Closed-wound negative pressure therapy dressing after loop ostomy closure: a retrospective comparative study.

Closed-wound negative pressure wound therapy (NPWT) dressings were recently introduced with the purpose to reduce incisional surgical site infections (iSSI) in high-risk wounds. The aim of this study was to compare iSSI rates in patients after ostomy closure with and without additional application of a closed-wound NPWT dressing. Single-center retrospective analysis of consecutive patients undergoing ileo- or colostomy closure over an 8-year period (January 2013-January 2021). Intradermal non-purse string technique with absorbable sutures were used in all patients. Since November 2018, all patients (study group) received a NPWT device for a maximum of 5 days postoperatively (PICO, SMITH AND NEPHEW). Primary outcome was iSSI rate within 30 days of surgery. SSI was defined in accordance with the Center of Disease Control (CDC) classification and included superficial and deep incisional SSI. Data was retrieved from the institutional enhanced recovery after surgery (ERAS) database, with standardized complication assessment by trained abstractors. In total, 85 patients (25%) in the study group were comparable with 252 (75%) patients in the control group regarding demographics (age, gender, body mass index, ASA score), ostomy type and anastomotic technique (all p > 0.05), but not wound contamination class (class III: 5% vs 0%, p < 0.001). Median time to NPWT removal was 4 (IQR 3-5) days. Incisional SSI were observed in 4 patients (4.7%) in the study group and in 27 patients (10.7%) in the control group (p = 0.097). These preliminary results suggest a potential benefit of systematic application of the NPWT device after loop ostomy closure. A randomized controlled study is needed.

Current Opinion on Peritoneal Carcinomatosis Treatment: a Survey of the Indian Society of Peritoneal Surface Malignancies (ISPSM).

PURPOSE: Patients with peritoneal carcinomatosis (PC) are increasingly treated with multidisciplinary combined approaches. The study aim was to assess current practice and perceptions of treatment modalities of PC. METHODS: Indian Society of Peritoneal Surface Malignancies (ISPSM) members were invited to complete an online survey. Current practice and perceptions of treatment modalities were assessed through 19 closed questions. Scores were assessed using a Likert scale (0: not important, 5: very important). Treatment modality satisfaction was assessed using a semantic scale (frustrated: 0, perfectly happy: 10). Participants were sent 3 reminders at 4-week intervals. RESULTS: Fifty-seven out of 182 members completed the survey (31%). Forty percent of participants had an experience of at least 10 years, and 75% stated treating less than 20 PC patients per year. Main treatment goals for patients with PC were cure (5/5) and symptom relief (4/5). Participant's satisfaction with treatment modalities for ovarian, colorectal, and gastric PC were 6/10, 5/10, and 2/10, respectively. Hyperthermic intraperitoneal chemotherapy (HIPEC) for ovarian (57%) and colorectal (44%) origins were considered to be useful. Clinical usefulness of chemotherapy for gastric PC was rated to be low (17%). CONCLUSIONS: Current treatment modalities fall short to satisfy the needs (cure, symptom relief) of patients with PC. Alternative systemic and intraperitoneal treatment modalities should be assessed.

Risk factors for conversion in laparoscopic and robotic rectal cancer surgery.

BACKGROUND: The aim of this study was to review risk factors for conversion in a cohort of patients with rectal cancer undergoing minimally invasive abdominal surgery. METHODS: A retrospective analysis was performed of consecutive patients operated on from February 2005 to April 2018. Adult patients undergoing low anterior resection or abdominoperineal resection for primary rectal adenocarcinoma by a minimally invasive approach were included. Exclusion criteria were lack of research authorization, stage IV or recurrent rectal cancer, and emergency surgery. Risk factors for conversion were investigated using logistic regression. A subgroup analysis of obese patients (BMI 30 kg/m2 or more) was performed. RESULTS: A total of 600 patients were included in the analysis. The overall conversion rate was 9·2 per cent. Multivariable analysis showed a 72 per cent lower risk of conversion when patients had robotic surgery (odds ratio (OR) 0·28, 95 per cent c.i. 0·15 to 0·52). Obese patients experienced a threefold higher risk of conversion compared with non-obese patients (47 versus 24·4 per cent respectively; P < 0·001). Robotic surgery was associated with a reduced risk of conversion in obese patients (OR 0·22, 0·07 to 0·71). CONCLUSION: Robotic surgery was associated with a lower risk of conversion in patients undergoing minimally invasive rectal cancer surgery, in both obese and non-obese patients.

