Chronic jejuno-colonic fistula and intestinal malabsorption due to multiple magnet ingestions: A case report and systematic review.

Magnet ingestion in children can lead to serious complications, both acutely and chronically. This case report discusses the treatment approach for a case involving multiple magnet ingestions, which resulted in a jejuno-colonic fistula, segmental intestinal volvulus, hepa-tosteatosis, and renal calculus detected at a late stage. Additionally, we conducted a literature review to explore the characteristics of intestinal fistulas caused by magnet ingestion. A six-year-old girl was admitted to the Pediatric Gastroenterology Department pre-senting with intermittent abdominal pain, vomiting, and diarrhea persisting for two years. Initial differential diagnoses included celiac disease, cystic fibrosis, inflammatory bowel disease, and tuberculosis, yet the etiology remained elusive. The Pediatric Surgery team was consulted after a jejuno-colonic fistula was suspected based on magnetic resonance imaging findings. The physical examination revealed no signs of acute abdomen but showed mild abdominal distension. Subsequent upper gastrointestinal series and contrast enema graphy confirmed a jejuno-colonic fistula and segmental volvulus. The family later reported that the child had swallowed a magnet two years prior, and medical follow-up had stopped after the spontaneous expulsion of the magnets within one to two weeks. Surgical intervention was necessary to correct the volvulus and repair the large jejuno-colonic fistula. To identify relevant studies, we conducted a detailed literature search on magnet ingestion and gastrointestinal fistulas according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. We identified 44 articles encompassing 55 cases where symptoms did not manifest in the acute phase and acute abdomen was not observed. In 29 cases, the time of magnet ingestion was unknown. Among the 26 cases with a known ingestion time, the average duration until fistula detection was 22.8 days (range: 1-90 days). Fistula repairs were performed via laparotomy in 47 cases.

Ventricular bigeminy associated with myocardial ischemia in a dog with a colonic torsion: a case report.

BACKGROUND: Ventricular bigeminy due to myocardial ischemia has been reported in humans as well as in canine patients with obstructive gastrointestinal diseases. This is the first case report of ventricular bigeminy in a dog with a colonic torsion that resolved after fluid resuscitation and restoration of myocardial perfusion. CASE PRESENTATION: An 11-year-old, male neutered mixed breed dog presented with a one day history of vomiting, tenesmus, and lethargy. Physical examination identified an irregular heart rhythm and intermittent pulse deficits. A ventricular arrhythmia represented by ventricular premature complexes (VPCs) organized in bigeminy, was appreciated on a 3-lead electrocardiogram (ECG) with a single lead (II) view. Abdominal radiographs confirmed a colonic torsion. Prior to anesthetic induction, ventricular bigeminy was non responsive to fentanyl or lidocaine. The patient was anesthetized and intravascular volume deficit was identified by dampened plethysmographic wave amplitude (plethysomographic variability), audible softening of the Doppler sound, and more pronounced pulse deficits. Fluid resuscitation was achieved with a combination of intravenous crystalloid and colloid fluid therapy comprising 7.2% hypertonic saline and 6% hetastarch. The patient's cardiac rhythm converted to normal sinus after fluid resuscitation. The colonic torsion was surgically corrected. The patient recovered well from anesthesia and was ultimately discharged from the hospital 5 days later. CONCLUSIONS: The present case report highlights that myocardial ischemia can lead to ventricular arrythmias, such as ventricular bigeminy. This is the first documented case of ventricular bigeminy in the canine patient with a colonic torsion. Assessment of patient volume status and appropriate fluid resuscitation along with continuous electrocardiogram (ECG) monitoring are vital to patient stability under general anesthesia.

[Gastrocolic fistula as infrequent cause of chronic diarrhea in a patient with percutaneous radiological gastrostomy]. / Fístula gastrocólica como causa infrecuente de diarrea persistente en un paciente portador de gastrostomía radiológica percutánea.

