A Prospective, Single-Arm Study to Evaluate the Safety and Efficacy of an Autologous Blood Clot Product in the Treatment of Anal Fistula.

BACKGROUND: Surgical treatment of complex perianal fistula is technically challenging, associated with risk of failure, and may require multiple procedures. In recent years, several biologic agents have been developed for permanently eradicating anal fistulous disease with variable success. In this study, the treatment is an autologous whole-blood product created from the patients' blood. It forms a provisional matrix that was found to be safe and effective in healing acute and chronic cutaneous wounds. OBJECTIVE: The study aimed to assess the efficacy and safety of an autologous blood clot product as a treatment for transsphincteric perianal fistulas. DESIGN: A prospective single-arm study. SETTINGS: A single tertiary medical center. PATIENTS: Patients with simple or complex transsphincteric fistulas confirmed by MRI were included in the study. Cause was either cryptoglandular or Crohn's disease related (in the absence of active luminal bowel disease). INTERVENTION: The outpatient procedure was performed under general anesthesia and consisted of: 1) physical debridement and cleansing of the fistula tract; 2) suture closure of the internal opening; and 3) instillation of the autologous blood clot product into the entire tract. MAIN OUTCOME MEASURES: Safety and efficacy at 6- and 12-months after surgery. RESULTS: Fifty-three patients (77% men) with a median age of 42 (20-72) years were included in the study. Three patients withdrew consent, and 1 patient was lost to follow-up. At the time of this interim analysis, 49 and 33 patients completed the 6- and 12-month follow-up period. Thirty-four of the 49 patients achieved complete healing (69%) at 6 months, but 20 of the 33 patients (60%) achieved healing after 1 year. All patients who achieved healing at 6 months remained healed at the 1-year mark. In a subgroup analysis of patients with Crohn's disease, 7 of 9 patients completed 1-year follow-up, with 5 patients (71%) achieving clinical remission. No major side effects or postoperative complications were noted, but 2 adverse events occurred (admission for pain control and coronavirus 2019 infection). LIMITATIONS: Noncomparative single-arm pilot study. CONCLUSIONS: Treatment with an autologous blood clot product in perianal fistular disease was found to be feasible and safe, with an acceptable healing rate in both cryptoglandular and Crohn's disease fistula-in-ano. Further comparative assessment is required to determine its potential role in the treatment paradigm of fistula-in-ano. See Video Abstract . BRAZO PARA EVALUAR LA SEGURIDAD Y EFICACIA DE RDVER, UN COGULO DE SANGRE AUTLOGO, EN EL TRATAMIENTO DE LA FSTULA ANAL: ANTECEDENTES:El tratamiento quirúrgico de la fístula perianal compleja es técnicamente desafiante, se asocia con riesgo de fracaso y puede requerir múltiples procedimientos. En los últimos años, se han desarrollado varios agentes biológicos con el fin de erradicar permanentemente la enfermedad fistulosa anal con éxito variable. El tratamiento RD2-Ver.02 es un producto de sangre total autólogo creado a partir de la sangre de los pacientes, que forma una matriz provisional que resultó segura y eficaz para curar heridas cutáneas agudas y crónicas.OBJETIVO:Evaluar la eficacia y seguridad de RD2-Ver.02 como tratamiento para las fístulas perianales transesfinterianas.DISEÑO:Un estudio prospectivo de un solo brazo.LUGARES:Un único centro médico terciario.PACIENTES:Se incluyeron en el estudio pacientes con fístulas transesfinterianas simples o complejas confirmadas mediante resonancia magnética. La etiología fue criptoglandular o relacionada con la enfermedad de Crohn (en ausencia de enfermedad intestinal luminal activa).INTERVENCIÓN:El procedimiento ambulatorio se realizó bajo anestesia general y consistió en: 1) desbridamiento físico y limpieza del trayecto fistuloso; 2) cierre con sutura de la abertura interna; y 3) instilación de RD2-Ver.02 en todo el tracto.PRINCIPALES MEDIDAS DE VALORACIÓN:Seguridad y eficacia a los 6 y 12 meses después de la cirugía.RESULTADOS:Se incluyeron en el estudio 53 pacientes (77% varones) con una mediana de edad de 42 (20-72) años. Tres pacientes retiraron su consentimiento y un paciente se perdió durante el seguimiento. En el momento de este análisis intermedio, 49 y 33 pacientes completaron el período de seguimiento de 6 y 12 meses, respectivamente. Treinta y cuatro (34) pacientes lograron una curación completa (69%) a los 6 meses, mientras que 20 de 33 pacientes (60%) lograron una curación después de un año. Todos los pacientes que lograron la curación a los 6 meses permanecieron curados al año. En un análisis de subgrupos de pacientes con enfermedad de Crohn, 7/9 pacientes completaron un seguimiento de un año y 5 pacientes (71%) alcanzaron la remisión clínica. No se observaron efectos secundarios importantes ni complicaciones postoperatorias, mientras que ocurrieron 2 eventos adversos (ingreso para control del dolor e infección por COVID-19).LIMITACIONES:Estudio piloto no comparativo de un solo brazo.CONCLUSIONES:Se encontró que el tratamiento con RD2-Ver.02 en la enfermedad fístula perianal es factible y seguro, con una tasa de curación aceptable tanto en la fístula criptoglandular como en la de Crohn en el ano. Se requiere una evaluación comparativa adicional para determinar su papel potencial en el paradigma de tratamiento de la fístula anal. (Pre-proofed version ).