ANTECEDENTES: El objetivo del estudio era revisar los factores de riesgo para la conversión en una cohorte de pacientes con cáncer de recto sometidos a cirugía abdominal mínimamente invasiva. MÉTODOS: Se realizó un análisis retrospectivo de pacientes consecutivos operados desde febrero de 2005 hasta abril de 2018. Se incluyeron pacientes adultos sometidos a resección anterior baja o resección abdominoperineal por adenocarcinoma primario de recto mediante abordaje mínimamente invasivo. Los criterios de exclusión fueron falta del consentimiento informado, cáncer de recto en estadio IV o recidivado y cirugía urgente. Los factores de riesgo para la conversión se determinaron mediante regresión logística. Se realizó un análisis de subgrupo en pacientes obesos (índice de masa corporal, IMC ≥ 30 kg/m2 ). RESULTADOS: Se incluyeron en el análisis un total de 600 pacientes. La tasa global de conversión fue del 9,2%. El modelo multivariado mostró un riesgo 72% menor de conversión cuando los pacientes fueron tratados mediante cirugía robótica (razón de oportunidades, odds ratio, OR 0,28, i.c. del 95% 0,15-0,52). Los pacientes obesos presentaron un riesgo de conversión tres veces mayor en comparación con los pacientes no obesos (47,3% versus 24,5%, P < 0,001). La cirugía robótica se asoció con una menor probabilidad de conversión en los pacientes obesos (OR 0,22; i.c. del 95% 0,07-0,71). CONCLUSIÓN: La cirugía robótica se asoció con un menor riesgo de conversión en pacientes sometidos a cirugía mínimamente invasiva de cáncer de recto, tanto en pacientes obesos como no obesos.

Identification of patients eligible for discharge within 48 h of colorectal resection.

BACKGROUND: This study aimed to identify patients eligible for a 48-h stay after colorectal resection, to provide guidance for early discharge planning. METHODS: A bi-institutional retrospective cohort study was undertaken of consecutive patients undergoing major elective colorectal resection for benign or malignant pathology within a comprehensive enhanced recovery pathway between 2011 and 2017. Overall and severe (Clavien-Dindo grade IIIb or above) postoperative complication and readmission rates were compared between patients who were discharged within 48 h and those who had hospital stay of 48 h or more. Multinominal logistic regression analysis was performed to ascertain significant factors associated with a short hospital stay (less than 48 h). RESULTS: In total, 686 of 5122 patients (13·4 per cent) were discharged within 48 h. Independent factors favouring a short hospital stay were age below 60 years (odds ratio (OR) 1·34; P = 0·002), ASA grade less than III (OR 1·42; P = 0·003), restrictive fluid management (less than 3000 ml on day of surgery: OR 1·46; P < 0·001), duration of surgery less than 180 min (OR 1·89; P < 0·001), minimally invasive approach (OR 1·92; P < 0·001) and wound contamination grade below III (OR 4·50; P < 0·001), whereas cancer diagnosis (OR 0·55; P < 0·001) and malnutrition (BMI below 18 kg/m2 : OR 0·42; P = 0·008) decreased the likelihood of early discharge. Patients with a 48-h stay had fewer overall (10·8 per cent versus 30·6 per cent in those with a longer stay; P < 0·001) and fewer severe (2·6 versus 10·2 per cent respectively; P < 0·001) complications, and a lower readmission rate (9·0 versus 11·8 per cent; P = 0·035). CONCLUSION: Early discharge of selected patients is safe and does not increase postoperative morbidity or readmission rates. In these patients, outpatient colorectal surgery should be feasible on a large scale with logistical optimization.