Introduction: Introduction: gastrocolic fistula is an infrequent but severe complication of percutaneous gastrostomy. Clinical suspicion in the presence of chronic diarrhea of unknown etiology manifesting after percutaneous radiological gastrostomy (PRG) tube replacement is key to early detection and treatment. Case report: we report the case of a patient with PRG that began with chronic diarrhea after tube replacement and developed severe malnutrition. Initial treatment was not effective, studies were extended with the finding of this complication in a CT image. The use of this tube was discontinued with resolution of diarrhea and a favorable nutritional outcome. Discussion: this case report shows the importance of considering gastrocolic fistula in the differential diagnosis of persistent diarrhea in a patient with a gastrostomy tube.

Introducción: Introducción: la fístula gastrocólica supone una complicación infrecuente pero potencialmente grave de las sondas de gastrostomía. La sospecha clínica ante una diarrea de origen incierto que comienza tras el recambio de la sonda es clave para la detección y el tratamiento precoces. Caso clínico: se presenta el caso de un paciente portador de gastrostomía radiológica percutánea (PRG) que comienza con diarrea persistente tras el primer recambio de la sonda y desnutrición grave secundaria. Tras el fracaso de las medidas terapéuticas iniciales se amplían los estudios, con hallazgo de esta complicación en la imagen de TC. Se suspende el uso de esta sonda con resolución de la diarrea y evolución nutricional favorable. Discusión: este caso pone de manifiesto la importancia de incluir la fístula gastrocólica en el diagnóstico diferencial de la diarrea persistente en un paciente portador de sonda de gastrostomía.

Calprotectina fecal no monitoramento de pacientes com Doença de Crohn envolvendo o cólon / Fecal calprotectin in monitoring patients with Crohn's disease involving the colon

