Emergency appendicectomy during COVID-19 pandemic - A single UK centre experience.

Background - In December 2019 following an outbreak of Novel coronavirus infection (COVID-19) in Wuhan, China, it spread rapidly overwhelming the healthcare systems globally. With little knowledge of COVID-19 virus, very few published reports on surgical outcomes; hospitals stopped elective surgery, whilst emergency surgery was offered only after exhausting all conservative treatment modalities. This study presents our experience of outcomes of emergency appendectomies performed during the pandemic. Methods - Prospectively we collected data on 132 patients in peak pandemic period from 1st March to 5th June 2020 and data compared with 206 patients operated in similar period in 2019. Patient demographics, presenting symptoms, pre-operative events, investigations, surgical management, postoperative outcomes and complications were analysed. Results - Demographics and ASA grades of both cohorts were comparable. In study cohort 84.4% and 96.7% in control cohort had laparoscopic appendicectomy. Whilst the study cohort had 13.6% primary open operations, control cohort had 5.3%. Mean length of stay and early post-operative complications (<30 days) were similar in both cohorts apart from surgical site infections (p = 0.02) and one mortality in study cohort. Conclusion - In these overwhelming pandemic times, although conservative treatment of acute appendicitis is an option, a proportion of patients will need surgery. Our study shows that with careful planning and strict theatre protocols, emergency appendicectomy can be safely offered with minimal risk of spreading COVID-19 infection. These observations warrant further prospective randomised studies. Keywords - appendicectomy, COVID-19, Coronavirus, emergency surgery, laparoscopy.

Impact of medial-to-lateral vs lateral-to-medial approach on short-term and cancer-related outcomes in laparoscopic colorectal surgery: A retrospective cohort study.

BACKGROUND: Laparoscopic surgery is the favoured method of colorectal cancer resections. It is surgeon expertise and discretion to choose whether to mobilize colon lateral-to-medial or medial-to-lateral. We aim to identify the advantage of one approach over the other in short-term and cancerrelated outcomes. METHODS: A retrospective review of a prospectively maintained database of all laparoscopic colorectal resections with curative-intent, in a single unit, from March 2013 to October 2014. Data was collected on patient demographics, method of laparoscopic mobilisation, operating time, length-of-stay, post-operative complications, clearance of circumferential resection margins lymph node harvest and follow-up. RESULTS: 137 patients with comparable patient demographics had laparoscopic colorectal cancer resection. 76 (60.3%) male and 50 (39.7%) female patients. 58(46.0%) of resections were performed using medial-to-lateral approach, while 68(54.0%) lateral-to-medial. Lateral group had on average 14(0-38) lymph nodes with specimen compared to 17 (6-45) in medial group. There was a statistically significant difference in the major complication rate (Clavien-Dindo IV) between the groups with 1(1.7%) in the medial-to-lateral group compared to 7 (10.2%) in the lateral-to-medial group, (p .035). Patients in the medial-to-lateral group had median length-of-stay of 7 days (range 2-55) compared to 7 days (range 2-75) in the lateral-to-medial group. There was no statistically significant difference in survival between both groups up-to 1334 days p=.413. CONCLUSION: Our study shows that mobilising the colon medially in laparoscopic colorectal cancer resection increases the lymph node harvest, gives comparable CRM clearance, similar length of hospital stay and complications. It makes no statistically significant difference in the overall patient survival.

Patient outcome of emergency laparotomy improved with increasing "number of surgeons on-call" in a university hospital: Audit loop.

