Risk factors for postoperative cervical haematoma in patients undergoing thyroidectomy: a retrospective, multicenter, international analysis (REDHOT study).

Background: Postoperative cervical haematoma represents an infrequent but potentially life-threatening complication of thyroidectomy. Since this complication is uncommon, the assessment of risk factors associated with its development is challenging. The main aim of this study was to identify the risk factors for its occurrence. Methods: Patients undergoing thyroidectomy in seven high-volume thyroid surgery centers in Europe, between January 2020 and December 2022, were retrospectively analysed. Based on the onset of cervical haematoma, two groups were identified: Cervical Haematoma (CH) Group and No Cervical Haematoma (NoCH) Group. Univariate analysis was performed to compare these two groups. Moreover, employing multivariate analysis, all potential independent risk factors for the development of this complication were assessed. Results: Eight thousand eight hundred and thirty-nine patients were enrolled: 8,561 were included in NoCH Group and 278 in CH Group. Surgical revision of haemostasis was performed in 70 (25.18%) patients. The overall incidence of postoperative cervical haematoma was 3.15% (0.79% for cervical haematomas requiring surgical revision of haemostasis, and 2.35% for those managed conservatively). The timing of onset of cervical haematomas requiring surgical revision of haemostasis was within six hours after the end of the operation in 52 (74.28%) patients. Readmission was necessary in 3 (1.08%) cases. At multivariate analysis, male sex (P < 0.001), older age (P < 0.001), higher BMI (P = 0.021), unilateral lateral neck dissection (P < 0.001), drain placement (P = 0.007), and shorter operative times (P < 0.001) were found to be independent risk factors for cervical haematoma. Conclusions: Based on our findings, we believe that patients with the identified risk factors should be closely monitored in the postoperative period, particularly during the first six hours after the operation, and excluded from outpatient surgery.

Minimally invasive versus open adrenalectomy for adrenocortical carcinoma: the keys surgical factors influencing the outcomes-a collective overview.

PURPOSE: Adrenocortical carcinoma (A.C.C.) is a rare tumour, often discovered at an advanced stage and associated with a poor prognosis. Surgery is the treatment of choice. We aimed to review the different surgical approaches trying to compare their outcome. METHODS: This comprehensive review has been carried out according to the PRISMA statement. The literature search was performed in PubMed, Scopus, the Cochrane Library and Google Scholar. RESULTS: Among all studies identified, 18 were selected for the review. A total of 14,600 patients were included in the studies, of whom 4421 were treated by mini-invasive surgery (M.I.S.). Ten studies reported 531 conversions from M.I.S. to an open approach (OA) (12%). Differences were reported for operative times as well as for postoperative complications more often in favour of OA, whereas differences for hospitalization time in favour of M.I.S. Some studies showed an R0 resection rate from 77 to 89% for A.C.C. treated by OA and 67 to 85% for tumours treated by M.I.S. The overall recurrence rate ranged from 24 to 29% for A.C.C. treated by OA and from 26 to 36% for tumours treated by M.I.S. CONCLUSIONS: OA should still be considered the standard surgical management of A.C.C. Laparoscopic adrenalectomy has shown shorter hospital stays and faster recovery compared to open surgery. However, the laparoscopic approach resulted in the worst recurrence rate, time to recurrence and cancer-specific mortality in stages I-III ACC. The robotic approach had similar complications rate and hospital stays, but there are still scarce results about oncologic follow-up.

Effect of the COVID-19 pandemic on surgery for indeterminate thyroid nodules (THYCOVID): a retrospective, international, multicentre, cross-sectional study.