[SURGICAL TREATMENT USING ROBOTIC APPROACH FOR OBSTRUCTED DEFECATION SYNDROME (ODS)].

INTRODUCTION: Obstructed Defecation Syndrome (ODS) is a complex surgical condition which involves structural and functional problems which significantly affects quality of life. There is limited information about the Da-Vinci Robotic System use in the treatment of this condition. This study examines the outcomes of robotic-assisted rectopexy. The primary outcome is recovery from surgery, with secondary outcomes including post-surgical complications, length of hospital stay, rehospitalization rate and recurrence after surgery. METHODS: A retrospective analysis was conducted of prospectively collected data for patients who underwent robotic assisted surgery for ODS between 2011-2022. A colorectal surgeon performed all surgeries at the Sheba Medical Center using the Da Vinci™ robotic system. This analysis uses descriptive statistics and presents the results as medians and ranges. RESULTS: Out of 33 patients included, 26 (84.9%) were female. Median age was 67 years (Range:19-85 years). Median American Society of Anesthesiology (ASA) score was 2 (1-3). Median Charlson's comorbidity score was 3 (0-4). Median patients' Body Mass Index (BMI) was 23.2 (15.6-33.4) kg/m2. Eight patients (24.4%) underwent previous procedure for ODS. Most (23) patients included (69.7%) underwent robotic assisted ventral rectopexy. Other interventions included combined anterior and posterior rectopexy (9.1%), combined ventral rectopexy and sacrocolpopexy (12.1%) and posterior rectopexy (9.1%). No cases of conversion to laparoscopic /open techniques were recorded. Median operation time was 135 minutes (70-270). One intra-operative complication recorded was an injury to the rectum during anterior dissection (3%). No significant blood loss was recorded. A total of 27 patients (81.8%) were operated using the Da Vinci Si system, and the rest (6) using the 6 Da Vinci Xi system. Two patients had post-operative complications. Median length of stay (LOS) was 4 days (2-6 days). Readmission rate within 30 days was 9.1%. Two patients (6.1%) had recurrence of rectal prolapse. Median follow-up was 60 (4-116) months. CONCLUSIONS: Robotic-assisted surgery for obstructed defecation syndrome is safe, with fast recovery of the patient and it is efficient during long-term follow-up.