AIM: Emergency laparotomy is a commonly performed high-mortality surgical procedure. The National Emergency Laparotomy Network (NELA) published an average mortality rate of 11.1% and a median length of stay equivalent to 16.3 days in patients undergoing emergency laparotomy. This study presents a completed audit loop after implementing the change of increasing the number of on-call surgeons in the general surgery rota of a university hospital. The aim of this study was to evaluate the outcomes of emergency laparotomy in a single UK tertiary centre after addition of one more consultant in the daily on-call rota. METHODS: This is a retrospective study involving patients who underwent emergency laparotomy between March to May 2013 (first audit) and June to August 2015 (second audit). The study parameters stayed the same. The adult patients undergoing emergency laparotomy under the general surgical take were included. Appendicectomy, cholecystectomy and simple inguinal hernia repair patients were excluded. Data was collected on patient demographics, ASA, morbidity, 30-day mortality and length of hospital stay. Statistical analysis including logistic regression was performed using SPSS. RESULTS: During the second 3-month period, 123 patients underwent laparotomy compared to 84 in the first audit. Median age was 65(23-93) years. 56.01% cases were ASA III or above in the re-audit compared to 41.9% in the initial audit. 38% patients had bowel anastomosis compared to 35.7% in the re-audit with 4.2% leak rate in the re-audit compared to 16.6% in the first audit. 30-day mortality was 10.50% in the re-audit compared to 21% and median length of hospital stay 11 days in the re-audit compared to 16 days. The lower ASA grade was significantly associated with increased likelihood of being alive, as was being female, younger age and not requiring ITU admission post-operatively. However, having a second on-call consultant was 2.231 times more likely to increase the chances of patients not dying (p = 0.031). CONCLUSION: Our audit-loop suggests that adding a second consultant to the daily on-call rota significantly reduces postoperative mortality and morbidity. Age, ASA and ITU admission are other independent factors affecting patient outcomes. We suggest this change be applied to other high volume centres across the country to improve the outcomes after emergency laparotomy.

Transanal endoscopic microsurgery for T1 and T2 rectal cancers: a meta-analysis and meta-regression analysis of outcomes.

The objective of this study is to assess transanal endoscopic microsurgery (TEM) as a surgical strategy for stage I rectal cancer. The literature lacks level I and level II evidence of the oncologic competence of TEM. Three randomized controlled, one prospective, and seven retrospective comparative studies were evaluated. End-points included perioperative outcomes, margin involvement, disease-free and overall survival, and recurrence. The number of patients with major (odds ratio (OR) = 0.24, 95% confidence interval (CI) 0.07-0.91) and overall postoperative complications (OR = 0.16, 95% CI 0.06-0.38) were significantly lower in TEM. The disease-free survival was higher in standard resection (SR) group compared with TEM (OR = 0.46, 95% CI 0.24-0.88). The number of patients with positive margins were less in the SR group (OR = 6.49, 95% CI 1.49-24.91), which was associated with lower local recurrence (OR = 4.92, 95% CI 1.81-13.41) and overall recurrence rate (OR = 2.03, 95% CI 1.15-3.57). No survival advantage was observed in favor of either procedure. TEM had lower rate of positive margins and longer disease-free survival when compared with transanal excision (TAE). TEM seems to be superior to SR concerning morbidity whilst less effective in obtaining negative surgical margins, and it is associated with higher local and overall recurrence. No survival advantage was observed in favor of either procedure. Unfavorable tumor preoperative histology does not seem to influence the selection between TEM and SR. TEM is more effective than TAE in obtaining negative surgical margins and shows a greater disease-free survival.

The use of self-expanding stents in esophageal and gastroesophageal junction cancer palliation: a meta-analysis and meta-regression analysis of outcomes.

BACKGROUND: The objective of this study was to examine the impact of self-expanding stents versus locoregional treatment modalities in the setting of esophageal cancer palliation. METHODS: The present meta-analysis pooled the effects of outcomes of 1,027 patients enrolled in 16 randomized controlled trials. RESULTS: The meta-analysis revealed an advantage to the use of stents compared to locoregional modality treatments with respect to the number of patients requiring reinterventions, although the latter treatment arm had a higher 1-year survival. No difference was observed between the use of the antireflux stents and conventional stents in relieving reflux. Previous chemoradiotherapy had no impact on complications, procedural deaths, and overall patient survival. Differences in outcomes among stents were minimal. CONCLUSIONS: Conventional self-expanding stents and anti-reflux stents are equally effective. Although the risk difference for 1-year survival favoured locoregional palliative treatment modalities, the latter were associated with a higher number of patients requiring reintervention.

Minimally invasive versus open esophagectomy: meta-analysis of outcomes.

