other with ulcerative colitis, who present nonspecific symptoms, and after resection of an intestinal lesion, a gastrointestinal NET (GINET) is diagnosed. DISCUSSION AND CONCLUSION: The GINET have an insidious clinic and these can be confused with those of the IBD. There could be an association between both pathologies; an important role of the chronic intestinal inflammatory process is suggested. The best treatment for GINET is the resection.

INTRODUCCIÓN: Los pacientes con enfermedad inflamatoria intestinal (EII) tienen mayor riesgo de desarrollar neoplasias gastrointestinales y el adenocarcinoma es el relacionado con más frecuencia y el tumor neuroendocrino (TNE) el más raro. CASO CLÍNICO: Se presentan los casos de dos pacientes, uno con enfermedad de Crohn y otro con colitis ulcerosa, que cursan con clínica inespecífica, y tras resección de la lesión intestinal se diagnostica un TNE gastrointestinal (TNEGI). DISCUSIÓN Y CONCLUSIONES: Los TNEGI tienen una clínica insidiosa y pueden confundirse con los de la EII. Es posible un nexo entre ambas entidades, lo que sugiere un papel importante del proceso inflamatorio crónico intestinal. El tratamiento de elección de los TNEGI es la resección.

Quantification of Immune Dysregulation by Next-generation Polymerase Chain Reaction to Improve Sepsis Diagnosis in Surgical Patients.

OBJECTIVES: To quantify immunological dysfunction in surgical patients with presence/absence of sepsis using a droplet digital polymerase chain reaction (ddPCR) transcriptomic analysis. The study also aims to evaluate this approach for improving identification of sepsis in these patients. BACKGROUND: Immune dysregulation is a central event in sepsis. Quantification of the expression of immunological genes participating in the pathogenesis of sepsis could represent a new avenue to improve its diagnosis. METHODS: Expression of 6 neutrophil protease genes (MMP8, OLFM4, LCN2/NGAL, LTF, PRTN3, MPO) and also of 5 genes involved in the immunological synapse (HLA-DRA, CD40LG, CD3E, CD28, ICOS) was quantified in blood from 101 surgical patients with sepsis, 53 uninfected surgical patients, and 16 blood donors by using ddPCR. Areas under receiver operating characteristic curves (AUROC) and multivariate regression analysis were employed to test individual genes and gene ratios to identify sepsis, in comparison with procalcitonin. RESULTS: Sepsis-induced overexpression of neutrophil protease genes and depressed expression of immunological synapse genes. MMP8/HLA-DRA, LCN2/HLA-DRA outperformed procalcitonin in differentiating between patients with sepsis and surgical controls in the AUROC analysis: LCN2/HLA-DRA: 0.90 (0.85-0.96), MMP8/HLA-DRA: 0.89 (0.84-0.95), procalcitonin: 0.80 (0.73-0.88) (AUROC, confidence interval 95%), and also in the multivariate analysis: LCN2/HLA-DRA: 8.57 (2.25-32.62); MMP8/HLA-DRA: 8.03 (2.10-30.76), procalcitonin: 4.20 (1.15-15.43) [odds ratio (confidence interval 95%)]. Gene expression levels of HLA-DRA were an independent marker of hospital mortality. CONCLUSIONS: Quantifying the transcriptomic ratios MMP8/HLA-DRA, LCN2/HLA-DRA by ddPCR is a promising approach to improve sepsis diagnosis in surgical patients.

[Tumor neuroendocrino ano-rectal: desde un pólipo con buen pronóstico hasta un carcinoma letal]. / Ano-rectal neuroendocrine tumour: from a polyp with a good prognosis to a lethal carcinoma.