The value of CA125 in predicting acute complicated colonic diverticulitis.

BACKGROUND: CA125 is a widely used serum marker for epithelial ovarian cancer which levels may also rise in benign conditions involving peritoneal irritation. We aimed to determine if serum CA125 levels can predict disease severity in patients presenting with acute diverticulitis. METHODS: We conducted a single-center prospective observational study, analyzing CA125 serum levels in patients who presented to the emergency department with computerized tomography-proven acute left-sided colonic diverticulitis. Univariate, multivariate, and receiver operating characteristic (ROC) analyses were used to correlate CA125 serum levels at time of initial presentation with the primary outcome (complicated diverticulitis) and secondary clinical outcomes (need for urgent intervention, length of hospital stay (LOS) and readmission rates). RESULTS: One hundred and fifty-one patients were enrolled between January 2018 and July 2020 (66.9% females, median age 61 years). Twenty-five patients (16.5%) presented with complicated diverticulitis. CA125 levels were significantly higher among patients with complicated (median: 16 (7-159) u/ml) vs. uncomplicated (8 (3-39) u/ml) diverticulitis (p < 0.001) and also correlated with the Hinchey severity class (p < 0.001). Higher CA125 levels upon admission were associated with a longer LOS and a greater chance to undergo invasive procedure during the hospitalization. In patients with a measurable intra-abdominal abscess (n = 24), CA125 levels were correlated with the size of the abscess (Spearman's r = 0.46, p = 0.02). On ROC analysis to predict complicated diverticulitis, the area under the curve (AUC) for CA125 (AUC = 0.82) was bigger than for the leukocyte count (AUC = 0.53), body temperature (AUC = 0.59), and neutrophil-lymphocyte ratio (AUC = 0.70) - all p values < 0.05. On multivariate analysis of factors available at presentation, CA125 was found to be the only independent predictor of complicated diverticulitis (OR 1.12 (95% CI 1.06-1.19), p < 0.001). CONCLUSIONS: The results from this feasibility study suggest that CA125 may accurately discriminate between simple and complicated diverticulitis, meriting further prospective investigation.

Neutrophil to Lymphocyte Ratio in Patients Who Received Neoadjuvant Treatment before Gastrectomy.

BACKGROUND: The neutrophil to lymphocyte ratio (NLR) has demonstrated prognostic value in various malignant conditions, including gastric adenocarcinoma. However, chemotherapy may affect NLR. OBJECTIVES: To evaluate the prognostic value of NLR as an accessory decision-making tool in terms of operating patients after neoadjuvant chemotherapy in patients with resectable gastric cancer. METHODS: We collected oncologic, perioperative, and survival data of patients with gastric adenocarcinoma who underwent curative intent gastrectomy and D2 lymphadenectomy between 2009 and 2016. The NLR was calculated from preoperative laboratory tests and classified as high (> 4) and low (≤ 4). The t-test, chi-square, Kaplan-Meier analysis, and Cox multivariate regression models were used to assess associations of clinical, histologic, and hematological variables with survival. RESULTS: For 124 patients the median follow-up was 23 months (range 1-88). High NLR was associated with greater rate of local complication (r=0.268, P < 0.01). The rate of major complications (Clavien-Dindo ≥ 3) was higher in the high NLR group (28% vs. 9%, P = 0.022). Among the 53 patients who received neoadjuvant chemotherapy, those with low NLR had significantly improved disease-free survival (DFS) (49.7 vs. 27.7 months, P = 0.025). Low NLR was not significantly associated with overall survival (mean survival, 51.2 vs. 42.3 months, P = 0.19). Multivariate regression identified NLR group (P = 0.013), male gender (P = 0.04), and body mass index (P = 0.026) as independently associated with DFS. CONCLUSIONS: Among gastric cancer patients planned for curative intent surgery who underwent neoadjuvant chemotherapy, NLR may have prognostic value, particularly regarding DFS and postoperative complications.