ANTECEDENTES: Este estudio tuvo como objetivo identificar pacientes candidatos para una estancia hospitalaria de 48 horas tras resecciones colónicas, con el fin de proporcionar una guía de planificación del alta precoz. MÉTODOS: Estudio de cohortes retrospectivo de pacientes consecutivos sometidos a resección colorrectal electiva mayor por patología benigna o maligna en el marco de un programa integral de recuperación intensificada (enhanced recovery pathway, ERP), de dos hospitales entre 2011 y 2017. Se compararon las tasas de complicaciones postoperatorias globales y graves (Clavien ≥ IIIb) y de reingresos entre dos grupos (< 48 horas versus ≥ 48 horas de estancia hospitalaria). Se llevó a cabo una regresión logística multinominal de factores significativos (P < 0,05) asociados con una estancia corta (< 48 horas). RESULTADOS: En total, 686/5.122 pacientes (13,4%) fueron dados de alta dentro de las primeras 48 horas. Los factores independientes que propiciaron una estancia corta fueron la edad < 60 años (razón de oportunidades, odds ratio, OR 1,34, P = 0,002), puntuación < 3 de la American Society of Anesthesiologists (ASA) (OR 1,42, P = 0,003), manejo restrictivo del aporte de líquidos (< 3000 mL en el día de la cirugía: OR 1,46, P < 0,001), duración de la cirugía < 180 minutos (OR 1,89, P < 0,001), abordaje mínimamente invasivo (OR 1,92, P < 0,001) and tipo de herida clase < 3 (OR 4,5, P < 0,001), mientras que el diagnóstico de cáncer (OR 0,55, P < 0,001) y la malnutrición (IMC < 18 kg/m2 : OR 0,42, P = 0,008) disminuyeron la probabilidad de alta precoz. Los pacientes con una estancia de 48 horas tuvieron menos complicaciones globales (10,8% versus 30,6%, P < 0,001), menos complicaciones graves (2,6% versus 10,2%, P < 0,001) y una menor tasa de reingresos (9% versus 11,8%, P = 0,035). CONCLUSIÓN: El alta precoz en pacientes seleccionados es segura y no aumenta las tasas de morbilidad postoperatoria o de reingresos. En estos pacientes, la cirugía colorrectal ambulatoria debería ser viable a gran escala con una optimización de la logística.

Variation in training requirements within general surgery: comparison of 23 countries.

Background: Many differences exist in postgraduate surgical training programmes worldwide. The aim of this study was to provide an overview of the training requirements in general surgery across 23 different countries. Methods: A collaborator affiliated with each country collected data from the country's official training body website, where possible. The information collected included: management, teaching, academic and operative competencies, mandatory courses, years of postgraduate training (inclusive of intern years), working-hours regulations, selection process into training and formal examination. Results: Countries included were Australia, Belgium, Canada, Colombia, Denmark, Germany, Greece, Guatemala, India, Ireland, Italy, Kuwait, the Netherlands, New Zealand, Russia, Saudi Arabia, South Africa, South Korea, Sweden, Switzerland, UK, USA and Zambia. Frameworks for defining the outcomes of surgical training have been defined nationally in some countries, with some similarities to those in the UK and Ireland. However, some training programmes remain heterogeneous with regional variation, including those in many European countries. Some countries outline minimum operative case requirement (range 60-1600), mandatory courses, or operative, academic or management competencies. The length of postgraduate training ranges from 4 to 10 years. The maximum hours worked per week ranges from 38 to 88 h, but with no limit in some countries. Conclusion: Countries have specific and often differing requirements of their medical profession. Equivalence in training is granted on political agreements, not healthcare need or competencies acquired during training.

Antecedentes: Existen muchas diferencias entre los programas de formación quirúrgica de posgrado del mundo. El objetivo de este estudio fue proporcionar una visión general de los requisitos formativos en cirugía general en 23 países diferentes. Métodos: En cada uno de los países participantes, un colaborador recopiló datos de la página web del organismo oficial encargado de la formación, si era posible. La información incluyó: gestión, formación, competencias académicas y operatorias, cursos obligatorios, años de formación de postgrado (que incluía el período de internado), regulaciones sobre las horas de trabajo, proceso de selección para la formación y existencia de un examen final. Resultados: Se incluyeron los datos de Australia, Bélgica, Canadá, Colombia, Dinamarca, Alemania, Grecia, Guatemala, India, Irlanda, Italia, Kuwait, Países Bajos, Nueva Zelanda, Rusia, Arabia Saudita, Sudáfrica, Corea del Sur, Suecia, Suiza, Reino Unido, Estados Unidos de América y Zambia. En algunos países existen los marcos normativos para definir los resultados del programa de formación, con ciertas semejanzas a los del Reino Unido e Irlanda. Sin embargo, algunos programas de formación, incluso en muchos países europeos, son muy heterogéneos con variaciones regionales. Pocos países describen el número mínimo de procedimientos quirúrgicos (rango 60 a 1.600), los cursos obligatorios o competencias quirúrgicas, académicos o de gestión exigidos. La duración de la formación postgraduada osciló de los 4 a los 10 años. El número de horas trabajadas máximas por semana oscilaron entre 38 y 88, sin límite en algunos países. Conclusión: Cada país tiene unos requisitos específicos, a menudo diferentes, para la formación de sus médicos. La convalidación se otorga por acuerdos políticos, más que por las necesidades médicas o por las competencias adquiridas durante la formación.

