Does Prophylactic Negative-Pressure Wound Therapy Prevent Surgical Site Infection After Laparotomy? A Systematic Review and Meta-analysis of Randomized Controlled trials.

BACKGROUND: Prophylactic negative-pressure wound therapy (pNPWT) may prevent surgical site infection (SSI) after laparotomy, but existing meta-analyses pooling only high-quality evidence have failed to confirm this effect. Recently, several randomized controlled trials (RCTs) have been published. We performed an updated systematic review and meta-analysis to determine if pNPWT reduces the incidence of SSI after laparotomy. METHODS: MEDLINE, Embase, CENTRAL and Web of Science were searched on the 25.08.2021 for RCTs reporting on the incidence of SSI in patients who underwent laparotomy with and without pNPWT. The systematic review was compliant with the AMSTAR2 recommendation and registered into PROSPERO. Risk ratios (RR) for SSI in patients with pNPWT, and risk difference (RD) between control and pNPWT patients, were obtained using random effects models. Heterogeneity was quantified using the I2 value, and investigated using subgroup analyses, funnel plots and bubble plots. Risk of bias of included RCTs was assessed using the RoB2 tool. RESULTS: Eleven RCTs were included, representing 973 patients who received pNPWT and 970 patients who received standard wound dressing. Pooled RR and RD between patients with and without pNPWT were of, respectively, 0.665 (95% CI 0.49-0.91, I2: 38.7%, p = 0.0098) and -0.07 (95% CI -0.12 to -0.03, I2: 53.6%, p = 0.0018), therefore demonstrating that pNPWT decreases the incidence of SSI after laparotomy. Investigation of source of heterogeneity identified a potential small-study effect. CONCLUSION: The protective effect of pNPWT against SSI after laparotomy is confirmed by high-quality pooled evidence.

[Hemorrhoidal disease in 2022 : how to select the most appropriate treatment ?] / Maladie hémorroïdaire en 2022 : comment choisir le traitement adapté ?

Hemorrhoidal disease is frequent and can lead to major alteration of quality of life. Conservative treatment, instrumental therapies and surgical approach play a complementary role in the management of hemorrhoidal disease. Understanding all techniques is mandatory to guide the patient and offer the best individualized treatment. Guidelines issued by scientific societies can facilitate the therapeutic decision.

La maladie hémorroïdaire est fréquente et ses répercussions sur la qualité de vie peuvent être majeures. Traitement conservateur, procédés non chirurgicaux et interventions chirurgicales jouent un rôle complémentaire dans le traitement d'une maladie hémorroïdaire symptomatique. Pour guider le patient et lui offrir la prise en charge la plus adaptée à sa situation, une connaissance des différents traitements est indispensable. Les recommandations des sociétés savantes, basées sur des avis d'experts, peuvent faciliter la décision thérapeutique.

Impact of Nonalcoholic Steatohepatitis on the Outcome of Patients Undergoing Roux-en-Y Gastric Bypass Surgery: a Propensity Score-Matched Analysis.

PURPOSE: It is currently unknown whether NASH (nonalcoholic steatohepatitis), as compared to simple steatosis, is associated with impaired postoperative weight loss and metabolic outcomes after RYGB surgery. To compare the effectiveness of Roux-en-Y gastric bypass (RYGB) on patients with NASH versus those with simple nonalcoholic fatty liver (NAFL). MATERIALS AND METHODS: We retrospectively retrieved data from 515 patients undergoing RYGB surgery with concomitant liver biopsy. Clinical follow-up and metabolic assessment were performed prior to surgery and 12 months after surgery. We used multivariate analysis of variance (MANOVA) and propensity score matching and we assessed for changes in markers of hepatocellular injury and metabolic outcomes. RESULTS: There were 421 patients with simple NAFL, and 94 with NASH. Baseline alanine and aspartate aminotransferases were significantly higher in patients with NASH (p < 0.01). Twelve months after the RYGB surgery, as determined by both MANOVA and propensity score matching, patients with NASH exhibited a significantly greater reduction in alanine aminotransferase (ß-coefficient - 12 iU/l [- 22 to - 1.83], 95% CI, adjusted p = 0.021) compared to their NAFL counterparts (31 matched patients in each group with no loss to follow-up at 12 months). Excess weight loss was similar in both groups (ß-coefficient 4.54% [- 3.12 to 12.21], 95% CI, adjusted p = 0.244). Change in BMI was comparable in both groups (- 14 (- 16.6 to - 12.5) versus - 14.3 (- 17.3 to - 11.9), p = 0.784). CONCLUSION: After RYGB surgery, patients with NASH experience a greater reduction in markers for hepatocellular injury and similar weight loss compared to patients with simple steatosis.