Risk Factors for Readmission and Mortality Following Colonic Surgery: A Consecutive Retrospective Series of More Than 2500 Cases.

Introduction: The optimal strategy to reduce short-term readmission rates following colectomy remains unclear. Identifying possible risk factors can minimize the burden associated with surgical complications leading to readmissions. Materials and Methods: A retrospective review of all adult patients who underwent colectomies between January 2008 and December 2020 in a large tertiary medical center was conducted. Data were collected from patient's medical charts and analyzed. Results: Overall, 2547 patients were included in the study (53% females; mean age 68.3 years). The majority of patients (83%, n = 2112) were operated in an elective setting, whereas 435 patients (17%) underwent emergency colonic resection. Overall, the 30-day readmission rate was 8.3% (n = 218) with an overall 30-day mortality rate of 1.65% (n = 42). Multivariable analysis of possible risk factors for 30-day readmission demonstrated that patient age (odds ratio [OR] 0.98; P = .002), length of stay before surgery (OR 1.01; P = .003), and blood transfusion rate during hospitalization (OR 2.09; P < .001) were all independently associated with an increased risk. Laparoscopic colectomy (OR 0.53; P = .001) was associated with a reduced risk for readmission. Multivariable analysis of risk factors for mortality showed that age (OR 1.10; P < .001), cognitive decline (OR 12.35; P < .001), diabetes (OR 1.00; P = .004), and primary ostomy formation (OR 2.80; P = .006) were all associated with higher mortality. Conclusion: Patient age, history of cognitive decline, and blood transfusion along with a longer hospital stay were all correlated with an increased risk for 30-day patient readmission following colectomy.

Laser hemorrhoidoplasty for II-IV grade hemorrhoids: should we treat them the same?

Laser Hemorrhoidoplasty (LHP) is a novel therapeutic option for hemorrhoids. In this study, we aimed to evaluate the post-operative outcomes of patients undergoing LHP surgery based on hemorrhoid grade. A retrospective analysis of a prospective database of all patients who underwent LHP surgery between September 2018 and October 2021 was performed. Patients' demographics, clinical perioperative data, and post-operative outcomes were recorded and analyzed. One hundred and sixty two patients that underwent laser hemorrhoidoplasty (LHP) were included. Median operative time was 18 min (range 8-38). Median total energy applied was 850 Joule (450-1242). Complete remission of symptoms following surgery was reported by 134 patients (82.7%), while 21 patients (13%) reported partial symptomatic relief. Nineteen patients (11.7%) presented with post-operative complications, and 11 patients (6.75%) were re-admitted following surgery. Post-operative complication rate was significantly higher in patients with grade 4 hemorrhoids compared to grades 3 or 2, due to a higher rate of post-operative bleeding (31.6% vs. 6.5% and 6.7%, respectively; p = 0.004). Furthermore, post-operative readmission rate (26.3% vs. 5.4% and 6.2%; p = 0.01) and reoperation rate were also significantly higher in grade IV hemorrhoids (21.1% vs. 2.2% and 0%; p = 0.001). Multivariate analysis found that grade IV hemorrhoids had a significantly higher risk for post-operative bleeding (OR 6.98, 95% CI 1.68-28.7; p = 0.006), 30-day readmission (OR 5.82, 95% CI 1.27-25.1; p = 0.018), and hemorrhoids recurrence (OR 11.4, 95% CI 1.18-116; p = 0.028). LHP is an effective treatment for hemorrhoids grades II-IV, but carries significant risk for bleeding and re-intervention in patients with grade IV hemorrhoids.

Outcomes of Laser-Assisted Closure (SiLaC) Surgery for Chronic Pilonidal Sinus Disease.