INTRODUÇÃO: Considerada uma doença crônica e sem cura que acomete adolescentes e adultos jovens, as principais características clínicas da DC incluem febre, palidez, perda de peso, massas abdominais, fístulas e fissuras perianais. Devido à heterogeneidade das manifestações clínicas, seu diagnóstico e monitoramento é obtido através de uma avaliação combinada das características clínicas com os achados endoscópicos, histopatológicos, laboratoriais e de imagem. De maneira geral, as análises laboratoriais contribuem na avaliação de sinais de resposta inflamatória aguda e/ou crônica, essenciais para o direcionamento do início e da manutenção do tratamento farmacológico. Atualmente, devido às suas correlações com alterações na atividade inflamatória, os testes laboratoriais de proteína C reativa (PCR) e velocidade de hemossedimentação (VHS) estão disponíveis no SUS. A CF apresenta boa correlação com a atividade inflamatória do trato intestinal, fazendo dela um importante marcador inflamatório na DC, especialmente quando o objetivo a monitorização do tratamento, a fim de reduzir o número de colonoscopias indesejadas. PERGUNTA: No monitoramento de pacientes com doença de Crohn (DC) envolvendo o cólon em atividade, a calprotectina fecal (CF) é mais sensível e/ou específica que a proteína C reativa (PCR) ou a velocidade de hemossedimentação (VHS) para identificar e/ou afastar doença com atividade endoscópica? EVIDÊNCIAS CLÍNICAS: A colonoscopia foi considerada padrão ouro no monitoramento da atividade da DC em todos os estudos que avaliaram marcadores inflamatórios, como possível substituto no monitoramento dos pacientes com DC. Quatro revisões sistemáticas foram incluídas, sendo duas com meta-análises. Para síntese de resultados e realização do GRADE foi escolhida a revisão sistemática mais recente, a qual teve maior número de estudos incluídos na síntese de dados. A partir da mesma, foi observado uma sensibilidade de 0,83 (IC 95% 0,77 a 0,87) e especificidade de 0,76 (0,68 a 0,82) no monitoramento da atividade da DC. A síntese de resultados mostrou que a CF apresenta um odds ratio diagnóstico de 13,8 (IC 95% 9,1-20,9) no monitoramento da atividade da doença, o que significa dizer que o exame apresenta 14 vezes mais chances de identificar o paciente que está com doença ativa comparado com aquele com doença inativa. Os estudos foram considerados como de qualidade da evidência criticamente baixa a baixa. O nível de certeza da evidência foi moderado. AVALIAÇÃO ECONÔMICA: Ao comparar a sensibilidade da CF com PCR para o desfecho de colonoscopias evitadas, observou-se equivalência entre as tecnologias. Consequentemente, a eficácia das duas tecnologias resulta em números iguais de colonoscopias evitadas. Portanto, a principal diferença nesta análise foi o custo adicional do teste de CF em relação ao PCR, que foi de R$ 450,90. No entanto, em contrapartida, a eficácia da CF para o desfecho de monitoramento adequado da atividade da Doença de Crohn (DC) foi ligeiramente maior (∆ 0,03263), resultando em uma RCEI de R$ 13.818,57 por indivíduo adequadamente monitorado. O valor de RCEI por número de colonoscopia evitadas e monitoramento adequado ao comparar com VSH foi de R$ 10.046,73 e R$ 7.525,00, respectivamente. ANÁLISE DE IMPACTO ORÇAMENTÁRIO: O horizonte temporal estabelecido para a análise de impacto orçamentário foi de cinco anos. Para o cálculo da população elegível, partiu-se do número de pacientes com DC que estão em tratamento no DATASUS e, a partir de então, definiu-se o número de pacientes que necessitam de monitoramento da atividade da DC. O market share utilizado para o cenário proposto foi de 5% a 25%, assumindo que 74% dos pacientes com DC fazem o monitoramento com PCR e 26% com VHS. Considerando a incorporação do teste de CF no SUS houve um incremento de custo de R$ 39.675,00 no primeiro ano, chegando a R$ 231.755,00 no quinto ano de análise, resultando em um total acumulado de R$ 660.907,00 ao longo de cinco anos. MONITORAMENTO DO HORIZONTE TECNOLÓGICO: Realizaram-se buscas estruturadas nos campos de pesquisa das bases de dados ClinicalTrials.gov e Cortellis™, a fim de se localizar demais dispositivos médicos utilizados no procedimento de testagem para a calprotectina fecal no monitoramento de pacientes com doença de crohn envolvendo o cólon. As pesquisas nas bases de dados não apresentaram resultados para novos dispositivos médicos utilizados em procedimentos de análises laboratoriais que realizem a testagem da calprotectina fecal. CONSIDERAÇÕES FINAIS: Não houve estudos que comparassem diretamente a CF com os outros marcadores inflamatórios. Para determinar a sensibilidade e especificidade da CF, os estudos disponíveis utilizavam os escores endoscópicos como padrão ouro. Foi observado uma sensibilidade de 0,83 (IC 95% 0,77 a 0,87) e especificidade de 