INTRODUCCIÓN: Aunque los tumores neuroendocrinos rectales son neoplasias poco frecuentes, su incidencia está aumentando en las tres últimas décadas. El objetivo de este trabajo es el estudio del comportamiento de dichos tumores basándonos en sus variables clínicas, diagnósticas, terapéuticas y anatomopatológicas en un hospital terciario. MÉTODO: Estudio retrospectivo de los tumores neuroendocrinos rectales desde el año 2000 hasta el año 2017 en nuestro hospital. Se realizó una búsqueda informatizada en el programa SNOMED del servicio de anatomía patológica, empleando los criterios «tumor neuroendocrino¼ y «tumor carcinoide¼. RESULTADOS: Se hallaron 16 pacientes con tumor neuroendocrino ano-rectal. El 75% eran varones. La mediana de edad fue de 53 años (rango: 34-83). El diagnóstico fue incidental en el 62,5%. El tratamiento fue endoscópico en 13 (81%) pacientes y quirúrgico en 3 (19%). El 75% de las lesiones fueron T1. El 68,7% de los tumores presentaban un grado de agresividad G1. La media de seguimiento fue de 29 meses; no hubo recidivas. Durante el seguimiento fallecieron 3 (18,5%) pacientes, todos ellos con tumor G3 metastásico, y la supervivencia media fue de 8 meses. CONCLUSIONES: Los tumores neuroendocrinos rectales son cada vez más frecuentes y presentan unos patrones variables, cuyo pronóstico dependerá de su agresividad histológica. El aumento de su incidencia puede deberse a una mayor concienciación de la existencia de estos tumores, a las campañas de cribado del cáncer colorrectal, al aumento del número de colonoscopias realizadas y a la generalización de los estudios histológicos con marcadores neuroendocrinos. BACKGROUND: Although rectal neuroendocrine tumours are rare neoplasms, their incidence is increasing in the last three decades. The objective of this work is to study the behaviour of these tumours based on their clinical, diagnostic, therapeutic, and pathological variables in a tertiary hospital. METHOD: Retrospective study of rectal neuroendocrine tumours from 2000 to 2017 in our hospital. A computerized search was performed in the SNOMED program of the pathological anatomy service, using the criteria "neuroendocrine tumour" and "carcinoid tumour". RESULTS: We found 16 patients with ano-rectal neuroendocrine tumour; 75% were male. The median age was 53 years (range: 34-83). The diagnosis was incidental in 62.5%, with endoscopic treatment in 13 patients (81%) and surgical treatment in 3 (19%). 75% of the lesions were T1. 68.7% of the tumours showed a degree of G1 aggression. The mean follow-up was 29 months; no recurrences. During follow-up, three patients died (18.5%), all of them with metastatic G3 tumour and the mean survival was 8 months. CONCLUSIONS: The rectal neuroendocrine tumours are increasingly frequent and present variable patterns, whose prognosis will depend on their histological aggressiveness. The increase incidence may be due to a greater awareness of the existence of these tumours, to colorectal cancer screening, to the increase in the number of colonoscopies performed and to the generalization of histological studies with neuroendocrine markers.

Estado de la cirugía de la enfermedad inflamatoria en España. Resultado de una encuesta nacional / Perceptions on the surgical treatment of inflammatory bowel disease in Spain. Results of a national survey

INTRODUCCIÓN: La incidencia de la enfermedad inflamatoria intestinal (EII) está aumentando en España, pero existe poca información sobre su abordaje multidisciplinar, en particular sobre su manejo quirúrgico. El objetivo de este estudio es evaluar la opinión de los cirujanos españoles sobre la situación actual de la cirugía de la EII en nuestro país. MÉTODOS: Se realizó un estudio descriptivo del tipo encuesta cerrada que se envió a través de correo electrónico a los miembros de la Asociación Española de Cirujanos (AEC) durante los meses de enero a marzo de 2015. El cuestionario constaba de 52 ítems con preguntas sobre estructura y proceso, sobre el tratamiento quirúrgico y sobre la opinión de los cirujanos acerca de la calidad, satisfacción e investigación sobre la EII en su centro y en España. RESULTADOS: Un total de 192 cirujanos respondieron a la encuesta, la mayoría procedentes de hospitales de tercer nivel (45%), la mayoría de diferentes hospitales, algunos del mismo centro. Solo el 48,5% de los hospitales tienen equipos multidisciplinares de EII. El planteamiento quirúrgico inicial es laparoscópico en el 56,1% de los casos y el 80% de los participantes en los centros con equipos multidisciplinares considera el timing apropiado. El número de intervenciones anuales de EII en hospitales de tercer nivel es ma's alto que en hospitales de segundo nivel tanto en colitis ulcerosa (57 vs. 24% operan 10-15 pacientes/año, p < 0,001) como en enfermedad de Crohn (68 vs. 28% operan 3-5 pacientes/mes, p < 0,001). La mayoría de los centros, incluso los grandes hospitales, operan a menos de 10 pacientes con colitis ulcerosa al año y realizan _3 reservorios en J o pouch al año (por colitis ulcerosa y otras indicaciones) (p < 0,001). El 95% de los cirujanos considera que debe promoverse la centralización de casos complejos en unidades especializadas y la creación de registros nacionales. CONCLUSIONES: Según esta encuesta, parece que el volumen de cirugías de EII en España por centro no es elevado, ni siquiera en grandes hospitales, y muchos centros no cuentan con un equipo multidisciplinar de EII. No existen protocolos claros de derivación quirúrgica a centros de referencia o especializados. La mayoría de los participantes creen necesario el desarrollo de registros y aumentar la formación y la investigación en la cirugía de la EII en nuestro país

