Abdominal drainage after elective colorectal surgery: propensity score-matched retrospective analysis of an Italian cohort.

BACKGROUND: In Italy, surgeons continue to drain the abdominal cavity in more than 50 per cent of patients after colorectal resection. The aim of this study was to evaluate the impact of abdominal drain placement on early adverse events in patients undergoing elective colorectal surgery. METHODS: A database was retrospectively analysed through a 1:1 propensity score-matching model including 21 covariates. The primary endpoint was the postoperative duration of stay, and the secondary endpoints were surgical site infections, infectious morbidity rate defined as surgical site infections plus pulmonary infections plus urinary infections, anastomotic leakage, overall morbidity rate, major morbidity rate, reoperation and mortality rates. The results of multiple logistic regression analyses were presented as odds ratios (OR) and 95 per cent c.i. RESULTS: A total of 6157 patients were analysed to produce two well-balanced groups of 1802 patients: group (A), no abdominal drain(s) and group (B), abdominal drain(s). Group A versus group B showed a significantly lower risk of postoperative duration of stay >6 days (OR 0.60; 95 per cent c.i. 0.51-0.70; P < 0.001). A mean postoperative duration of stay difference of 0.86 days was detected between groups. No difference was recorded between the two groups for all the other endpoints. CONCLUSION: This study confirms that placement of abdominal drain(s) after elective colorectal surgery is associated with a non-clinically significant longer (0.86 days) postoperative duration of stay but has no impact on any other secondary outcomes, confirming that abdominal drains should not be used routinely in colorectal surgery.

Carcinomas of the Thyroid with Ewing Family Tumor Elements (CEFTEs): A Diagnostic Challenge Before Surgery.

Carcinomas of the thyroid with Ewing family tumor elements (CEFTEs) are small cell thyroid tumors characterized by epithelial differentiation and EWSR1-FLI1 rearrangements. In contrast to primary thyroid Ewing sarcomas, these rare tumors have a favorable prognosis. CEFTEs may co-exist with papillary thyroid carcinoma (PTC) foci and are thought to arise from either PTCs or main cells of solid cell nests (SCN). Due to their rare occurrence, characteristic clinical presentations, preoperatory sonographic (US) findings, and fine-needle aspiration (FNA) cytologic features were ill-defined until now. We report a case of a 40-year-old male who was referred to the thyroid clinic for a progressively enlarging, hard, painless, cervical mass. US examination revealed a hypoechoic nodule with lobulated margins and scant intranodular vascular signals of the right thyroid lobe. Evidence of extracapsular spread was not identified. FNA provided a Bethesda V cytology classification on conventional smears. Repeat FNA sampling with the use of a CytoFoam Core allowed a preoperative diagnosis consistent with undifferentiated thyroid carcinoma. Total thyroidectomy without lymph node dissection was performed. Histologic examination with subsequent molecular studies provided the diagnosis of papillary carcinoma of the thyroid with Ewing family tumour elements (CEFTEs). No additional treatment was rendered and the patient showed no evidence of local or distant disease by clinical examination, US, and 18FDG-TAC/PET after 6 months of follow-up. This is the first reported case of CEFTE with complete clinical, US, cytologic, and immunohistochemical preoperatory assessment.

Management and 1-year outcomes of anastomotic leakage after elective colorectal surgery.

PURPOSE: To analyze different types of management and one-year outcomes of anastomotic leakage (AL) after elective colorectal resection. METHODS: All patients with anastomotic leakage after elective colorectal surgery with anastomosis (76/1,546; 4.9%), with the exclusion of cases with proximal diverting stoma, were followed-up for at least one year. Primary endpoints were as follows: composite outcome of one-year mortality and/or unplanned intensive care unit (ICU) admission and additional morbidity rates. Secondary endpoints were as follows: length of stay (LOS), one-year persistent stoma rate, and rate of return to intended oncologic therapy (RIOT). RESULTS: One-year mortality rate was 10.5% and unplanned ICU admission rate was 30.3%. Risk factors of the composite outcome included age (aOR = 1.08 per 1-year increase, p = 0.002) and anastomotic breakdown with end stoma at reoperation (aOR = 2.77, p = 0.007). Additional morbidity rate was 52.6%: risk factors included open versus laparoscopic reoperation (aOR = 4.38, p = 0.03) and ICU admission (aOR = 3.63, p = 0.05). Median (IQR) overall LOS was 20 days (14-26), higher in the subgroup of patients reoperated without stoma. At 1 year, a stoma persisted in 32.0% of patients, higher in the open (41.2%) versus laparoscopic (12.5%) reoperation group (p = 0.04). Only 4 out of 18 patients (22.2%) were able to RIOT. CONCLUSION: Mortality and/or unplanned ICU admission rates after AL are influenced by increasing age and by anastomotic breakdown at reoperation; additional morbidity rates are influenced by unplanned ICU admission and by laparoscopic approach to reoperation, the latter also reducing permanent stoma and failure to RIOT rates. TRIAL REGISTRATION: ClinicalTrials.gov # NCT03560180.