Thresholds for optimal fluid administration and weight gain after laparoscopic colorectal surgery.

Background: Perioperative fluid overload is an important modifiable risk factor for adverse outcomes after colorectal surgery. This study aimed to define critical thresholds for perioperative fluid management and postoperative weight gain for patients undergoing elective laparoscopic colorectal surgery. Methods: This was an analysis of consecutive elective laparoscopic colorectal resections at Lausanne University Hospital from May 2011 to May 2017. Main outcomes were overall, major (Clavien-Dindo grade IIIb or above) and respiratory complications, and postoperative ileus. Thresholds regarding perioperative fluid management and postoperative weight gain were identified through receiver operating characteristic (ROC) analysis and clinical judgement. Independent risk factors for all four outcomes were assessed by multinominal logistic regression. Results: Overall and major complications occurred in 210 (36·2 per cent) and 46 (7·9 per cent) of 580 patients respectively. Twenty-three patients (4·0 per cent) had respiratory complications and 98 (16·9 per cent) had postoperative ileus. Median length of hospital stay was 5 (i.q.r. 3-9) days. Based on respiratory complications, thresholds for perioperative intravenous fluid administration (postoperative day (POD) 0) were set pragmatically at 3000 ml for colonic (calculated threshold 3120 ml (area under ROC curve (AUROC) 0·63)) and 4000 ml for rectal (AUROC 0·79) procedures. Postoperative weight gain of 2·5 kg at POD 2 was predictive of respiratory complications. Multivariable analysis retained perioperative intravenous fluid administration over the above thresholds as an independent risk factor for overall (odds ratio (OR) 2·25, 95 per cent c.i. 1·23 to 4·11), major (OR 2·49, 1·17 to 5·31) and respiratory (OR 4·71, 1·42 to 15·58) complications. Weight gain above 2·5 kg at POD 2 was identified as a risk factor for respiratory complications (OR 3·58, 1·10 to 11·70) and ileus (OR 1·82, 1·02 to 3·52). Conclusion: Perioperative intravenous fluid and weight thresholds were associated with postoperative adverse outcomes. These thresholds need independent validation.

Short-term postoperative outcomes following robotic versus laparoscopic ileal pouch-anal anastomosis are equivalent.

BACKGROUND: Minimally invasive approaches have become the standard of care for ileal pouch-anal anastomoses (IPAA). There are few reports comparing outcomes following a laparoscopic versus robotic approach. Our aim was to determine if there were any differences in the 30-day postoperative outcomes following IPAA performed laparoscopically versus robotically. METHODS: A retrospective chart review of all laparoscopic and robotic IPAA performed between January 1, 2015 and June 30, 2018 was carried out. Patients included were adult patients who underwent a proctectomy and IPAA utilizing either a laparoscopic or robotic approach. Data collected included patient demographics, operative variables, and 30-day postoperative outcomes. RESULTS: A total of 132 patients had a minimally invasive IPAA; 58 were performed laparoscopically and 74 robotically. Less than half the patients were female (n = 55; 41.7%) with a median age of 37 years (range 18-68 years). The majority of patients had a diagnosis of ulcerative colitis (n = 103; 78.0%) with medically refractory disease (n = 87; 65.9%). A greater proportion of patients in the laparoscopic cohort had a prolonged length of stay (n = 27; 46.6% versus n = 18; 24.3%; p < 0.001) and a two-stage approach (n = 56; 96.6% versus n = 37; 50%; p < 0.001), but there were no differences in the rates between the laparoscopic versus robotic cohorts of superficial surgical site infection (6.9% versus 6.8%; p = 0.99), peripouch abscess (15.5% versus 6.8%; p = 0.11), anastomotic leak (6.9% versus 2.7%; p = 0.21), pelvic abscess (15.5% versus 6.8%; p = 0.11), and pelvic sepsis (15.5% versus 6.8%; p = 0.11), readmission (24.1% versus 17.6%; p = 0.35) or reoperation (6.9% versus 5.4%; p = 0.72). On multivariable analysis, only male sex remained predictive of prolonged length of stay, and a robotic approach trended toward a decreased rate of prolonged length of stay. CONCLUSIONS: Laparoscopic and robotic IPAA have equivalent postoperative morbidity underscoring the safety of the continued expansion of the robotic platform for pouch surgery.