0,76 (0,68 a 0,82) no monitoramento da atividade da DC com CF. A síntese de resultados mostrou que o exame apresenta 14 vezes mais chances de identificar o paciente que está com doença ativa comparado com aquele com doença inativa. A qualidade metodológica das revisões sistemáticas incluídas foi considerada criticamente baixa (25%) a baixa (75%). Pelo GRADE, considerando uma corte simulada com 1.000 pacientes testados com prevalência de, 10, 40 e 80% de doença ativa, a certeza da evidência gerada foi julgada como moderada. O CADTH e o SBU destacam o uso da CF no monitoramento da atividade das DII. De maneira geral, ao ser utilizado no monitoramento da atividade da DC, o teste de CF pode resultar em um incremento de R$660.907,00 em cinco anos. PERSPECTIVA DO PACIENTE: Foi aberta Chamada Pública nº 26/2023 para inscrição de participantes para a Perspectiva do Paciente, durante o período de 13/07/2023 a 23/07/2023, e 148 pessoas se inscreveram. A seleção dos representantes titular e suplente ocorreu por meio de sorteio em plataforma on-line. Durante seu relato, a representante destacou os aspectos positivos de realizar o monitoramento da doença de Crohn com o exame de calprotectina fecal. Pontuou que com a sua realização, não tem sido mais necessário realizar colonoscopia - exame que exige todo um preparo anterior e que a deixa debilitada. RECOMENDAÇÃO PRELIMINAR DA CONITEC: Os membros do Comitê de Produtos e Procedimentos presentes na 16ª Reunião Extraordinária da Conitec, realizada no dia 31 de outubro de 2023, deliberaram por unanimidade que a matéria fosse disponibilizada em consulta pública com recomendação preliminar desfavorável à incorporação no SUS da Calprotectina Fecal (CF) no monitoramento de pacientes com doença de Crohn envolvendo o cólon. O comitê considerou que é necessário aguardar o retorno da consulta pública, na expectativa de que as contribuições forneçam uma melhor compreensão dos benefícios da tecnologia para a indicação em avaliação. CONSULTA PÚBLICA: A Consulta Pública nº 64/2023 foi realizada entre os dias 29/12/2023 e 17/01/2024. Foram recebidas 266 contribuições, sendo 161 pelo formulário para contribuições técnico-científicas e 105 pelo formulário para contribuições sobre experiência ou opinião de pacientes, familiares, amigos ou cuidadores de pacientes, profissionais de saúde ou pessoas interessadas no tema. Dentre estas, 100% das contribuições expressaram discordância em relação à recomendação preliminar da Conitec e opinaram pela incorporação da tecnologia no SUS. Após análise do conteúdo das contribuições técnico-científicas, mais 126 contribuições do formulário técnico-científico foram consideradas como de experiência ou opinião. Dessa forma, a análise foi realizada sobre o total de 231 contribuições sobre experiência e opinião. Os respondentes destacaram que a tecnologia deve ser incorporada por ser um procedimento menos invasivo, mais seguro e acessível, contribuindo para melhor acompanhamento da doença e resultando em menor custo em relação à tecnologia disponível atualmente no SUS para diagnóstico e monitoramento da doença (colonoscopia). Foram consideradas para análise 31 contribuições técnico-científicas, sendo 28 realizadas por profissionais da Saúde e 2 por empresa fabricante da tecnologia. Foram recebidos 15 anexos com documentos solicitando a incorporação com referências de Consensos Nacionais e Internacionais, diretrizes e outros estudos demonstrando a importância e a necessidade do exame na prática clínica. RECOMENDAÇÃO FINAL DA CONITEC: Os membros do Comitê de Produtos e Procedimentos presentes na 127ª Reunião Ordinária da Conitec, realizada no dia 08 de março de 2024, deliberaram por unanimidade, recomendar a incorporação no SUS da calprotectina fecal no monitoramento de pacientes com doença de Crohn envolvendo o cólon, conforme Protocolo Clínico do Ministério da Saúde. Para essa recomendação os membros do Comitê consideraram fundamental as contribuições advindas da consulta pública, que apresentaram a importância da realização do exame no monitoramento dos pacientes em tratamento, por ser de fácil acesso, menos invasivo e custo-efetivo. Consideraram também as opiniões dos especialistas presentes na reunião que apresentaram estudo recentemente publicado e confirmaram que a realização do exame de calprotectina fecal poderá diminuir a realização de exames de colonoscopias no monitoramento dos pacientes, diminuindo filas de espera para a realização do exame. Foi assinado o Registro de Deliberação nº 885/2024. DECISÃO: incorporar, no âmbito do Sistema Único de Saúde - SUS, o exame de calprotectina fecal no monitoramento de pacientes com doença de Crohn envolvendo o cólon, conforme Protocolo Clínico do Ministério da Saúde, publicada no Diário Oficial da União nº 77, seção 1, página 177, em 22 de abril de 2024.