Role of near-infrared fluorescence in colorectal surgery.

Near-infrared fluorescence (NIRF) is a technique of augmented reality that, when applied in the operating theatre, allows the colorectal surgeon to visualize and assess bowel vascularization, to identify lymph nodes draining a cancer site and to identify ureters. Herein, we review the literature regarding NIRF in colorectal surgery.

The Use of a Stoma Rod/Bridge to Prevent Retraction: A Systematic Review.

PURPOSE: We evaluated evidence related to the use of a rod (bridge) to prevent stoma retraction during loop ostomy construction. METHODS: We completed a systematic review of the literature. We searched MEDLINE, EMBASE, and COCHRANE databases up to December 4, 2019. We posed the following question based on a PICO format. Do adult patients undergoing ostomy surgery experience less stomal retraction when compared to patients managed without placement of a stoma rod? FINDINGS: Our initial search returned 182 articles; after reading studies in full, 5 articles were identified that collectively enrolled 1058 participants. Four studies were randomized controlled trials and one was a prospective cohort study. Meta-analysis could not be performed because of the small number of studies and the heterogeneity of outcomes measurements. The incidence of stoma retraction ranged between 0%-8% in patients managed with a rod and 0.78%-8.2% in patients with no rod. The number of reported adverse events was low. Placement of a stoma rod was associated with more adverse outcomes than in patients managed without a rod. Adverse events included local edema, stoma necrosis, skin necrosis, peristomal moisture-associated skin damage (irritant dermatitis), peristomal abscess, bleeding, and mucocutaneous separation. CONCLUSIONS: Stoma rod does not seem to reduce the risk of stoma retraction and might result in other adverse events. IMPLICATIONS: We recommend avoidance of stoma rod/bridge placement during ostomy surgery.

Current Surgical Strategies for the Treatment of Rectal Adenocarcinoma and the Risk of Local Recurrence.

BACKGROUND: Despite new medical and surgical strategies, 5-year local recurrence of rectal adenocarcinoma was reported in up to 25% of cases. Therefore, we aimed to review surgical strategies for the prevention of local recurrences in rectal cancer. SUMMARY: After implementation of the total mesorectal excision (TME), surgical resection of rectal adenocarcinoma with anterior resection or abdominoperineal excision (APE) allowed decrease in local recurrence (3% at 5 years). More recently, extralevator APE was described as an alternative to APE, decreasing specimen perforation and recurrence rate. Moreover, technique modifications were developed to optimize rectal resection, such as the laparoscopic or robotic approach, and transanal TME. However, the technical advantages conferred by these techniques did not translate into a decreased recurrence rate. Lateral lymph node dissection is another technique, which aimed at improving the long-term outcomes; nevertheless, there is currently no evidence to recommend its routine use. Strategies to preserve the rectum are also emerging, such as local excision, and may be beneficial for subgroups of patients. Key Messages: Rectal cancer management requires a multidisciplinary approach, and surgical strategy should be tailored to patient factors: general health, previous perineal intervention, anatomy, preference, and tumor characteristics such as stage and localization.

Surgical management of vascular Ehlers-Danlos syndrome and its challenges: a case report.

BACKGROUND: Ehlers-Danlos syndrome (EDS) is a heterogeneous group of rare inherited diseases involving connective tissue. Vascular EDS (vEDS) is associated with abnormal type III collagen, which is an essential component of skin, hollow organs and arterial walls, and causes potentially fatal visceral and arterial complications. The surgical management of these patients is challenging and should be limited to life-saving procedures. CASE DESCRIPTION: We report a case of a 42-year-old male who presented a hemorrhagic shock due to spontaneous rupture of an ascending branch of the left colic artery. The coexisting presence of multiple abdominal vascular abnormalities suggested the diagnosis of vEDS, later confirmed by the discovery of a new missense mutation in the COL3A1 gene with pathogenic significance. The post-operative course was marked by a mechanical ileus caused by an ischemic stenosis of the descending colon. Failure of conservative management and the well-known risk of colonic perforation in these patients led to the decision to perform a diverting ileostomy. CONCLUSION: The management of these patients is difficult, and risk-benefit assessments must be made on a case-by-case basis. Less invasive procedures should be considered whenever possible.