Impact of enhanced recovery on oncological outcomes following minimally invasive surgery for rectal cancer.

BACKGROUND: Oncological outcomes of locally advanced rectal cancer depend on the quality of surgical and oncological management. Enhanced recovery pathways (ERPs) have yet to be assessed for their oncological impact when used in combination with minimally invasive surgery. This study assessed outcomes with or without an ERP in patients with rectal cancer. METHODS: This was a retrospective analysis of all consecutive adult patients who underwent elective minimally invasive surgery for primary rectal adenocarcinoma with curative intent between February 2005 and April 2018. Both laparoscopic and robotic procedures were included. Short-term morbidity and overall survival were compared between patients treated according to the institutional ERP and those who received conventional care. RESULTS: A total of 600 patients underwent minimally invasive surgery, of whom 320 (53·3 per cent) were treated according to the ERP and 280 (46·7 per cent) received conventional care. ERP was associated with less overall morbidity (34·7 versus 54·3 per cent; P < 0·001). Patients in the ERP group had improved overall survival on univariable (91·4 versus 81·7 per cent at 5 years; hazard ratio (HR) 0·53, 95 per cent c.i. 0·28 to 0·99) but not multivariable (HR 0·78, 0·41 to 1·50) analysis. Multivariable analysis revealed age (HR 1·46, 1·17 to 1·82), male sex (HR 1·98, 1·05 to 3·70) and complications (HR 2·23, 1·30 to 3·83) as independent risk factors for compromised overall survival. Disease-free survival was comparable for patients who had ERP or conventional treatment (80·5 versus 84·6 per cent at 5 years respectively; P = 0·272). CONCLUSION: Treatment within an ERP was associated with a lower morbidity risk that may have had a subtle impact on overall but not disease-specific survival.

Guidelines for Perioperative Care in Elective Colorectal Surgery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations: 2018.

BACKGROUND: This is the fourth updated Enhanced Recovery After Surgery (ERAS®) Society guideline presenting a consensus for optimal perioperative care in colorectal surgery and providing graded recommendations for each ERAS item within the ERAS® protocol. METHODS: A wide database search on English literature publications was performed. Studies on each item within the protocol were selected with particular attention paid to meta-analyses, randomised controlled trials and large prospective cohorts and examined, reviewed and graded according to Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. RESULTS: All recommendations on ERAS® protocol items are based on best available evidence; good-quality trials; meta-analyses of good-quality trials; or large cohort studies. The level of evidence for the use of each item is presented accordingly. CONCLUSIONS: The evidence base and recommendation for items within the multimodal perioperative care pathway are presented by the ERAS® Society in this comprehensive consensus review.

Receiver operating characteristic analysis to determine optimal fluid management during open colorectal surgery.

AIM: The present study aimed to analyse fluid management and to define optimal fluid-related thresholds for elective open colorectal surgery. METHOD: A retrospective analysis was made of all consecutive elective open colorectal resections performed in our tertiary centre between May 2011 and May 2017. The main outcomes were postoperative complications [overall (I-V) and severe (IIIB-V) according to the Clavien classification], respiratory complications and postoperative ileus (POI). Critical thresholds regarding perioperative fluid management and postoperative weight gain were identified by using receiver operator characteristic (ROC) analysis. Independent risk factors for overall complications were identified by multivariable logistic regression analysis. RESULTS: Of 121 patients who had open operations, 84 (69%) had some complication and 26 (21%) had severe complications. Respiratory complications and POI occurred in 15 (12%) and 46 patients (38%), respectively. The thresholds for intravenous fluids were 3.5 l at postoperative day (POD) 0 [area under ROC curve (AUROC) 0.7 for any 0.69 for respiratory complications] and 3.5 kg weight gain at POD 2 (AUROC 0.82 for respiratory complications). Multivariable analysis revealed weight gain of > 3.5 kg at POD 2 (OR 5.9; 95% CI 1.3-16.6) as a significant risk factor for overall complications. Acute kidney injury was observed in five patients (4%), three (5%) in the group with > 3.5 l at POD 0 and two (3%) in the group with < 3.5 l at POD 0 (P = 0.64). Creatinine increase was transitory and all patients regained baseline levels before discharge. CONCLUSION: A weight gain of > 3.5 kg at POD 2 has been identified as the critical threshold for overall and respiratory complications and prolonged length of stay after open elective colorectal surgery.