Background: Management of pilonidal sinus (PNS) disease has changed notably in the past decade, with the introduction of novel surgical techniques and technological innovation. In this study, we summarized our initial experience with sinus laser-assisted closure (SiLaC) of pilonidal disease. Methods: A retrospective analysis of a prospective database of all patients who underwent minimally invasive surgery combined with laser therapy for PNS between September 2018 and December 2020 was performed. Patients' demographics, clinical and perioperative data, as well postoperative outcomes were recorded and analyzed. Results: A total of 92 patients (86 males, 93.4%) underwent SiLaC surgery for pilonidal sinus disease during the study period. Patients' median age was 22 (range 16-62 years), and 60.8% of them previously underwent abscess drainage due to PNS. SiLaC was performed under local anesthesia in 85.7% of cases (78 patients) with a median energy of 1081 J (range 13-5035 J). One patient was lost to follow-up, leaving 91 patients for final analysis. The primary outcome was complete healing rate, standing at 81.3% (74/91 patients). In 8 patients (8.8%), there was minor incomplete healing that did not require reintervention. Recurrent/nonhealing disease was seen in 9 patients (9.9%), requiring reoperation in 7 patients (8.4%). Of those, 4 patients underwent repeat SiLaC and 3 patients underwent wide excision. Analysis of risk factors for PNS recurrence demonstrated that general anesthesia (P = .02) was associated with increased risk for recurrence along with a trend for increased risk in patients with significant hairiness (P = .078). No differences were seen in age (P = .621), gender (P = .475), median sinus length (P = .397), and energy used (P = .904). Conclusion: Primary healing rate after SiLaC surgery for chronic PNS was >80% in our series. Ten percent of patients did not achieve complete healing but did not require surgery due to lack of symptoms.

Management of Chronic Anal Fissure with a Novel Topical Hemp-Herbal-Based Ointment: A Pilot Study.

Introduction: Anal fissure (AF) is a common anorectal disease. Although several pharmacological treatments are available, many patients still require surgical interventions. In this study, we aimed to evaluate the efficacy of an ointment based on a multifunctional blend of herbal ingredients including hemp (ProctoFiz) for chronic AF. Methods: A single-arm, questionnaire-based prospective study was conducted in a large tertiary center to evaluate the outcomes of patients suffering from chronic AF treated with topical ProctoFiz. Results: Ninety-two patients were included in the study, 54 (58.7%) were females with a median age of 39 (range 17-78). 32 patients (34.7%) suffered from recurrent AF before enrolling in the study, and 5 patients (5.4%) underwent previous surgical interventions for AF. Three patients (3.2%) were lost to follow-up, leaving 89 patients for analysis. Eighty patients (89.9%) reported significant improvement of symptoms after 1 week using ProctoFiz, and 79 patients reported continued improvement after 1 month of treatment. The mean pain Visual Analog Score (VAS) declined by 6.6 points (8.9 vs. 2.3; 95% CI: 7.20 to -5.99, p < 0.0001) following 1 week of treatment, with continuous improvement to a mean of 0.64 after 1 month. Negative impact on quality of life significantly decreased from a mean of 8.8 to 0.38 following a month of treatment (p < 0.0001), with significant reduction in the number of patients suffering from bleeding following bowel movements (64.1-2.5%; p = 0.0001). Conclusion: Hemp-based topical treatment of AF is feasible and significantly improves AF-correlated symptoms.

Seniority of the assistant surgeon and perioperative outcomes in robotic-assisted proctectomy for rectal cancer.