BACKGROUND: Since its outbreak in early 2020, the COVID-19 pandemic has diverted resources from non-urgent and elective procedures, leading to diagnosis and treatment delays, with an increased number of neoplasms at advanced stages worldwide. The aims of this study were to quantify the reduction in surgical activity for indeterminate thyroid nodules during the COVID-19 pandemic; and to evaluate whether delays in surgery led to an increased occurrence of aggressive tumours. METHODS: In this retrospective, international, cross-sectional study, centres were invited to participate in June 22, 2022; each centre joining the study was asked to provide data from medical records on all surgical thyroidectomies consecutively performed from Jan 1, 2019, to Dec 31, 2021. Patients with indeterminate thyroid nodules were divided into three groups according to when they underwent surgery: from Jan 1, 2019, to Feb 29, 2020 (global prepandemic phase), from March 1, 2020, to May 31, 2021 (pandemic escalation phase), and from June 1 to Dec 31, 2021 (pandemic decrease phase). The main outcomes were, for each phase, the number of surgeries for indeterminate thyroid nodules, and in patients with a postoperative diagnosis of thyroid cancers, the occurrence of tumours larger than 10 mm, extrathyroidal extension, lymph node metastases, vascular invasion, distant metastases, and tumours at high risk of structural disease recurrence. Univariate analysis was used to compare the probability of aggressive thyroid features between the first and third study phases. The study was registered on ClinicalTrials.gov, NCT05178186. FINDINGS: Data from 157 centres (n=49 countries) on 87 467 patients who underwent surgery for benign and malignant thyroid disease were collected, of whom 22 974 patients (18 052 [78·6%] female patients and 4922 [21·4%] male patients) received surgery for indeterminate thyroid nodules. We observed a significant reduction in surgery for indeterminate thyroid nodules during the pandemic escalation phase (median monthly surgeries per centre, 1·4 [IQR 0·6-3·4]) compared with the prepandemic phase (2·0 [0·9-3·7]; p<0·0001) and pandemic decrease phase (2·3 [1·0-5·0]; p<0·0001). Compared with the prepandemic phase, in the pandemic decrease phase we observed an increased occurrence of thyroid tumours larger than 10 mm (2554 [69·0%] of 3704 vs 1515 [71·5%] of 2119; OR 1·1 [95% CI 1·0-1·3]; p=0·042), lymph node metastases (343 [9·3%] vs 264 [12·5%]; OR 1·4 [1·2-1·7]; p=0·0001), and tumours at high risk of structural disease recurrence (203 [5·7%] of 3584 vs 155 [7·7%] of 2006; OR 1·4 [1·1-1·7]; p=0·0039). INTERPRETATION: Our study suggests that the reduction in surgical activity for indeterminate thyroid nodules during the COVID-19 pandemic period could have led to an increased occurrence of aggressive thyroid tumours. However, other compelling hypotheses, including increased selection of patients with aggressive malignancies during this period, should be considered. We suggest that surgery for indeterminate thyroid nodules should no longer be postponed even in future instances of pandemic escalation. FUNDING: None.

ACR TI-RADS Score combined with cytopathology classification improves the risk stratification of indeterminate thyroid nodules.

BACKGROUND: The aim of this retrospective study was the elaboration of a new diagnostic model that integrate cytological reports (2017 Bethesda System for Reporting Thyroid Cytopathology) with ultrasonographic features (based on ACR TI-RADS score) to achieve a more accurate definition of indeterminate thyroid nodule malignancy risk. METHODS: Ninety patients submitted to thyroidectomy were divided in three classes: low malignancy risk (AUS/FLUS with TI-RADS 2/TI-RADS 3 and FN/SFN with TI-RADS 2), intermediate malignancy risk (AUS/FLUS with TI-RADS 4/TI-RADS 5 and FN/SFN with TI-RADS 3/TI-RADS 4), and high malignancy risk (FN/SFN with TI-RADS 5). RESULTS: The surgical approach should be recommended in high-risk patients (81.82% of malignancies), carefully evaluated in intermediate risk (25.42%), whereas a conservative approach can be adopted in low-risk patients (0.00%). CONCLUSIONS: The integration of these two multiparametric systems in a Cyto-US score has proven to be a feasible and reliable aid to achieve a more accurate definition of malignancy risk.

The utility of intraoperative PTH dosage in primary hyperparathyroidism based on preoperative diagnosis and surgical choice.