Comparison of recovery and outcome after left and right colectomy.

AIM: The present study aimed to compare functional recovery and surgical outcomes after left and right colectomies. METHOD: Consecutive elective left and right colon resections for benign and malignant indications, performed between 2011 and 2016 and recorded in a prospectively maintained enhanced recovery database, were analysed. Demographic and surgical items, as well as functional recovery and 30-day complications, were compared between left-sided and right-sided colectomies. Multivariable analysis was performed to identify risk factors for postoperative ileus (POI). RESULTS: In total, 1001 left and 1041 right colectomies were comparable regarding demographic factors; only body mass index (BMI) was higher in patients undergoing left-sided resections (> 30 kg/m2 : 33% vs 27%, P = 0.004). Malignancy (29% vs 67%, P < 0.001) and Crohn's disease (1% vs 31%, P < 0.001) were preponderant in right colectomies, whereas diverticular disease (68% vs 1%, P < 0.001) was the most common indication for left colectomy. Compliance with the enhanced recovery pathway (ERP) was comparable. While the minimally invasive approach was the preferred approach for both sides (61% vs 64%, P = 0.158), left colectomies took longer (180 ± 80 min vs 150 ± 70 min, P < 0.001), needed more perioperative fluids (3.1 ± 1.4 l vs 2.7 ± 1.5 l, P < 0.001) and resulted in greater postoperative weight gain (3.9 ± 6.5 kg vs 2.6 ± 6 kg, P = 0.025). Crohn's disease (OR = 2.64, 95% CI: 1.27-5.46) and fluid overload (OR = 2.02, 95% CI: 1.06-3.82) were independent risk factors for POI. CONCLUSION: Despite equal ERP compliance, postoperative ileus was higher after right-sided colectomies. This finding was associated with Crohn's disease and fluid overload.

Timing, diagnosis, and treatment of surgical site infections after colonic surgery: prospective surveillance of 1263 patients.

BACKGROUND: Surgical site infections (SSIs) are the most frequent complication after colorectal surgery and have a major impact on length of stay and costs. AIM: To analyse the incidence, timing, and treatment of SSIs within 30 days after colonic surgery. METHODS: This was a quality improvement project through retrospective analysis of consecutive colonic surgeries between February 2012 and October 2017 at Lausanne University Hospital (CHUV). SSIs were prospectively assessed by an independent national surveillance programme (www.swissnoso.ch) up to 30 postoperative days. Treatment strategies including drainage of infection (direct wound opening or percutaneous) and surgical management were reviewed. FINDINGS: The study cohort included 1263 patients with 532 procedures (42%) performed as emergencies. SSIs were observed in 271 patients (21%), occurring at median postoperative day (POD) 9 (interquartile range (IQR): 4-16). Specifically, 53 (4%) were superficial incisional, 65 (5%) deep incisional, and 153 (12%) organ space infections (anastomotic insufficiency included). Superficial incisional SSI occurred at a median of POD 10.5 (IQR: 7-15), deep incisional at a median of POD 10 (8-15) and organ space at a median of POD 8 (5-11). Diagnosis was performed post discharge in 64 cases (24%). Whereas 47% of organ space infections were detected by POD 7, this rate was only 26% for superficial and deep incisional infections (P = 0.003). Surgical management was necessary in 133 cases (49%), and the remaining cases were managed by drainage without general anaesthesia (138 cases, 51%). CONCLUSION: Organ space infections occurred early in the postoperative course, whereas incisional infections were mostly detected post discharge over the entire 30-day observation period, emphasizing the importance of proper follow-up using a systematic, complete and independent surveillance programme.

A multicentre qualitative study assessing implementation of an Enhanced Recovery After Surgery program.