Intravascular placement and migration of a colonic stent into the inferior mesenteric vein.

Colonic self-expanding metal stents (SEMSs) are commonly used to treat large bowel obstruction due to gastrointestinal malignancy with great success. While mortality is negligible, morbidity from both early and late complications can be significant. Stent perforation, erosion and migration are the most feared complications. We present the first reported case of wire-associated colon perforation with placement and migration of an SEMS into the inferior mesenteric vein (IMV). A man in his early 60s presented with a large bowel obstruction due to a colorectal mass. He underwent endoscopic colonic SEMS placement for colonic decompression. The stent was later found to be within the IMV, requiring a colon resection and retrieval of the stent.

Gastrojejunal Fistula Following Gastrostomy Tube.

Gastrostomy tubes are often placed in patients with poor voluntary intake, oropharyngeal dysphagia, or chronic illness to provide definitive nutritional access. Despite the widespread use of gastrostomy tubes, some patients can experience complications associated with this procedure including gastrocolic-cutaneous fistula and dislodgement of gastrostomy tube. This case discusses an instance of gastrojejunal fistula formation over one year after gastrostomy tube placement likely due to tube dislodgement. Imaging showed gastrostomy tube traversing the posterior wall of the stomach and creating a fistula into the jejunum, with the balloon inflated within the jejunum. Gastrostomy tube was removed and replaced, with gastrostomy tube study showing no extravasation of contrast. Patient is now doing well-tolerating tube feeds at goal.

[Surgical treatment of a patient with tubular colonic duplication complicated by perforation and peritonitis]. / Uspeshnoe lechenie patsienta s tubulyarnoi duplikatsiei tolstoi kishki, oslozhnennoi perforatsiei i peritonitom.

We present successful treatment of a patient with tubular colonic duplication complicated by fecal impaction, perforation and fecal peritonitis. This anomaly is usually detected in children younger 2 years old. In adulthood, this diagnosis is of a precedent-setting nature. If the diagnosis was not confirmed in early childhood, the absence of typical clinical picture, long-term course of disease and difficult interpretation of clinical data complicate subsequent verification of congenital anomaly. Only infectious complications and emergency surgery in adults can make a correct diagnosis.

Laparoscopic management of iatrogenic colon perforation.

BACKGROUND: Iatrogenic colon perforation (ICP) due to colonoscopy is a severe complication and is associated with significant morbidity and mortality. The global estimated incidence of ICP is 0.03% and up to 3% for diagnostic and therapeutic colonoscopies, respectively. Treatment options include endoscopic repair, conservative therapy, and surgery. Treatment decision is based on the time and the setting of the diagnosis, the type, and location of the perforation, the presence of related pathologies, the clinical status and characteristic of the patient, and surgeon's skills. We present our experience in the treatment of ICPs. METHODS: A retrospective review was undertaken of all patients suffering from ICP at Bnai-Zion Medical Center between 1/1/2010 and 1/3/2021. Clinical presentation, therapeutic approach, and short-term outcomes were analyzed. RESULTS: There were 51 cases of ICPs. Fourteen (27%) were diagnosed by the gastroenterologist during the procedure, 2 of whom were treated with endoscopic clips. The rest of the patients (72.5%) were diagnosed in the ER after a CT scan. Forty-three patients (84%) went on to operative management: 5 (11%) operations started with laparotomy-all were conducted in the early study period (until 2013). All other operations (88%) started with a diagnostic laparoscopy, 4 of whom (10%) were converted to laparotomy. Out of the 38 laparoscopic cases 29 (80%) were treated with primary suturing. Seven patients went on to colon resection (5 of whom with primary anastomosis). Six patients required ICU admission-with 1/38 (2%) from the laparoscopic cases, and 5/9 (55%) from the laparotomy cases. A total of 49/51 (96%) patients recovered and were discharged after 5 ± 2 for conservative and laparoscopic cases, and 12 ± 9 for open cases. CONCLUSION: Laparoscopic treatment of ICP is safe and feasible in most cases. Our data supports a laparoscopic attempt at any such scenario.