BACKGROUND: The aim of this study was to evaluate the impact of the intraoperative PTH (ioPTH) monitoring in the success of parathyroidectomy based on the concordant or indeterminate preoperative imaging studies of localization and the performed surgical choices. METHODS: Fourthy-seven patients who received parathyroidectomy operations were divided in four groups: concordance of the imaging and ioPTH, concordance of the imaging and no ioPTH, indeterminate imaging and ioPTH and indeterminate imaging and no ioPTH. RESULTS: Overall, patients in whom ioPTH monitoring was not performed were healed in 89.47% of cases, while the percentage of recovery in patients receiving ioPTH was 85.71%. There were no differences in the changes in strategy or in the cure rates with the use of ioPTH. CONCLUSIONS: No significant differences were found, independently from the preoperative imaging agreement, in either the cure rate or in the change of intraoperative strategy using the ioPTH dosage.

Does the continuation of low-dose acetylsalicylic acid during the perioperative period of thyroidectomy increase the risk of cervical haematoma? A 1-year experience of two Italian centers.

Background: A growing number of patients taking antiplatelet drugs, mainly low-dose acetylsalicylic acid (ASA) (75-150 mg/day), for primary or secondary prevention of thrombotic events, are encountered in every field of surgery. While the bleeding risk due to the continuation of these medications during the perioperative period has been adequately investigated in several surgical specialties, in thyroid surgery it still needs to be clarified. The main aim of this study was to assess the occurrence of cervical haematoma in patients receiving low-dose acetylsalicylic acid, specifically ASA 100 mg/day, during the perioperative period of thyroidectomy. Methods: Patients undergoing thyroidectomy in two high-volume thyroid surgery centers in Italy, between January 2021 and December 2021, were retrospectively analysed. Enrolled patients were divided into two groups: those not taking ASA were included in Group A, while those receiving this drug in Group B. Univariate analysis was performed to compare these two groups. Moreover, multivariate analysis was employed to evaluate the use of low-dose ASA as independent risk factor for cervical haematoma. Results: A total of 412 patients underwent thyroidectomy during the study period. Among them, 29 (7.04%) were taking ASA. Based on the inclusion criteria, 351 patients were enrolled: 322 were included in Group A and 29 in Group B. In Group A, there were 4 (1.24%) cervical haematomas not requiring surgical revision of haemostasis and 4 (1.24%) cervical haematomas requiring surgical revision of haemostasis. In Group B, there was 1 (3.45%) cervical haematoma requiring surgical revision of haemostasis. At univariate analysis, no statistically significant difference was found between the two groups in terms of occurrence of cervical haematoma, nor of the other early complications of thyroidectomy. At multivariate analysis, the use of low-dose ASA did not prove to be an independent risk factor for cervical haematoma. Conclusions: Based on our findings, we believe that in patients receiving this drug, either for primary or secondary prevention of thrombotic events, its discontinuation during the perioperative period of thyroidectomy is not necessary.

Risk of Complications in Patients Undergoing Completion Thyroidectomy after Hemithyroidectomy for Thyroid Nodule with Indeterminate Cytology: An Italian Multicentre Retrospective Study.

There is still controversy as to whether patients undergoing a completion thyroidectomy after a hemithyroidectomy for a thyroid nodule with an indeterminate cytology have a comparable, increased or decreased risk of complications compared to those submitted to primary thyroid surgery. The main aim of this study was to investigate this topic. Patients undergoing a thyroidectomy for thyroid nodular disease with an indeterminate cytology in four high-volume thyroid surgery centres in Italy, between January 2017 and December 2020, were retrospectively analysed. Based on the surgical procedure performed, four groups were identified: the TT Group (total thyroidectomy), HT Group (hemithyroidectomy), CT Group (completion thyroidectomy) and HT + CT Group (hemithyroidectomy with subsequent completion thyroidectomy). A total of 751 patients were included. As for the initial surgery, 506 (67.38%) patients underwent a total thyroidectomy and 245 (32.62%) a hemithyroidectomy. Among all patients submitted to a hemithyroidectomy, 66 (26.94%) were subsequently submitted to a completion thyroidectomy. No statistically significant difference was found in terms of complications comparing both the TT Group with the HT + CT Group and the HT Group with the CT Group. The risk of complications in patients undergoing a completion thyroidectomy after a hemithyroidectomy for a thyroid nodule with an indeterminate cytology was comparable to that of patients submitted to primary thyroid surgery (both a total thyroidectomy and hemithyroidectomy).