BACKGROUND & AIMS: The existence of enhanced recovery specific guidelines (ERAS) is not enough to change patient management practice since many barriers exist to successful ERAS implementation. The present survey aimed to analyse motivations for implementation as well as encountered difficulties and challenges. Further, relevance and importance of perioperative care items and postoperative recovery targets were assessed. METHODS: A multicentre qualitative study was conducted between August and December 2016 among surgeons, anaesthesiologists and nurses from implemented ERAS centres in Switzerland (n = 16) and Sweden (n = 14). An online survey (31 closed questions) was sent by email, with reminders at 4, 8 and 12 weeks. RESULTS: Seventy-seven out of 146 experts completed the survey (response rate 52.7%). Main motivations to implement ERAS were the expectation to reduce complications (91%), higher patient satisfaction (73%) and shorter hospital stay (62%). The application of ERAS program represented major changes in clinical practice for 57% of participants without significant differences between various specialities (surgeons: 63%, nurses: 63%, anaesthesiologists: 36%, p = 0.185). The most important barriers for straightforward implementation were time restraints (69%), opposing colleagues (68%) and logistical reasons (66%). The 3 most frequently cited patient-related barriers to adopt ERAS were opposing personality (52%), co-morbidities (49%) and language barriers (31%). CONCLUSIONS: Implementing ERAS care into practice was challenging and required important changes in clinical practice for all involved specialities. Main reasons for implementation were the expectation to reduce complications and hospital stay with improved patients' satisfaction. Main barriers were time restraints, reluctance to change and logistics.

Pressurized IntraPeritoneal Aerosol Chemotherapy - Practical aspects.

INTRODUCTION: Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC) has been introduced as novel treatment for peritoneal carcinomatosis. Only proper patient selection, stringent safety protocol and careful surgery allow for a secure procedure. We hereby report the essentials for safe implementation. METHODS: All consecutive procedures within 20 months after PIPAC implementation were analyzed with regards to practical and surgical aspects. Special emphasis was laid on modifications of technique and safety measures during the implementation process with systematic use of a dedicated checklist. Further, surgical difficulty was documented by use of a visual analogue scale (VAS). RESULTS: 127 PIPAC procedures were performed in 58 patients from January 2015 until October 2016. 81% of patients had at least one previous laparotomy. Median operation time was 91 min (87-103) for the first 20 cases, 93 min (IQR 88-107) for PIPAC21-50, and 103 min (IQR 91-121) for the following 77 procedures. Primary and secondary non-access occurred in 3 patients (2%), all of them having prior hyperthermic intraperitoneal chemotherapy (HIPEC). Using open Hasson technique, one single bowel lesion occurred, which was the only intraoperative complication. One 5 mm and another 10/12 mm trocar were used in 88% of procedures while additional trocars were needed in 12%. No leak of cytostatics was observed and no procedure needed to be stopped. VAS for overall difficulty of the procedure was 3 ± 2.4, and 3 ± 2.9 and 3 ± 2.5, respectively, for abdominal access and intraoperative staging. CONCLUSIONS: With standardized surgical approach and dedicated safety checklist, PIPAC can be safely introduced in clinical routine with minimal learning curve.

Systematic review of pressurized intraperitoneal aerosol chemotherapy for the treatment of advanced peritoneal carcinomatosis.

BACKGROUND: Pressurized intraperitoneal aerosol chemotherapy (PIPAC) is a minimally invasive approach under investigation as a novel treatment for patients with peritoneal carcinomatosis of various origins. The aim was to review the available evidence on mechanisms, clinical effects and risks. METHODS: This was a systematic review of the literature on pressurized intraperitoneal chemotherapy published between January 2000 and October 2016. All types of scientific report were included. RESULTS: Twenty-nine relevant papers were identified; 16 were preclinical studies and 13 were clinical reports. The overall quality of the clinical studies was modest; five studies were prospective and there was no randomized trial. Preclinical data suggested better distribution and higher tissue concentrations of chemotherapy agents in PIPAC compared with conventional intraperitoneal chemotherapy by lavage. Regarding technical feasibility, laparoscopic access and repeatability rates were 83-100 and 38-82 per cent. Surgery-related complications occurred in up to 12 per cent. Postoperative morbidity was low (Common Terminology Criteria for Adverse Events grade 3-5 events reported in 0-37 per cent), and hospital stay was about 3 days. No negative impact on quality of life was reported. Histological response rates for therapy-resistant carcinomatosis of ovarian, colorectal and gastric origin were 62-88, 71-86 and 70-100 per cent respectively. CONCLUSION: PIPAC is feasible, safe and well tolerated. Preliminary good response rates call for prospective analysis of oncological efficacy.

Compliance with preoperative oral nutritional supplements in patients at nutritional risk--only a question of will?