Comment on: Should a colonoscopy be offered routinely to patients with CT proven acute diverticulitis? A retrospective cohort study and meta-analysis of best available evidence.

Latest evidence indicates that patients with acute diverticulitis have higher prevalence of colorectal cancer than reference patients. Therefore, colonoscopy should be offered after an episode of acute diverticulitis.

Factors influencing the spatial and temporal distribution of microplastics at the sea surface - A year-long monitoring case study from the urban Kiel Fjord, southwest Baltic Sea.

Microplastics are ubiquitous to most marine environments worldwide, and their management has become one of the major challenges facing stakeholders. Here we monitored monthly, between March 2018 and March 2019, the abundance of microplastics (0.3-18.2 mm) at the sea surface within the Kiel Fjord, southwest Baltic Sea. Microplastics were sampled at eight locations, inside and outside the fjord, near potential source of microplastics, such as the outlets of storm drains or the Kiel-Bülk wastewater treatment plant, the Schwentine River mouth and the entrance of the Kiel Canal. Weather (wind, precipitations) and seawater (salinity, temperature) parameters were compared to the spatiotemporal distribution of the microplastics. We found an overall stable, and low (0.04 particles/m3), microplastic load within the Kiel Fjord compared to other urban areas worldwide with comparable population densities. No relationship was found between the microplastic abundance and the environmental factors, but the few samples that yielded unusually high amount of microplastics were all preceded by rainfall and snow/ice melt. During such events, vast amounts of water, potentially contaminated with microplastics, were released into the fjord via the storm drainage system. The microplastic abundances at the wastewater plant outflow were among the lowest of our survey, likely thanks to an efficient filtering system. The results of this study highlight the importance to repeat microplastic samplings over time and space to determine with confidence baseline microplastic abundance and to detect unusual acute contamination, especially during snow and ice melting. Overall, the microplastic abundance within the Kiel Fjord was low, probably thanks to efficient waste management on land. However, improvements are still needed to filter millimetre-sized particles within the storm drainage system, which is likely a major source of microplastics into the marine environment.

Comparison of Outcomes between Obese and Non-Obese Patients in a Colorectal Enhanced Recovery After Surgery (ERAS) Program: A Single-Center Cohort Study.

INTRODUCTION: Obese patients are considered at increased risk of postoperative adverse events after colorectal surgery. OBJECTIVE: The objective of the present study was to compare postoperative outcomes between obese and non-obese patients undergoing elective colorectal surgery in an Enhanced Recovery After Surgery (ERAS) program. METHODS: A retrospective analysis of a prospective cohort including patients who underwent elective colorectal surgery and were included in an ERAS protocol between February 2014 and December 2017 at Geneva University Hospital, Geneva, Switzerland, was performed. Postoperative outcomes of obese and non-obese patients were compared. RESULTS: Data of 460 patients were analyzed, including 374 (81%) non-obese and 86 (19%) obese patients. Overall, there was no difference in postoperative outcomes between the 2 groups. Among patients undergoing oncologic surgery, obese subjects had a significantly higher rate of conversion to laparotomy (11.9 vs. 2.1%, p = 0.01) and longer time until return of bowel function (2.38 vs. 1.98 days, p = 0.03), without increased morbidity or longer length of stay. CONCLUSION: Obese and non-obese patients had similar postoperative outcomes after elective colorectal surgery with ERAS management. ERAS can potentially reduce the increased morbidity usually observed in obese patients following elective colorectal surgery.

Reducing anastomotic leak in colorectal surgery: The old dogmas and the new challenges.

Anastomotic leak (AL) constitutes a significant issue in colorectal surgery, and its incidence has remained stable over the last years. The use of intra-abdominal drain or the use of mechanical bowel preparation alone have been proven to be useless in preventing AL and should be abandoned. The role or oral antibiotics preparation regimens should be clarified and compared to other routes of administration, such as the intravenous route or enema. In parallel, preoperative antibiotherapy should aim at targeting collagenase-inducing pathogens, as identified by the microbiome analysis. AL can be further reduced by fluorescence angiography, which leads to significant intraoperative changes in surgical strategies. Implementation of fluorescence angiography should be encouraged. Progress made in AL comprehension and prevention might probably allow reducing the rate of diverting stoma and conduct to a revision of its indications.