Emergency duodenal resection for giant GIST with acute gastrointestinal bleeding A case report.

Gastrointestinal stromal tumors (GISTs) are rare tumors of the gastrointestinal tract, which cover about 1-2% of gastrointestinal neoplasms. They are more common in the stomach (40-60%) while a minor part in jejunum/ileus (25- 30%), duodenum (<5%), colorectal (5-15%) and esophagus (<1%). The clinical presentation depends on the primary localization of the neoplasma and tumor size, however in 18% it is asymptomatic. Gastrointestinal bleeding is the most dangerous complication, often necessitating emergency surgery and represents a common symptom of duodenal GIST. We present a case of a 82-year-old male presented with abdominal pain, asthenia and melena with haemodynamically stable. The patient underwent a recent coronary angioplasty and currently on double antiplatelet therapy. During observation a palpable mass was detected in the periumbilical region and right hypochondrium. A superior digestive endoscopy was performed which revealed an ab estrinseco compression of second duodenal segment and bleeding of third duodenal mucosa segment. No local haemostasis could be accomplished. An Angio-CT showed a large exophytic tumor arising from the 3th duodenal segment with approximately 13x9 cm, with apparent intratumoral bleeding. No indication for possible angioembolization. Due to gradual modification of the haemodynamic , the patient was submitted to emergency laparotomy. A segmental enterectomy was performed and the post-operative period ran without complications. The histopathologic exam showed a gastro-intestinal stromal tumor of epithelioid cell nature with low mitotic count (2 per 50HPF). The immunohistochemical analysis revealed positivity for CD117 (c-Kit) and DOG1 with Ki67<1%. KEY WORDS: Bleeding, Duodenal GIST, Gastrointestinal, Gastrointestinal stromal tumor.

Radiofrequency Thermal Ablation of Benign Thyroid Nodules: The Correlation Between Ultrasound Nodule Characteristics and Results.

Background. The aim of this observational study was to investigate for which nodules a better response to radiofrequency thermoablation (RFA) for nonfunctioning benign thyroid nodules is likely. Methods. Aesthetic score, compressive score, and volume of 32 benign nodules from 32 patients were registered during follow-up at baseline, 1, 3, 6, and 12 months. Results. A volume reduction rate (VRR) of 72.56% at 12 months after the procedure (P = .009) was registered. A significant (P < .001) improvement in the compressive and aesthetic scores was observed. Nodules with a baseline volume <20 mL had VRRs at 3 and 6 months that were significantly greater than those with volume >20 mL (P = .037). Conclusions. RFA was shown to be a safe and effective procedure for the management of benign thyroid nodules and that there is a correlation between the initial size of the nodule and the response to treatment.

Barbed versus traditional suture for enterotomy closure after laparoscopic right colectomy with intracorporeal mechanical anastomosis: a case-control study.

Our aim was to establish the safety and efficacy of barbed suture for enterotomy closure after laparoscopic right colectomy with intracorporeal anastomosis. This study included 47 patients who underwent laparoscopic right hemicolectomy with intracorporeal mechanical anastomosis and barbed suture enterotomy closure (barbed suture closure-BSC) for adenocarcinoma (with the exception of T4 lesions and metastasis), compared with 47 matched patients who underwent laparoscopic right hemicolectomy with intracorporeal mechanical anastomosis and conventional suture enterotomy closure (conventional suture closure-CSC) during the same period. Controls were matched for stage, age, and gender via a statistically generated selection of all laparoscopic right hemicolectomies performed from January 2009 until December 2015. There was no difference between the two groups in terms of age, sex, BMI, ASA, co-morbidity, previous abdominal surgery, cancer site and cancer staging. In terms of operating time (median 120 min for BSC and 127.5 min for CSC), histopathological results, surgical site complications (2.1% for BSC and 8.5% for CSC), hospitalization (median 6 days for BSC and 5 days for CSC), readmission rate (0%), there were no differences between the groups (p > 0.05). No significant differences were noted between the two groups in terms of the postoperative course. Our results support that the use of knotless barbed sutures for enterotomy closure after laparoscopic right colectomy with intracorporeal mechanical anastomosis is safe and reproducible.