BACKGROUND/OBJECTIVES: Preoperative nutrition has been shown to reduce morbidity after major gastrointestinal (GI) surgery in selected patients at risk. In a randomized trial performed recently (NCT00512213), almost half of the patients, however, did not consume the recommended dose of nutritional intervention. The present study aimed to identify the risk factors for noncompliance. SUBJECTS/METHODS: Demographic (n = 5) and nutritional (n = 21) parameters for this retrospective analysis were obtained from a prospectively maintained database. The outcome of interest was compliance with the allocated intervention (ingestion of ⩾ 11/15 preoperative oral nutritional supplement units). Uni- and multivariate analyses of potential risk factors for noncompliance were performed. RESULTS: The final analysis included 141 patients with complete data sets for the purpose of the study. Fifty-nine patients (42%) were considered noncompliant. Univariate analysis identified low C-reactive protein levels (P = 0.015), decreased recent food intake (P = 0.032) and, as a trend, low hemoglobin (P = 0.065) and low pre-albumin (P = 0.056) levels as risk factors for decreased compliance. However, none of them was retained as an independent risk factor after multivariate analysis. Interestingly, 17 potential explanatory parameters, such as upper GI cancer, weight loss, reduced appetite or co-morbidities, did not show any significant correlation with reduced intake of nutritional supplements. CONCLUSIONS: Reduced compliance with preoperative nutritional interventions remains a major issue because the expected benefit depends on the actual intake. Seemingly, obvious reasons could not be retained as valid explanations. Compliance seems thus to be primarily a question of will and information; the importance of nutritional supplementation needs to be emphasized by specific patients' education.

Preoperative immunonutrition in patients at nutritional risk: results of a double-blinded randomized clinical trial.

BACKGROUND/OBJECTIVES: To evaluate the impact of preoperative immunonutrition (IN) on postoperative morbidity in patients at risk of malnutrition undergoing major gastrointestinal (GI) surgery. SUBJECTS/METHODS: The combination of malnutrition and major GI surgery entails high morbidity. The Nutritional Risk Score (NRS) reliably identifies patients who need preoperative nutrition; the optimal nutritional formula for these patients still needs to be defined. In all, 152 patients with a NRS≥3 and undergoing elective major GI surgery were randomized between IN or isocaloric-isonitrogenous nutrition (ICN) given for 5 days preoperatively. Patients and caregivers were blinded for the allocated intervention. Thirty days complication rate was the primary endpoint. Infections, length of hospital stay and compliance were considered as secondary outcomes. RESULTS: Overall, 145 patients were available for analysis; the 73 patients in the IN group matched well with the 72 ICN patients with regards to patient's and surgical characteristics. In all, 39 IN and 33 ICN patients experienced a total of 48 and 50 postoperative complications, respectively (P=0.723). Both groups did not differ significantly concerning infectious (13 vs 9) complications. Independent risk factors for overall complications were malignant disease (odds ratio (OR)=4.304; confidence interval (CI) 1.317-14.002) and operative time (OR=1.004; CI 1.000-1.008). CONCLUSION: In patients at nutritional risk, complications, infections and hospital stay after major GI surgery were comparable regardless of preoperative supplementation with IN or ICN.

[Preoperative nutrition in abdominal surgery: recommendations and reality]. / Nutrition préopératoire en chirurgie viscérale: recommandations et réalité.

Malnutrition concerns up to 50% at in-hospital admission. Its diagnosis and treatment are fundamental parts of the surgical approach because nutritional status directly influences the clinical outcome. The Nutritional Risk Score (NRS-2002) represents the recommended screening tool by the European Society of Parenteral and Enteral Nutrition (ESPEN). Patients with a score > or = 3 and aged > 70 years old, should receive a nutritional support during 7-14 day before surgery. Depending on patient's clinical conditions, the enteral route of administration should be preferred. Despite strong evidence in favor of nutritional supplementation, much effort must be done to implement these supportive strategies in the everyday clinical practice.

[Epithelial neoplasia of the appendix: what has recently changed?]. / Néoplasie épithéliale de l'appendice: quoi de neuf?

Appendicular tumors are mostly found incidentally in up to 1.5% of all appendectomies. Neuroendocrine tumors are the commonest malignancies, and are associated with an excellent long-term prognosis. While small lesions located at the appendicular tip can be treated with simple appendectomy, advanced tumors require right hemicolectomy. Goblet cell carcinoids are rare tumors showing a mixed phenotype. Long-term outcome is impaired, and for most cases a right hemicolectomy is mandatory. Colonic-type adenocarcinomas have a similar behavior like conventional colonic cancer and should be treated similarly. Mucinous neoplasias possess the characteristic of extensive mucin production with intraperitoneal spread. Treatment options are ranging from right hemicolectomy to multivisceral resection with intraperitoneal chemotherapy.