The background of this study is to evaluate the impact of the assistant surgeon's in robotic-assisted proctectomy (RAP) on perioperative outcomes. A retrospective analysis of all patients who underwent RAP for rectal adenocarcinoma between 2011 and 2020 was conducted. Patient cohort was divided into three groups based on the assistant surgeon's training level: post-graduate years (PGY) 1-3 surgical residents (Group 1), PGY 4-5 surgical residents (Group 2), and board-certified general surgeons (Group 3). Overall, 175 patients were included in the study: 29 patients (17%) in Group 1, 84 (48%) in Group 2, and 62 (35%) in Group 3. The median tumor distance from the anal verge was 8 cm in all groups (p = 0.73). The median operative time was similar across all groups: 290, 291, and 281 min in Groups 1, 2, and 3, respectively (p = 0.69). In a multivariable analysis, the lack of association between assistant training level and procedure time maintained when adjusting for the year of operation (p = 0.84). Patients operated with junior residents as assistant surgeons (Group 1) had a more postoperative complications (p = 0.01) and a slightly longer hospital length of stay [7 days, interquartile range (IQR) 3], compared to those operated by assistant surgeons that were senior residents or attendings (6 IQR 2.5, and 6 IQR 2 in Groups 2 and 3, respectively; p = 0.02). Conversion rates (p = 0.12), intraoperative complications (p = 0.39), major postoperative complications (Clavien-Dindo ≥ 3; p = 0.32), 30-day readmission (p = 0.45), and mortality (p = 0.99) were similar between the groups. Robotic-assisted proctectomy performed with the assistance of a junior resident was found to be correlated with worse postoperative outcomes compared to more experienced assistants. No difference was seen in intraoperative outcomes.

Naples Prognostic Score to Predict Postoperative Complications After Colectomy for Diverticulitis.

BACKGROUND: The Naples Prognostic Score (NPS) has proven efficacy as a prognostic tool for postoperative outcomes in patients undergoing surgery for neoplastic diseases. However, the role of the NPS score in inflammatory surgical diseases has not yet been studied. We aimed to evaluate NPS predictive value in patients undergoing colectomy due to diverticulitis. METHODS: A single-center retrospective study including all patients who underwent colectomy for diverticulitis between July 2008 and March 2020 was established. Patients' demographics, clinical and surgical data were recorded and analyzed. Patients were scored on a scale of 0-4 and received one point for preoperation albumin <4 g/dL, cholesterol ≤180 mg/dL, Neutrophil to Lymphocyte Ratio >2.96, and Lymphocyte to Monocyte ≤4.44. RESULTS: Out of 3292 patients admitted because of diverticulitis during the study period, 159 patients (4.83%) underwent colectomy. Of those patients, fifty patients were eligible for NPS analysis. 35 patients (70%) were females with a mean age of 62.81 ± 14.51. Thirty-two (64%) patients underwent an elective operation. The postoperative complications rate was 36% (N = 18). The mortality rate was 6% (N = 3). ROC showed a strong association between the NPS and mortality (area = .88, P = .03) and wound infection (area = .78, P = .01). In patients who underwent urgent surgery, there was an association between NPS and re-operation (P = .04). There was a correlation between NPS and Clavien-Dindo score (Spearman's coefficient = .284, P = .045). CONCLUSIONS/DISCUSSION: The Naples prognostic score is an effective tool for predicting postoperative complications in patients undergoing colectomy for diverticulitis. It may assist the surgeon in deciding on extent of the operation for diverticulitis and in elective cases also on timing.

[UPPER GASTROINTESTINAL BLEEDING CAUSED BY BREAST ANGIOSARCOMA METASTASIS LOCATED IN THE GASTRO-ESOPHAGEAL JUNCTION].

INTRODUCTION: Angiosarcomas are rare and aggressive tumors that originate from endothelial cells and make up roughly 2-3% of all soft-tissue sarcomas. Breast angiosarcomas may be idiopathic or secondary to radiation therapy or chronic lymphatic edema. Primary angiosarcoma of the gastrointestinal (GI) tract is rare and usually causes abdominal pain or GI bleeding. In this case report, we present a patient who appeared with upper gastrointestinal bleeding due to a radiation-induced breast angiosarcoma metastatic lesion in the gastroesophageal junction (GEJ). To the best of our knowledge, breast angiosarcoma metastases to the GEJ were not previously described, and moreover, GI bleeding secondary to breast angiosarcoma GI metastases was not previously reported.

