Laparoscopic appendectomy in complicated appendicitis with compromised appendix base: a retrospective cohort study.

BACKGROUND: Patients with compromised appendix base constitute a subgroup of patients with complicated appendicitis, and there is few available information. OBJECTIVE: To study the frequency of stump leaks and fistulae in patients with complicated appendicitis with compromised stump. METHOD: This is an observational, retrospective study of patients that underwent laparoscopic appendectomy with compromised appendix stump. RESULTS: From 2015 to 2019, 158 patients with complicated appendicitis were operated, of them 54 had compromised base or stump. There were 66.7% men, with a mean age of 38.7 years. For stump closure, a simple knot was employed in 57.4%, and in 42.6% an invaginated suture was employed. Regarding complications, 16.7% developed intraabdominal abscess, 7.4% ileus and 7.4% had wound infection. We found one stump leak and one stump fistula. The mean length of stay was 5.4 days (range: 1-20). There were 5 reoperations, 4 for abscess drainage and 1 for stump leak. CONCLUSIONS: Patients with acute complicated appendicitis with compromised appendicular base, laparoscopic surgery either with simple knot or with invaginated suture resulted in low frequency of stump leaks and fistula.

ANTECEDENTES: Los pacientes con base apendicular comprometida constituyen un subgrupo de pacientes con apendicitis complicada y existe poca información al respecto. OBJETIVO: Conocer la frecuencia de fístulas y fugas fecales en pacientes con apendicitis complicada con base apendicular comprometida. MÉTODO: Se trata de un estudio observacional, retrospectivo y transversal de pacientes operados de apendicectomía laparoscópica con base apendicular comprometida. RESULTADOS: De 2015 a 2019 se encontraron 158 casos de apendicitis complicada, de los cuales 54 tenían la base apendicular comprometida. Hubo predominio de varones (66.7%) y la edad media fue de 38.7 años. En el 57.4% de los casos se realizó un nudo simple y en el 42.6% un punto transfictivo con invaginación del muñón. En relación con las complicaciones, el 16.7% desarrollaron abscesos intraabdominales, el 7.4% íleo y el 7.4% infección de herida. Hubo un paciente con fuga del muñón y un paciente con fístula cecal. El tiempo medio de estancia hospitalaria fue de 5.4 días (rango: 1-20). Se realizaron cinco reintervenciones: cuatro para drenaje de absceso intraabdominal y una por fuga del muñón. CONCLUSIONES: En los pacientes con base apendicular comprometida, el manejo laparoscópico con ligadura simple o con punto transfictivo resulta en una baja frecuencia de fuga y fístula del muñón apendicular.

COVID-19 and Canadian Gastroenterology Trainees.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has impacted endoscopy services and education worldwide. This study aimed to characterize the impact of COVID-19 on gastroenterology trainees in Canada. METHODS: An analysis of Canadian respondents from the international EndoTrain survey, open from April 11 to May 2 2020 and distributed by program directors, trainees, and national and international gastroenterology societies' representatives, was completed. The survey included questions on monthly endoscopy volume, personal protective equipment availability, trainee well-being and educational resources. The primary outcome was change in procedural volume during the COVID-19 pandemic. Secondary outcomes included trainee's professional and personal concerns, anxiety and burnout. RESULTS: Thirty-four Canadian trainees completed the survey. Per month, participants completed a median of 30 esophagogastroduodenoscopies (interquartile range 16 to 50) prior to the pandemic compared to 2 (0 to 10) during the pandemic, 20 (8 to 30) compared to 2 (0 to 5) colonoscopies and 3 (1 to 10) compared to 0 (0 to 3) upper gastrointestinal bleeding procedures. There was a significant decrease in procedural volumes between the pre-COVID-19 and COVID-19 time periods for all procedures (P < 0.001). Thirty (88%) trainees were concerned about personal COVID-19 exposure, 32 (94%) were concerned about achieving and/or maintaining clinical competence and 24 (71%) were concerned about prolongation of training time due to the pandemic. Twenty-six (79%) respondents experienced some degree of anxiety, and 10 (31%) experienced some degree of burnout. CONCLUSION: The COVID-19 pandemic has substantially impacted gastroenterology trainees in Canada. As the pandemic eases, it important for gastrointestinal programs to adapt to maximize resident learning, maintain effective clinical care and ensure development of endoscopic competence.