Symptomatic pile tailored procedure. A new perspective for hemorrhoidal disease treatment.

AIM: Aim of the present paper was to evaluate the role of tailored different single pile treatment in the clinical outcome of hemorrhoids. MATERIAL OF STUDY: The surgical strategy considered to treat only pathological piles with different procedure according to each pathological Goligher's degree, presence of fibrous, inelastic redundant internal pile(F) and presence of external pathological pile (external pile congestion or subversion of dental line (E) and skin tag not tolerated from the patient (S)). We treated with Hemorrhoidopexy second and third degree pile without F or ES; with Hemorrhoidopexy and excision of external component every second and third degree pile with E or S and with complete semi-closed pile excision all third degree with F and IV degree piles. The number of post operative days of self administered analgesics was the primary end point and short/long term post operative complications, hospital stay, re-admission and recurrence were secondary end points. RESULTS: 157 patients were treated. No differences were noted in term of time of discharge between hemorrhoidopexy and complete or external excision. The painkiller assumption increases with the number of treated pile (r= 0.227, p=0.006). We observed 10.2% early complications (48h) all secondary to urinary retention and 7% late complications (2-15days) within only one reoperation for bleeding. After mean follow up of 16 months no patients required further treatments for hemorrhoids. DISCUSSIONS: A tailored approach showed to be effective in terms of short and long term complications and moreover to relapse. CONCLUSIONS: Single pile tailored treatment showed good results. KEY WORDS: Excision, Hemorrhoids, Hemorrhoidectomy, Hemorrhoidopexy, Pain, Tailored.

Antibiotics-first strategy for uncomplicated acute appendicitis in adults is associated with increased rates of peritonitis at surgery. A systematic review with meta-analysis of randomized controlled trials comparing appendectomy and non-operative management with antibiotics.

BACKGROUND: Acute appendicitis is the most common surgical diagnosis in young patients, with lifetime prevalence of about 7%. Debate remains on whether uncomplicated AA should be operated or not. Aim of this meta-analysis of randomized controlled trials was to assess current evidence on antibiotic treatment for uncomplicated AA compared to standard surgical treatment. METHODS: Systematic literature search was performed using PubMed, EMBASE, Medline, Google Scholar and Cochrane Central Register of Controlled Trials databases for randomized controlled trials comparing antibiotic therapy (AT) and surgical therapy-appendectomy (ST) for uncomplicated AA. Trials were reviewed for primary outcome measures: treatment efficacy based on 1 year follow-up, recurrence at 1 year follow-up, complicated appendicitis with peritonitis identified at the time of surgical operation and post-intervention complications. Secondary outcomes were length of hospital stay and period of sick leave. RESULTS: Five RCTs comparing AT and ST qualified for inclusion in meta-analysis, with 1.351 patients included: 632 in AT group and 719 in ST group. Higher rate of treatment efficacy based on 1 year follow-up was found in ST group (98.3% vs 75.9%, P < 0.0001), recurrence at 1 year was reported in 22.5% of patients treated with antibiotics. Rate of complicated appendicitis with peritonitis identified at time of surgical operation was higher in AT group (19.9% vs 8.5%, P = 0.02). No statistically significant differences were found when comparing AT and ST groups for the outcomes of overall post-intervention complications (4.3% vs 10.9%, P = 0.32), post-intervention complications based on the number of patients who underwent appendectomy (15.8% vs 10.9%, P = 0.35), length of hospital stay (3.24 ± 0.40 vs 2.88 ± 0.39, P = 0.13) and period of sick leave (8.91 ± 1.28 vs 10.27 ± 0.24, P = 0.06). CONCLUSIONS: With significantly higher efficacy and low complication rates, appendectomy remains the most effective treatment for patients with uncomplicated AA. The subgroups of patients with uncomplicated AA where antibiotics can be more effective, should be accurately identified.

IPOD Study: Management of Acute Left Colonic Diverticulitis in Italian Surgical Departments.