Lateral lymph node dissection for low rectal cancer: Is it necessary?

Rectal cancer constitutes a major public health issue. Total mesorectal excision has remained the gold standard treatment for mid and low rectal tumors since its introduction in the late 1980s. Removal of all lymph nodes located in the mesorectum has indeed improved pathological and oncological outcomes. However, when cancer spreads to the lateral lymph nodes (located along the iliac and obturator arteries) Western and Japanese practices differ. Where the Western guidelines consider this condition as an advanced form of the disease and use neoadjuvant radiochemotherapy liberally, the Japanese guidelines define it as a local disease and proceed to lateral lymph node dissection with or without neoadjuvant treatment. Herein, we review the current literature regarding both therapeutic strategies, with the aim of contributing to potential improvements in treatment and outcome for patients with low and mid rectal cancer.

Does Surgical Approach in Pelvic Floor Repair Impact Sexual Function in Women?

INTRODUCTION: Surgical routes used to correct complex pelvic floor disorders (CPFDs) may have a negative impact on women's sexual function. Currently, there is no evidence concerning the impact of a specific surgical procedure on postoperative sexual function in women. AIM: The aim of this study was to compare an abdominal approach with rectopexy and sacrocolpopexy to a perineal procedure with abdominal rectopexy, regarding female sexual function in cases of CPFDs. METHODS: Women who were operated for CPFDs between January 2003 and June 2010 were retrospectively asked to answer the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire-12, the Miller Score of Incontinence, and a urinary incontinence frequency score. We also questioned them about their sexual function and satisfaction before and after the operation using visual analogic scores. MAIN OUTCOME MEASURE: We compared the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire-12 before and after the surgery in both groups, and we made an intragroup comparison. RESULTS: There were 334 women identified, but only 51 could be included. Globally, we found no statistically significant differences in terms of sexual function before and after surgery between the 25 groups. Intragroup comparison demonstrated that, within the perineal approach group, patients experienced a decrease in their sexual arousal after the procedure. The choice of surgical route for pelvic floor disorders does not seem to have an impact on the results of postoperative sexual function in women. This study adds to the limited literature on sexual outcomes of surgery for CPFD. It is limited principally due to its retrospective design and the small number of patients included. CONCLUSION: Both surgical routes have very similar outcomes on most sexual questions. A perineal approach combined with abdominal rectopexy did, however, demonstrate a slight decrease in sexual arousal of the patients after the intervention. Zawodnik A, Balaphas A, Buchs NC, et al. Does Surgical Approach in Pelvic Floor Repair Impact Sexual Function in Women? Sex Med 2019;7:522-529.

Correction to: Mucosal advancement flap for recurrent complex anal fistula: a repeatable procedure.

The name of the second author of this article was incorrectly presented as "Riccardo Scarpa Cosimo" this should have been "Cosimo Riccardo Scarpa".

Mucosal advancement flap for recurrent complex anal fistula: a repeatable procedure.

PURPOSE: Mucosal advancement flap (MAF) is the best option for complex anal fistula (AF) treatment. Recurrence is not rare and the best surgical option for his handling is a challenge considering the incontinence risk and the healing rate. We aimed to determine the feasibility and outcomes of a second MAF for recurrent complex AF previously treated with mucosal advancement flap. METHODS: We retrospectively identified 32 patients undergoing two or more MAF for recurrent AF in a larger cohort of 121 consecutive cases of MAF operated by the same senior colorectal surgeon. Only complex AF of cryptoglandular origin was enrolled. A long-term follow-up was performed collecting clinical and functional data. RESULTS: Among 121 patients (group A) treated with mucosal advancement flap, 32 (26.4%) (group B) recurred with a complex AF requiring a second mucosal advancement flap procedure. Success rate of group B is 78.1%. Six patients of group B recurred a second time, another MAF was performed with healing in all cases. Complication rate (Clavien Dindo 3b) of group B is 9.4% compared to 8.3% of group A. A slight continence deficit (Miller score 1, 2, and 4) was detected after the first MAF in 3 patients. The Miller score for these patients did not change after the subsequent MAF. CONCLUSIONS: MAF is effective for treatment of complex recurrent AF. A pre-existing MAF procedure does not worsen the healing rate of the second flap. The rate of surgical complications is similar with those reported in the literature for MAFs.