Peroral endoscopic myotomy as treatment for Zenker's diverticulum (Z-POEM): a multi-center international study.

BACKGROUND: Peroral endoscopic myotomy for the treatment of Zenker's diverticulum (Z-POEM) is a novel technique that has been described in several recent reports. This method utilizes the third space (submucosal layer) to create a tunnel to facilitate complete visualization of the septum and hence cutting it entirely. Conventional endoscopic septotomy carries the risk of recurrence due to incomplete visualization of the septum. While surgical correction is a risky and lengthy procedure in old comorbid patients with Zenker's diverticulum. The aim of this study is to assess the efficacy and safety of Z-POEM. METHODS: The study enrolled 24 patients diagnosed with Zenker's diverticulum (ZD) who underwent Z-POEM at seven independent endoscopy centers in five different countries. RESULTS: Mean patient age ± standard deviation (SD) was 74.3 ± 11 years. Most of the patients were males (n = 20, 83.3%); four (16.7%) were females. More than 50% of the patients (n = 14, 58.3%) had associated comorbidities. The mean size of the diverticula was 4 cm (range 2-7 cm). The Kothari-Haber Score was used to assess clinical symptoms; values ranged from 6 to 14 (median = 9). We achieved 100% technical success with a median procedure time of 61 min and no adverse events. Median hospital stay was 1 day (range 1-5 days). There is a significant reduction in the Kothari-Haber Score after Z-POEM (P < 0.0001). Technical success was achieved in 100% of the patients. Clinical success was achieved in 23/24 (95.8%) of the patients with a median follow-up of 10 months (range 6-24 months). CONCLUSION: Z-POEM is a safe and effective modality for managing ZD.

Impact of COVID-19 on endoscopy trainees: an international survey.

BACKGROUND AND AIMS: Although coronavirus disease 2019 (COVID-19) has affected endoscopy services globally, the impact on trainees has not been evaluated. We aimed to assess the impact of COVID-19 on procedural volumes and on the emotional well-being of endoscopy trainees worldwide. METHODS: An international survey was disseminated over a 3-week period in April 2020. The primary outcome was the percentage reduction in monthly procedure volume before and during COVID-19. Secondary outcomes included potential variation of COVID-19 impact between different continents and rates and predictors of anxiety and burnout among trainees. RESULTS: Across 770 trainees from 63 countries, 93.8% reported a reduction in endoscopy case volume. The median percentage reduction in total procedures was 99% (interquartile range, 85%-100%), which varied internationally (P < .001) and was greatest for colonoscopy procedures. Restrictions in case volume and trainee activity were common barriers. A total of 71.9% were concerned that the COVID-19 pandemic could prolonged training. Anxiety was reported in 52.4% of respondents and burnout in 18.8%. Anxiety was independently associated with female gender (odds ratio [OR], 2.15; P < .001), adequacy of personal protective equipment (OR, 1.75; P = .005), lack of institutional support for emotional health (OR, 1.67; P = .008), and concerns regarding prolongation of training (OR, 1.60; P = .013). Modifying existing national guidelines to support adequate endoscopy training during the pandemic was supported by 68.9%. CONCLUSIONS: The COVID-19 pandemic has led to restrictions in endoscopic volumes and endoscopy training, with high rates of anxiety and burnout among endoscopy trainees worldwide. Targeted measures by training programs to address these key issues are warranted to improve trainee well-being and support trainee education.

Robotic-assisted Roux-en-Y hepaticojejunostomy after bile duct injury.