BACKGROUND: In recent years, the emergency management of acute left colonic diverticulitis (ALCD) has evolved dramatically despite lack of strong evidence. As a consequence, management strategies are frequently guided by surgeon's personal preference, rather than by scientific evidence. The primary aim of IPOD study (Italian Prospective Observational Diverticulitis study) is to describe both the diagnostic and treatment profiles of patients with ALCD in the Italian surgical departments. METHODS: IPOD study is a prospective observational study performed during a 6-month period (from April 1 2015 to September 1 2015) and including 89 Italian surgical departments. All consecutive patients with suspected clinical diagnosis of ALCD confirmed by imaging and seen by a surgeon were included in the study. The study was promoted by the Italian Society of Hospital Surgeons and the World Society of Emergency Surgery Italian chapter. RESULTS: Eleven hundred and twenty-five patients with a median age of 62 years [interquartile range (IQR), 51-74] were enrolled in the IPOD study. One thousand and fifty-four (93.7%) patients were hospitalized with a median duration of hospitalization of 7 days (IQR 5-10). Eight hundred and twenty-eight patients (73.6%) underwent medical treatment alone, 13 patients had percutaneous drainage (1.2%), and the other 284 (25.2%) patients underwent surgery as first treatment. Among 121 patients having diffuse peritonitis, 71 (58.7%) underwent Hartmann's resection. However, the Hartmann's resection was used even in patients with lower stages of ALCD (36/479; 7.5%) where other treatment options could be more adequate. CONCLUSIONS: The IPOD study demonstrates that in the Italian surgical departments treatment strategies for ALCD are often guided by the surgeon's personal preference.

Total mesorectal excision for mid and low rectal cancer: Laparoscopic vs robotic surgery.

AIM: To compare the short- and long-term outcomes of laparoscopic and robotic surgery for middle and low rectal cancer. METHODS: This is a retrospective study on a prospectively collected database containing 111 patients who underwent minimally invasive rectal resection with total mesorectal excision (TME) with curative intent between January 2008 and December 2014 (robot, n = 53; laparoscopy, n = 58). The patients all had a diagnosis of middle and low rectal adenocarcinoma with stage I-III disease. The median follow-up period was 37.4 mo. Perioperative results, morbidity a pathological data were evaluated and compared. The 3-year overall survival and disease-free survival rates were calculated and compared. RESULTS: Patients were comparable in terms of preoperative and demographic parameters. The median surgery time was 192 min for laparoscopic TME (L-TME) and 342 min for robotic TME (R-TME) (P < 0.001). There were no differences found in the rates of conversion to open surgery and morbidity. The patients who underwent laparoscopic surgery stayed in the hospital two days longer than the robotic group patients (8 d for L-TME and 6 d for R-TME, P < 0.001). The pathologic evaluation showed a higher number of harvested lymph nodes in the robotic group (18 for R-TME, 11 for L-TME, P < 0.001) and a shorter distal resection margin for laparoscopic patients (1.5 cm for L-TME, 2.5 cm for R-TME, P < 0.001). The three-year overall survival and disease-free survival rates were similar between groups. CONCLUSION: Both L-TME and R-TME achieved acceptable clinical and oncologic outcomes. The robotic technique showed some advantages in rectal surgery that should be validated by further studies.

A systematic review and meta-analysis of total thyroidectomy versus bilateral subtotal thyroidectomy for Graves' disease.