INTRODUCTION: The incidence of inflammatory bowel disease (IBD) is increasing in Spain but there is little information on the availability of multidisciplinary care. This study aims to assess surgeon's opinions on the current situation of surgery for IBD in Spain. METHODS: An electronic closed survey was sent to members of the Spanish Association of Surgeons (AEC) from January to March 2015. This was a 52-item anonymised questionnaire with questions about how the treatment of IBD patients is organized in each centre, the existence of specific units, the management strategy in IBD patients, and the opinion of colorectal, general and trainee surgeons about the surgical treatment of IBD in their centre and in Spain. RESULTS: One hundred and ninety-two surgeons responded. Most participants work in tertiary hospitals (45%), most of them from different hospitals, some from the same hospital. Only 50% of hospitals have multidisciplinary teams for IBD. The initial approach is laparoscopic in 56% of cases, and 80% of participants in centres with multidisciplinary teams consider the timing of surgery to be appropriate. The annual number of IBD surgeries in tertiary hospitals is higher than in secondary hospitals in ulcerative colitis (57 vs. 24% 10-15 patients/year, P<.001) and Crohn's disease (68 vs. 28% 3-5 patients/month, P<.001). Most centres operate less than 10 ulcerative colitis patients per year, even larger centres (67%) and they perform _3 J-pouches/month (ulcerative colitis and other indications) (P<.001). Ninetyfive percent of surgeons consider that centralization of complex cases in specialized units and the creation of national registries should be developed. The majority of participants (70%) believe that there is a deficit in research and educational activities in IBD surgery in Spain. CONCLUSION: This survey suggests that most Spanish hospitals have a low volume of IBD surgery, even large tertiary hospitals, and many centres do not have a multidisciplinary team dedicated to IBD patients. Most survey participants believe it is necessary to develop registries and increase training and research in IBD surgery in Spain

Perceptions on the surgical treatment of inflammatory bowel disease in Spain. Results of a national survey. / Estado de la cirugía de la enfermedad inflamatoria en España. Resultado de una encuesta nacional.

INTRODUCTION: The incidence of inflammatory bowel disease (IBD) is increasing in Spain but there is little information on the availability of multidisciplinary care. This study aims to assess surgeon's opinions on the current situation of surgery for IBD in Spain. METHODS: An electronic closed survey was sent to members of the Spanish Association of Surgeons (AEC) from January to March 2015. This was a 52-item anonymised questionnaire with questions about how the treatment of IBD patients is organized in each centre, the existence of specific units, the management strategy in IBD patients, and the opinion of colorectal, general and trainee surgeons about the surgical treatment of IBD in their centre and in Spain. RESULTS: One hundred and ninety-two surgeons responded. Most participants work in tertiary hospitals (45%), most of them from different hospitals, some from the same hospital. Only 50% of hospitals have multidisciplinary teams for IBD. The initial approach is laparoscopic in 56% of cases, and 80% of participants in centres with multidisciplinary teams consider the timing of surgery to be appropriate. The annual number of IBD surgeries in tertiary hospitals is higher than in secondary hospitals in ulcerative colitis (57 vs. 24% 10-15 patients/year, P<.001) and Crohn's disease (68 vs. 28% 3-5 patients/month, P<.001). Most centres operate less than 10 ulcerative colitis patients per year, even larger centres (67%) and they perform ≤3 J-pouches/month (ulcerative colitis and other indications) (P<.001). Ninety-five percent of surgeons consider that centralization of complex cases in specialized units and the creation of national registries should be developed. The majority of participants (70%) believe that there is a deficit in research and educational activities in IBD surgery in Spain. CONCLUSION: This survey suggests that most Spanish hospitals have a low volume of IBD surgery, even large tertiary hospitals, and many centres do not have a multidisciplinary team dedicated to IBD patients. Most survey participants believe it is necessary to develop registries and increase training and research in IBD surgery in Spain.

How to reduce the laparoscopic colorectal learning curve.

BACKGROUND: The laparoscopic approach for colorectal pathologies is becoming more widely used, and surgeons have had to learn how to perform this new technique. The purpose of this work is to study the indicators of the learning curve for laparoscopic colectomy in a community hospital and to find when the group begins to improve. METHODOLOGY: From January 1 2005 to December 31 2012, 313 consecutive laparoscopic colorectal surgeries were performed (105 rectal and 208 colonic) by at least 60% of the same surgical team (6 members) in each operation. We evaluate the learning curve by moving averages and cumulative sums (CUSUM) for different variables related to the surgery outcomes. RESULTS: Moving average curves for postoperative stay, fasting, and second step analgesia show a stabilizing trend toward improvement as we get more experience. However, intensive care unit stay, number of lymph nodes achieved, and operating time did not show a clear decreasing tendency. CUSUM curves of conversion, specimens<12 lymph nodes, and complications all show a clear turning point marked on all the charts around the procedure 60, accumulating a positive trend toward improvement. The CUSUM curve of the "learning variable" shows this improvement point at procedure 70. CONCLUSIONS: The laparoscopic colectomy learning curve accelerates with a collective team involvement in each procedure. The CUSUM and moving average curves are useful for initial and ongoing monitoring of new surgical procedures. The markers of the learning curve evidenced in our study are the conversion rate, postoperative surgical morbidity, and the number of patients with a lymph node count<12. WHAT IS NEW IN THIS PAPER?: The significance of this study is the evaluation of the learning curve, in laparoscopic colorectal surgery, of a surgical team in a community hospital, using moving average and CUSUM curves. This study demonstrated that the number of patients needed to achieve skilful practice decreased when there is collective team involvement in each procedure.