BACKGROUND: A meta-analysis of the current literature was performed to compare the perioperative outcome measures and oncological impact between minimally invasive and open esophagectomy. METHODS: Using the electronic databases Medline, Embase, Pubmed and the Cochrane Library, we performed a meta-analysis pooling the effects of outcomes of 1,008 patients enrolled into eight comparative studies, using classic and modern meta-analytic methods. RESULTS: Two comparisons were considered for this systematic review: (I) open thoracotomy vs. VATS/laparoscopy esophagectomy and (II) open thoracotomy vs. VATS esophagectomy. In comparison I: both procedures report equally comparable outcomes (removed lymph nodes, 30-day mortality, 3-year survival) with the exception of overall morbidity (P = 0.038; in favor of the MIE arm) and anastomotic stricture (P < 0.001; in favor of the open thoracotomy arm). In comparison II: No differences were noted between treatment arms concerning postoperative outcomes and survival. CONCLUSIONS: In summary, both arms were comparable with regard to perioperative results and prognosis. Further prospective comparative or randomized-controlled trials focusing on the oncological impact of MIE are needed.

Clinical outcome of primary infrainguinal subintimal angioplasty in diabetic patients with critical lower limb ischemia.

PURPOSE: To evaluate the clinical outcome of subintimal angioplasty in diabetic patients with critical limb ischemia (CLI) compared to nondiabetics irrespective of the patency status of the treated arteries. METHODS: The records of 99 consecutive patients (53 men; median age 78.5 years, range 42-92) suffering from CLI who underwent primary infrainguinal subintimal angioplasty in 112 limbs within a 6-month period were studied retrospectively. A third of the patients (n=33) were diabetic. The technical success, perioperative morbidity/mortality, and clinical success were compared between the diabetic and nondiabetic patients. Kaplan-Meier life-table analysis was used to analyze clinical success, limb salvage, and survival for both groups. RESULTS: The overall technical success was 89% (81% in diabetics, 93% in nondiabetics, p=0.05). Perioperative morbidity was 8% (16.7% in diabetics, 3.9% in nondiabetics, p=0.03). The perioperative mortality was zero. The clinical success at 12, 24, and 36 months was 74%, 72%, and 65% in nondiabetics and 69%, 63%, and 54% in diabetics, respectively (p=0.17). The limb salvage rate at 36 months was 88% overall (90% in nondiabetics, 82% among diabetics, p=0.20). The 36-month survival rate was 61% in nondiabetics and 57% in diabetics (p=0.29). CONCLUSIONS: In terms of clinical outcome, infrainguinal subintimal angioplasty is almost equally effective in diabetics as in nondiabetics suffering from CLI.

Vascular endothelial growth factor modulates the Tie-2:Tie-1 receptor complex.

The receptor tyrosine kinase Tie-1 is expressed predominantly in endothelial cells where it physically associates with the related receptor Tie-2. Positive signalling through Tie-2 is associated with microvessel stability and suppression of this signal is thought to be required for vascular endothelial growth factor (VEGF)-induced microvessel remodelling or growth. Here we examine the effects of VEGF on Tie-1 and the Tie-2:Tie-1 complex. We show that VEGF induces generation of the Tie-1 endodomain and loss of the full-length receptor. The effects of VEGF on endodomain formation are not suppressed by inhibitors of protein kinase C and do not involve the nitric oxide signalling pathway. Tyrosine kinase inhibitors, in contrast, do abolish endodomain generation in response to the endothelial growth factor. VEGF stimulation of cells does not cause dissociation of the Tie-2:Tie-1 complex; rather the complex is converted to a form comprising the full-length-Tie-2 and Tie-1 endodomain. VEGF can therefore switch the Tie-2:Tie-1 complex between two different forms in endothelial cells. The ability of VEGF to modulate Tie-1 and the Tie-2:Tie-1 complex provides a mechanism whereby this initiator of vessel growth and remodelling can directly modulate receptors involved in vessel stabilization. Such cross-talk is likely to be important in the coordinate control of blood vessel formation during development and in postnatal angiogenesis.