BACKGROUND: Our aim was to perform a meta-analysis of high-quality published trials, randomized and observational, comparing total thyroidectomy (TT) and bilateral subtotal thyroidectomy (ST) for Graves' disease. METHODS: All studies published from 1970 to August 2012 were identified. All randomized controlled trials (RCTs) were included. Selection of high-quality, nonrandomized comparative studies (NRCTs) was based on a validated tool (Methodological Index for Nonrandomized Studies). Recurrent hyperthyroidism during follow-up, progression of ophthalmopathy, postoperative temporary and permanent hypoparathyroidism, and permanent recurrent laryngeal nerve (RLN) palsy were compared using odds ratios (ORs). RESULTS: Twenty-three studies were included (4 RCTs and 19 NRCTs) compromising 3,242 patients (1,665 TT, 1,577 ST). TT was associated with a decrease in recurrent hyperthyroidism (P < .00001; OR, 0.10; 95% confidence interval [CI], 0.06-0.18), but with an increase in both temporary (P < .00001; OR, 2.70; 95% CI, 2.04-3.56) and permanent hypoparathyroidism (P = .005; OR, 2.91; 95% CI, 1.59-5.32). Progression of ophthalmopathy (P = .76; OR, 0.90; 95% CI, 0.48-1.71) and permanent RLN palsy (P = .82; OR, 0.91; 95% CI, 0.41-2.02) were similar. CONCLUSION: TT offers a better chance of cure of hyperthyroidism than bilateral ST and can be accomplished safely with only a small increase in temporary and permanent hypoparathyroidism.

Fast-track surgery in real life: how patient factors influence outcomes and compliance with an enhanced recovery clinical pathway after colorectal surgery.

The aim of this prospective cohort study was to identify the patient factors that predict postoperative deviation from each item of a fast-track colorectal surgery protocol (FT) and these factors' influences on postoperative outcomes. A total of 606 patients with colorectal pathology from 2005 to 2011 were analyzed to assess the relationships between patient factors, the outcome variables, and the items of the FT program. The median length of stay was 5 days, and readmission rate was 2.3%. The morbidity rate was 26.7%. Independent predictors of prolonged length of stay were older than 75 years of age, ASA grade 3 and 4, and the presence of an ileostomy. Independent predictors of morbidity were age above 75 years old and ASA grade, whereas age was confirmed as an independent predictor of mortality. Male sex, age above 75 years old, and ASA 3 and 4 were identified as independent predictors of negative compliance to most of the postoperative FT items.

Intracorporeal versus extracorporeal anastomosis after laparoscopic right hemicolectomy for cancer: a systematic review and meta-analysis.

PURPOSE: The aim of this systematic review was to compare intracorporeal (IA) versus extracorporeal anastomosis (EA) after laparoscopic right hemicolectomy for cancer. METHODS: The meta-analysis was conducted following all aspects of the Cochrane Handbook for systematic reviews and Preferred Reporting Items for Systematic Reviews and Meta-analysis statement. Studies published from 2009 to 2012 that compare IA and EA after laparoscopic right hemicolectomy were identified. The included non-randomized studies were assessed for their methodological quality using the revised and modified grading system of the Scottish Intercollegiate Guidelines Network. Intraoperative, early postoperative, and postoperative recovery outcomes were compared using weighted mean differences and odds ratios. RESULTS: Five non-randomized controlled trials published between 2009 and 2011, comprising 425 patients, were included in this analysis. IA was associated with significant faster bowel movement, faster first flatus, shorter time to solid diet, decreased use of analgesics, and shorter duration of the hospital stay. No differences were observed for nasogastric tube reintroduction rate, operative time, incision length, number of nodes harvested, intraoperative complications, mortality, non-surgical site complications, surgical site complications (anastomotic leakage, anastomotic bleeding, wound infection, ileus), reintervention, and readmission rate. CONCLUSIONS: Even when the limitations are taken into account due to the observational nature of the included studies, the results suggest that the IA after laparoscopic right hemicolectomy for cancer results in better postoperative recovery outcomes, such as shorter hospital stay, faster bowel movement recovery, faster first flatus, faster time to solid diet, and lesser analgesic usage.

Laparoscopic surgery improves postoperative outcomes in high-risk patients with colorectal cancer.