BACKGROUND: The Da Vinci Robotic Surgical System has positioned itself as a tool that improves the ergonomics of the surgeon, facilitating dissection in confined spaces and enhancing the surgeon's skills. The technical aspects for successful bile duct repair are well-vascularized ducts, tension-free anastomosis, and complete drainage of hepatic segments, and all are achievable with robotic-assisted approach. METHODS: This was a retrospective study of our prospectively collected database of patients with iatrogenic bile duct injury who underwent robotic-assisted Roux-en-Y hepaticojejunostomy. Pre-, intra-, and short-term postoperative data were analyzed. RESULTS: A total of 30 consecutive patients were included. The median age was 46.5 years and 76.7% were female. Neo-confluences with section of hepatic segment IV were performed in 7 patients (those classified as Strasberg E4). In the remaining 23, a Hepp-Couinaud anastomosis was built. There were no intraoperative complications, the median estimated blood loss was 100 mL, and the median operative time was 245 min. No conversion was needed. The median length of stay was 6 days and the median length of follow-up was 8 months. The overall morbidity rate was 23.3%. Two patients presented hepaticojejunostomy leak. No mortality was registered. CONCLUSION: Robotic surgery is feasible and can be safely performed, with acceptable short-term results, in bile duct injury repair providing the advantages of minimally invasive surgery. Further studies with larger number of cases and longer follow-up are needed to establish the role of robotic assisted approaches in the reconstruction of BDI.

Minimally invasive approach (robotic and laparoscopic) to biliary-enteric fistula secondary to cholecystectomy bile duct injury.

Spontaneous biliary-enteric fistula after laparoscopic cholecystectomy bile duct injury is an extremely rare entity. Y-en-Roux hepaticojejunostomy has been demonstrated to be an effective surgical technique to repair iatrogenic bile duct injuries. Seven consecutive patients underwent robotic-assisted (n = 5) and laparoscopic (n = 2) biliary-enteric fistula resection and bile duct repair at our hospital from January 2012 to May 2017. We reported our technique and described post-procedural outcomes. The mean age was 52.4 years, mostly females (n = 5). The mean operative time was 240 min for laparoscopic cases and 322 min for robotic surgery, and the mean estimated blood loss was 300 mL for laparoscopic and 204 mL for robotic cases. In both groups, oral feeding was resumed between day 2 or 3 and hospital length of stay was 4-8 days. Immediate postoperative outcomes were uneventful in all patients. With a median of 9 months of follow-up (3-52 months), no patients developed anastomosis-related complications. We observed in this series an adequate identification and dissection of the fistulous biliary-enteric tract, a safe closure of the fistulous orifice in the gastrointestinal tract and a successful bile duct repair, providing the benefits of minimally invasive surgery.

C-Reactive Protein as a Predictor of Difficult Laparoscopic Cholecystectomy in Patients with Acute Calculous Cholecystitis: A Multivariate Analysis.

BACKGROUND: Laparoscopic cholecystectomy (LC) is the treatment of choice for mild and moderate acute cholecystitis. The aim of this study was to analyze the utility of C-reactive protein (CRP) as a predictor of difficult laparoscopic cholecystectomy (DLC) in patients with acute cholecystitis. MATERIALS AND METHODS: We conducted a prospective study. All patients included were treated with emergency LC. Patients were analyzed as DLC and nondifficult laparoscopic cholecystectomy (NDLC). Multiple logistic regression and receiver-operating characteristic curve analysis were employed to explore which variables were statistically significant in predicting a DLC. Two different models were analyzed. RESULTS: A total of 66 patients were included (37.9% DLC versus 62.1% NDLC). Ideal cutoff point for CRP was calculated as 11 mg/dL, with sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for predicting DLC being 92% (95% CI 75-97.8), 82.9% (95% CI 68.7-91.5), 76.7%, and 94.4%, respectively. In the first model multivariate analysis, age >45 years, male sex, gallbladder wall thickness ≥5 mm, and pericholecystic fluid collection were significant predictors of DLC, with an area under the curve (AUC) of 0.89. In the second model multivariate analysis, only CRP ≥11 (odds ratio, OR = 17.9, P = .013) was significant predictor of presenting DLC, with an AUC of 0.96. CONCLUSIONS: Preoperative CRP with values ≥11 mg/dL was associated with the highest odds (OR = 17.9) of presenting DLC in our study. This value possesses good sensitivity, specificity, PPV, and NPV for predicting DLC in our population with acute calculous cholecystitis.