Escala predictiva de los resultados adversos en la hemorragia digestiva alta no varicosa / It not climbs predictiva of the adverse results in the high digestive hemorrhage varicose

Introducción: Existen varios sistemas de puntuación para predecir los resultados adversos en los pacientes con hemorragia digestiva alta no varicosa, pero no se han validado lo suficiente y cada uno pertenece a distintas poblaciones fuentes. Objetivo: Demostrar la utilidad de una escala propuesta para predecir las probabilidades de resangrado, de mortalidad y de necesidad de cirugía en los pacientes con hemorragia digestiva alta no varicosa. Métodos: Se realizó un estudio retrospectivo de una prueba diagnóstica en el hospital de Prenda, Luanda, Angola desde enero del 2021 hasta mayo del 2022. El universo estuvo formado por 93 pacientes atendidos durante ese período con el criterio de inclusión de tener el diagnóstico de hemorragia digestiva alta de origen no varicoso. Resultados: De un total de 93 pacientes se obtuvo como desenlace primario una recurrencia del sangrado de 18 pacientes para un 19,35 por ciento del total, seguido con 12 fallecidos para un 12,90 por ciento del total y cuatro fallecidos para un 4,40 por ciento del total. Los valores predictivos de la escala de forma general fueron, al ser aplicada una sensibilidad de 0,91, la especificidad de un 0,92, el valor predictivo negativo de un 0,95 y el valor predictivo negativo de un 0,86. Conclusiones: La escala propuesta tiene una sensibilidad y especificidad adecuada para predecir, en los pacientes con hemorragia digestiva alta no varicosa, la probabilidad de resangrado, de mortalidad y la necesidad de cirugía(AU)

Introduction: Several scoring systems exist to predict adverse outcomes in patients with nonvariceal upper gastrointestinal bleeding, but they have not been sufficiently validated and each pertains to different source populations. Objective: To demonstrate the usefulness of a proposed scoring scale to predict the probability of rebleeding, mortality, and need for surgery in patients with nonvariceal upper gastrointestinal bleeding. Methods: A retrospective study of a diagnostic test was performed at the hospital of Prenda, Luanda, Angola, from January 2021 to May 2022. The study universe consisted of 93 patients attended during that period, with the inclusion criterion of having a diagnosis of upper gastrointestinal bleeding of nonvariceal origin. Results: From a total of 93 patients, the primary outcome was a recurrence of bleeding in 18 patients, accounting for 19.35 percent of the total; followed by 12 deaths, representing 12.90 percent of the total, and four deaths, accounting for 4.40 percent of the total. After the scale was applied, the following general predictive values were obtained: sensitivity of 0.91, specificity of 0.92, negative predictive value of 0.95 and negative predictive value of 0.86. Conclusions: The proposed scale presents adequate sensitivity and specificity for predicting the probability of fatal rebleeding and the need for surgery in patients with nonvariceal upper gastrointestinal bleeding(AU)

Colonic Perforation Secondary to COVID-19 Induced Hemorrhagic Colitis in a Patient Heterozygous for Factor V Leiden.

Up to 17.6% of COVID-19 positive patients present with gastrointestinal symptoms and bowel wall abnormalities have been described in up to 31% of COVID-19 positive patients. Here, we present a case of a 40-year-old male diagnosed with COVID-19 complicated by hemorrhagic colitis leading to colonic perforation. CT scan of abdomen and pelvis demonstrated markedly distended descending and sigmoid colon with poorly defined wall, pneumatosis, and pneumoperitoneum. The patient was taken for emergent exploratory laparotomy for extended left hemicolectomy, partial omentectomy, transverse colostomy creation, abdominal washout, repair of small bowel, and appendectomy. The patient was brought back for repeat exploratory laparotomy with ICG perfusion assessment. Patient was found to be heterozygous for factor V Leiden mutation and was never vaccinated for COVID-19. Our case demonstrates a novel use for indocyanine green (ICG) to assess perfusion and underscores the importance of completing a thorough hypercoagulable evaluation following COVID-19 induced thrombotic event.

Incidence of colonoscopy-related perforation and risk factors for poor outcomes: 3-year results from a prospective, multicenter registry (with videos).