BACKGROUND: Patients with significant comorbidities often are denied laparoscopic colorectal resections, because they are thought to be too "high-risk." This study was designed to examine the feasibility and safety of laparoscopic colorectal resections in high-risk colorectal cancer patients and to compare them with a similar cohort of patients undergoing open resections in the same time period. METHODS: This was a single-center, prospective, cohort study conducted at a high-volume, nonuniversity, tertiary care hospital. From a database of 616 patients submitted to elective colorectal surgery for cancer within a fast-track protocol (January 2005 to November 2011), 188 patients who met at least one minor (age >80 years and body mass index (BMI) >30 m/kg(2)) and one major (cardiac, pulmonary, renal or liver disease, diabetes mellitus) criterion were classified as high-risk. Differences in baseline characteristics, intraoperative outcomes, and short-term (30-day) postoperative outcomes, as well as the pathology findings and the readmission and reoperation rates, were compared between the open and laparoscopic cohorts in both high- and low-risk groups and between high- and low-risk groups. RESULTS: During the study period, 68 high-risk patients underwent laparoscopic resections and 120 had open surgeries. A shorter length of postoperative stay (6 vs. 9 days, p < 0.0001) and fewer postoperative nonsurgical complications (4 % vs. 19 %, p = 0.003) were observed among the laparoscopic group. Postoperative major (p = 0.774) and minor complications (p = 0.3) and reoperations (p = 0.196) were similar between the two groups, and a significantly lower rate of mortality (1.5 vs. 7.5 %, p = 0.038) was observed in the laparoscopic group than in the open group. CONCLUSIONS: Laparoscopic colorectal resection can be safely performed on "high-risk" surgical patients with better results than a similar group of high-risk patients undergoing open colon resections.

Fast-track colorectal surgery: protocol adherence influences postoperative outcomes.

PURPOSE: This single-center prospective cohort study, conducted outside of a clinical trial, tried to identify the importance of each fast-track surgery procedure and protocol adherence level on clinical outcomes after colorectal surgery. METHODS: From a prospectively maintained database, 606 patients who underwent elective laparoscopic or open colorectal resection within a well established fast-track surgery (FT) protocol, between 2005 and 2011, were identified. Univariate and multivariate analysis were performed to assess the relationship between each FT procedure with an adherence rate <100 % and the outcome variables (length of stay-LOS, 30-day morbidity and readmission rate). Patients were divided into four adherence level groups to FT procedures-100 %, 85-95 %,70-80 %, and <65 %. Each adherence group was compared with the other groups to evaluate differences in clinical outcome variables. RESULTS: Group comparisons revealed that higher levels of FT protocol adherence corresponded to significantly improved LOS and morbidity rates. Readmission rates were only significantly different between the full fast-track pathway and the less implemented groups. Multivariate analyses revealed that the fast removal of bladder catheter positively influenced length of stay (p < 0.0001) and 30-day morbidity (p < 0.0001). Laparoscopy surgery, no drain positioning and enforced mobilization improved LOS (p = 0.027, p < 0.0001, p = 0.002, respectively). Early solid feeding improved LOS (p < 0.0001), morbidity (p < 0.0001) and readmission rate (p = 0.011). CONCLUSION: Postoperative outcomes after colorectal surgery are directly proportional to FT protocol adherence. The early removal of the bladder catheter and early postoperative solid feeding independently influenced the length of hospital stay and 30-day morbidity rates.

General surgeons' views on Oncologic Multidisciplinary Group meetings as part of colorectal cancer care.

This study aimed to assess the current effectiveness of Oncologic Multidisciplinary Groups (OMGs) meetings across central Tuscany through surgeons' reports and their individual perceived benefits on colorectal cancer management. One hundred and sixty-seven general surgeons received a questionnaire with 21 questions covering organizational characteristics of OMGs and the individual perceived benefits of OMGs. The responses were analyzed by hospital setting (teaching vs. community hospital). The reply rate was 62.8 %, and 82 respondent surgeons (49.1 %) were involved in the treatment of colorectal cancer patients. At community hospitals, there was a more frequent participation of medical oncologists, radiation oncologists and pathologists; a less selection of discussed cases was performed; and almost all decisions were inserted into official patient charts (p < 0.05). Community hospital surgeons perceived more of a benefit than academic surgeons: OMGs ensure that all treatment options are considered and improve timeliness of care, patient outcomes, patient satisfaction and communication with patients (p < 0.05). The surveyed surgeons reported that OMGs offer a modest degree of protection from malpractice but improve communications between colleagues and are an opportunity for personal professional development. Professionals regularly participating in well-conducted and well-organized OMGs for colorectal cancer felt that the multidisciplinary strategy may be advantageous to both patients and caregivers.