Risk of colorectal cancer in patients with diverticular disease.

Colorectal cancer constitutes an important burden on the healthcare system. Screening at-risk populations to reduce colorectal cancer-related morbidity and mortality has become part of good clinical practice. However, recommendations regarding subgroups of patients with diverticular disease are subject to controversy. Herein, we review the most recent literature regarding the prevalence of colorectal cancer in patients with diverticular disease, diverticulitis and uncomplicated diverticulitis. The recent literature does not identify diverticular disease as a long-term risk factor for colorectal cancer. However, the risk of colorectal cancer is increased in the short-term period after hospitalization related to diverticular disease. According to a recent systematic review and meta-analysis, the prevalence of colorectal cancer is 1.6% in patients with acute diverticulitis who underwent colonoscopy. The risk of having colorectal cancer after an episode of acute diverticulitis is 44-fold higher than that of an age- and gender-adjusted reference population. Despite lower among patients with uncomplicated episode, the risk of colorectal cancer remains 40-fold higher in that subpopulation than that in the reference population. To conclude, the recent literature describes an increased risk of colorectal cancer among patients with acute diverticulitis compared to the reference population. Colonoscopy is therefore recommended in patients with diverticulitis to exclude colorectal cancer.

Plastic ingestion and trophic transfer between Easter Island flying fish (Cheilopogon rapanouiensis) and yellowfin tuna (Thunnus albacares) from Rapa Nui (Easter Island).

Millimetre-sized fragments have been documented in many fish species, but their transfer through food webs is still poorly understood. Here we quantified and described plastic fragments in the digestive tracts of 43 Easter Island flying fish (Cheilopogon rapanouiensis) and 50 yellowfin tunas (Thunnus albacares) from coastal waters around Rapa Nui (Easter Island) in the South Pacific subtropical gyre, and of fish preyed upon by T. albacares. Overall, seven C. rapanouiensis (16%) individuals had ingested microplastics, most of which resembled the common planktonic prey of the fish. One microplastic was found in the gut of a fish ingested by a tuna, which indicates that trophic transfer may occur between tuna and prey. A single T. albacares (2%) had ingested five mesoplastics (15.2-26.3 mm) that were probably not mistaken for prey items, but rather accidentally ingested during foraging on fish prey. The absence of microplastics in T. albacares suggests that such small particles, if transferred from the prey, do not accumulate in the relatively large digestive tract of large predators. On the other hand, larger plastic items may accumulate in the gut of tunas, to which they may induce deleterious effects that still need to be examined. However, only a small portion of the fish had ingested mesoplastics. The results of this study suggest that microplastic contamination is not an immediate threat to large predatory fish, such as T. albacares, along the coast of Easter Island within the South Pacific subtropical gyre.

Capture, swallowing, and egestion of microplastics by a planktivorous juvenile fish.

Microplastics (<5 mm) have been found in many fish species, from most marine environments. However, the mechanisms underlying microplastic ingestion by fish are still unclear, although they are important to determine the pathway of microplastics along marine food webs. Here we conducted experiments in the laboratory to examine microplastic ingestion (capture and swallowing) and egestion by juveniles of the planktivorous palm ruff, Seriolella violacea (Centrolophidae). As expected, fish captured preferentially black microplastics, similar to food pellets, whereas microplastics of other colours (blue, translucent, and yellow) were mostly co-captured when floating close to food pellets. Microplastics captured without food were almost always spit out, and were only swallowed when they were mixed with food in the fish's mouth. Food probably produced a 'gustatory trap' that impeded the fish to discriminate and reject the microplastics. Most fish (93% of total) egested all the microplastics after 7 days, on average, and 49 days at most, substantially longer than food pellets (<2 days). No acute detrimental effects of microplastics on fish were observable, but potential sublethal effects of microplastics on the fish physiological and behavioural responses still need to be tested. This study highlights that visually-oriented planktivorous fish, many species of which are of commercial value and ecological importance within marine food webs, are susceptible to ingest microplastics resembling or floating close to their planktonic prey.