Inflammatory markers may predict post-operative complications and recurrence in Crohn's disease patients undergoing gastrointestinal surgery.

BACKGROUND: Most Crohn's Disease (CD) patients will require surgical intervention over their lifetime, with considerably high rates of post-operative complications. Risk stratification with reliable prognostic tools may facilitate clinical decision making in these patients. Blood cell interaction based inflammatory markers have proven useful in predicting patient outcomes in oncological and benign diseases. The aim of this study was to investigate their prognostic value in CD patients undergoing surgery. METHODS: A retrospective single institution study of CD patients who underwent surgery between the years 2008 and 2019 was conducted. Data were collected from medical records and analysed for association of Platelet-to-Lymphocyte Ratio (PLR), Neutrophil-to-Lymphocyte Ratio (NLR), Lymphocyte-to-Monocyte Ratio (LMR) and the modified Systemic Inflammatory Score (mSIS) with post-operative outcomes. RESULTS: A total of 81 patients were included in the analysis. Half were females; mean age was 36 ± 15.54 years. Fifty seven percent (n = 46) were operated in expedited settings, with 23.5% developing post-operative complications. In elective patients, higher pre-operative NLR (P = 0.029) and PLR (P = 0.034) were associated with major post-operative complications, higher NLR (P = 0.029) and PLR (P = 0.034) were associated with re-operation and higher PLR correlated with Clavien-Dindo score (P = 0.032). In patients operated in expedited operations, higher pre-operative NLR (P = 0.021) and lower pre-operative LMR (P = 0.018) were associated with thromboembolic events and higher mSIS was associated with major post-operative complications (P = 0.032). CONCLUSIONS: Blood cell interaction based inflammatory markers confer an association with post-operative complications in CD patients undergoing surgery. These indices may facilitate patient selection and optimization when considering the risks and benefits of surgical interventions.

Manual Closed Reduction of Incarcerated Hernia: Is It Safe in the Emergency Department?

BACKGROUND: Emergency surgical repair is the standard approach to the management of an incarcerated abdominal wall hernia (IAWH). In cases of very high-risk patients, manual closed reduction (MCR) of IAWH may prevent the need for emergency surgery. OBJECTIVES: To evaluate the safety, success rate, and complications of MCR in the management of IAWH conducted in an emergency department. METHODS: The data of all patients who underwent MCR between 2012 and 2018 were retrospectively collected. Patient demographics, presenting symptoms, clinical parameters, and management during the hospitalization were retrieved from the medical charts. RESULTS: Overall, 548 patients underwent MCR during the study period. The success rate was 25.4% (139 patients). One patient had a complication that required a laparotomy 2 days after his discharge. A recurrent incarceration occurred in 23%, 60% of them underwent successful repeated MCR and the others underwent emergency surgery. Six patients (1.4%) had a bowel perforation after a failed MCR. CONCLUSIONS: MCR can be performed safely in the emergency department and should be consider as an option to treat IAWH, especially in high operative risk patients.

Surgical Outcomes of Minimally Invasive Trephine Surgery for Pilonidal Sinus Disease and Risk Factors for Recurrence.