BACKGROUND AND AIMS: Perforation is a life-threatening adverse event of colonoscopy that often requires hospitalization and surgery. We aimed to prospectively assess the incidence of colonoscopy-related perforation in a multicenter registry and to analyze the clinical factors associated with poor clinical outcomes. METHODS: This prospective observational study was conducted at six tertiary referral hospitals between 2017 and 2020, and included patients with colonic perforation after colonoscopy. Poor clinical outcomes were defined as mortality, surgery, and prolonged hospitalization (> 13 days). Logistic regression was used to identify factors associated with poor clinical outcomes. RESULTS: Among 84,673 patients undergoing colonoscopy, 56 had colon perforation (0.66/1000, 95% confidence interval [CI] 0.51-0.86). Perforation occurred in 12 of 63,602 diagnostic colonoscopies (0.19/1000, 95% CI 0.11-0.33) and 44 of 21,071 therapeutic colonoscopies (2.09/1000, 95% CI 1.55-2.81). Of these, 15 (26.8%) patients underwent surgery, and 25 (44.6%) patients had a prolonged hospital stay. One patient (1.8%) died after perforation from a diagnostic colonoscopy. In the multivariate analysis, diagnostic colonoscopy (adjusted odds ratio [aOR] 196.43, p = 0.025) and abdominal rebound tenderness (aOR 17.82, p = 0.012) were independent risk factors for surgical treatment. The location of the sigmoid colon (aOR 18.57, p = 0.048), delayed recognition (aOR 187.71, p = 0.008), and abdominal tenderness (aOR 63.20, p = 0.017) were independent risk factors for prolonged hospitalization. CONCLUSIONS: This prospective study demonstrated that the incidence of colonoscopy-related perforation was 0.66/1000. The incidence rate was higher in therapeutic colonoscopy, whereas the risk for undergoing surgery was higher in patients undergoing diagnostic colonoscopy. Colonoscopy indication (diagnostic vs. therapeutic), physical signs, the location of the sigmoid perforation, and delayed recognition were independent risk factors for poor clinical outcomes in colonoscopy-related perforation.

Impact of a digital surgical workflow including Digital Device Briefing Tool on morbidity and mortality in a patient population undergoing primary stapled colorectal anastomosis for benign or malignant colorectal disease: protocol for a multicentre prospective cohort study.

INTRODUCTION: With growing emphasis on surgical safety, it appears fundamental to assess the safety of colorectal resection involving primary stapled anastomosis. Surgical stapling devices can considerably foster patient safety in colorectal surgery, but their misuse or malfunction encompass a unique risk of postoperative complications. The Digital Device Briefing Tool (DDBT) is a digital cognitive aid developed to enhance safe use of the Ethicon circular stapling device during colorectal resection. The purpose of this study is to evaluate how a digital operative workflow, including DDBT, compared with routine surgical care, affects morbidity and mortality in patients undergoing left-sided colorectal resection with primary stapled colorectal anastomosis for colorectal cancer or benign disease. METHODS AND ANALYSIS: A multicentre, prospective cohort study will be conducted at five certified academic colorectal centres in Germany. It compares a non-digital with a Johnson & Johnson digital solution (Surgical Process Institute Deutschland (SPI))-guided operative workflow in patients undergoing left hemicolectomy, sigmoidectomy, anterior rectal resection and Hartmann reversal procedure. The sample size is set at 528 cases in total, divided into 3 groups (a non-digital and two SPI-guided workflow cohorts, with and without DDBT) in a ratio of 1:1:1, with 176 patients each. The primary endpoint is a composite outcome comprising the overall rate of surgical complications, including death, during hospitalisation and within the first 30 days after colorectal resection. Secondary endpoints include operating time, length of hospital stay and 30-day hospital readmission rate. ETHICS AND DISSEMINATION: This study will be performed in line with the Declaration of Helsinki. The ethics committee of the Charité-University Medicine Berlin, Germany, approved the study (No: 22-0277-EA2/060/22). Study Investigators will obtain written informed consent from each patient before a patient may participate in this study. The study results will be submitted to an international peer-reviewed journal. TRIAL REGISTRATION NUMBER: DRKS00029682.