Background: Minimally invasive surgical (MIS) techniques for pilonidal sinus disease (PNS) have gained popularity in recent years, due to faster recovery and lower complication rate compared with conventional methods. Our aim was to assess recurrence rate following MIS Trephine procedure for PNS and to identify possible risk factors for recurrence. Materials and Methods: A prospective cohort, including patients who underwent PNS Excision by Trephine MIS Procedure over 5 years in a large tertiary medical center was established. Patient data were collected from medical charts and patient telephone survey to asses recurrence rate. Results: Two hundred three patients underwent MIS Trephine procedure for PNS, with data available on 130 patients (64.2%). Overall recurrence and nonhealing wound rate was 33.07% (43 patients), with disease recurrence occurring in mean time of 13.3 months (range 2-47 months). Thirty-six patients underwent repeat MIS Trephine surgery with recurrence occurring in 6 patients (4.6%). Overall healing rate following repeat surgery was 91.5% (119 patients). Univariate analysis of preoperative and clinical factors, including body mass index (P = .77), smoking status (P = .53), number of sinus tracts (P = .78), previous abscess drainage (P = .45), and diameter size of the trephine blade (P = .72) demonstrated no correlation to disease recurrence following surgery. Multivariate Cox regression analysis showed similar results, with only young age (<30 years) associated with disease recurrence (P = .01). Conclusion: Recurrence following minimally invasive trephine excision for PNS is fairly high, but repeat surgery in recurring patients has a high rate of a successful outcome.

Management of Acute Appendicitis during the COVID-19 Pandemic: A Single Tertiary Center Experience.

BACKGROUND: The coronavirus disease-2019 (COVID-19) outbreak had an effect on healthcare. OBJECTIVES: To evaluate the presentation and management of patients with acute appendicitis. METHODS: A retrospective study was conducted of all patients presenting with acute appendicitis to the emergency department of a large tertiary center during March and April 2020. Clinical features, diagnostic workup, and management were compared. RESULTS: Seventy-four patients presented with acute appendicitis during the pandemic compared to 60 patients during the same time the year before. There were no significant differences in patient demographics: age (P = 0.65), gender (P = 0.73), smoking status (P = 0.48). During COVID-19 patients were more likely to complain of right lower quadrant pain (100% vs. 78.3%, P < 0.01). Rates of surgical treatment was similar (83.8% vs. 81.7%, P = 1); mean operative time was longer during COVID-19 (63 ± 23 vs. 52 ± 26 minutes, P = 0.03). There were no significant differences in intra-operative findings including the presence of appendiceal perforation (16.3% vs. 14.5%, P = 0.8), abscess (6.1% vs. 9.7%, P = 0.73), or involvement of cecum or terminal ileum (14.28% vs. 19.63%, P = 1). Postoperative treatment with antibiotics was more prevalent during COVID-19 (37.1% vs. 18%, P = 0.04). Length of stay (1.82 ± 2.04 vs. 2.74 ± 4.68, P = 0.2) and readmission rates (6% vs. 11.3%, P =0.51) were similar. CONCLUSIONS: The COVID-19 pandemic did not significantly affect the presentation, clinical course, management, and outcomes of patients presenting with acute appendicitis.

The Effect of the COVID-19 Outbreak on Trauma-Related Visits to a Tertiary Hospital Emergency Department.

BACKGROUND: The novel coronavirus disease (COVID-19) pandemic changed medical environments worldwide. OBJECTIVES: To evaluate the impact of the COVID-19 pandemic on trauma-related visits to the emergency department (ED). METHODS: A single tertiary center retrospective study was conducted that compared ED attendance of patients with injury-related morbidity between March 2020 (COVID-19 outbreak) and pre-COVID-19 periods: February 2020 and the same 2 months in 2018 and 2019. RESULTS: Overall, 6513 patients were included in the study. During the COVID-19 outbreak, the daily number of patients visiting the ED for acute trauma declined by 40% compared to the average in previous months (P < 0.01). A strong negative correlation was found between the number of trauma-related ED visits and the log number of confirmed cases of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) in Israel (Pearson's r = -0.63, P < 0.01). In the COVID-19 period there was a significant change in the proportion of elderly patients (7% increase, P = 0.002), admissions ratio (12% increase, P < 0.001), and patients brought by emergency medical services (10% increase, P < 0.001). The number of motor vehicle accident related injury declined by 45% (P < 0.01). CONCLUSIONS: A significant reduction in the number of trauma patients presenting to the ED occurred during the COVID-19 pandemic, yet trauma-related admissions were on the rise.