Colorectal surgery in Italy during the Covid19 outbreak: a survey from the iCral study group.

BACKGROUND: The COVID19 pandemic had a deep impact on healthcare facilities in Italy, with profound reorganization of surgical activities. The Italian ColoRectal Anastomotic Leakage (iCral) study group collecting 43 Italian surgical centers experienced in colorectal surgery from multiple regions performed a quick survey to make a snapshot of the current situation. METHODS: A 25-items questionnaire was sent to the 43 principal investigators of the iCral study group, with questions regarding qualitative and quantitative aspects of the surgical activity before and after the COVID19 outbreak. RESULTS: Two-thirds of the centers were involved in the treatment of COVID19 cases. Intensive care units (ICU) beds were partially or totally reallocated for the treatment of COVID19 cases in 72% of the hospitals. Elective colorectal surgery for malignancy was stopped or delayed in nearly 30% of the centers, with less than 20% of them still scheduling elective colorectal resections for frail and comorbid patients needing postoperative ICU care. A significant reduction of the number of colorectal resections during the time span from January to March 2020 was recorded, with significant delay in treatment in more than 50% of the centers. DISCUSSION: Our survey confirms that COVID19 outbreak is severely affecting the activity of colorectal surgery centers participating to iCral study group. This could impact the activity of surgical centers for many months after the end of the emergency.

The impact of log odds of positive lymph nodes (LODDS) in colon and rectal cancer patient stratification: a single-center analysis of 323 patients.

Log odds of positive nodes (LODDS), defined as the log of the ratio between the number of positive nodes and the number of negative nodes, has been recently introduced as a tool in predicting prognosis. This study aims to establish the effective and prognostic value of LODDS in predicting the survival outcome of CRC patients undergoing surgical resection. The study population is represented by 323 consecutive patients with primary colon or rectal adenocarcinoma thatunderwent curative resection. LODDS values were calculated by empirical logistic formula, log(pnod + 0.5)/(tnod - pnod + 0.5). It was defined as the log of the ratio between the number of positive nodes and the number of negative nodes. The patients were divided into three groups: LODDS0 (≤ - 1.36), LODDS1 (> - 1.36 ≤ - 0.53) and LODDS2 (> - 0.53). Kaplan-Meier curve analyses showed 3-year OS rates of the patients staged by LODDS classification. These values were 88.3, 74.8 and 61.8% for LODDS0, LODDS1 and LODDS2, respectively (P ≤ 0.001). In a multivariate analysis, LODDS is an independent prognostic factor of 3-year OS. This is in contrast to pN stage and lymph node ratio, which shows no statistical significance. ROC analyses showed that LODDS predicted OS better than lymph node ratio. LODDS classification has a better prognostic effect than pN stage and lymph node ratio. LODDS offers a finer stratification and accurately predicts survival of CRC patients.

Preoperative trans-jugular porto-systemic shunt for oncological gastric surgery in a cirrhotic patient.

Abdominal surgery in cirrhotic patients with portal hypertension is associated with high incidence of disease and mortality. In these patients, oncological gastric procedures with lymph-nodes dissection show much higher complication rates than in normotensive portal vein patients. Thus, normalization of portal vein pressure may be a favorable determinant factor to reduce complications. We report a case of a patient with hepatitis C virus-related hepatic cirrhosis, esophageal varices, portal hypertension and gastric cancer. We demonstrated the efficacy of a preoperative trans-jugular porto-systemic shunt to perform oncological radical resection more safely. We retained preoperative the trans-jugular porto-systemic shunt in the patients with elevated portal pressure and gastric cancer to perform a gastrectomy more safely and to decrease morbidity and mortality of these cases.

Does ghost ileostomy have a role in the laparoscopic rectal surgery era? A randomized controlled trial.

BACKGROUND: Anastomotic leakage following anterior rectal resection is the most important and most commonly faced complication of laparoscopy and open surgery. To prevent this complication, the construction of a preventing stoma is usually adopted. It is not easy to decide whether to construct a protective stoma in patients with a medium risk of anastomotic leakage. In these patients, ghost ileostomy (GI), a pre-stage ileostomy that can be externalized and opened if needed, has proved useful. We conducted a prospective, randomized, controlled study to evaluate the advantages of GI in laparoscopic rectal resection. METHODS: All patients with surgical indications for laparoscopic rectal resection who were at medium risk for anastomotic leakage from January 2007 to January 2013 were included and were randomly divided in 2 groups. All of the patients were subjected to laparoscopic anterior rectal resection with the performance of GI (group A) or without the construction of any protective stoma (group B). The presence and severity of clinically evident postoperative anastomotic leakage and other postoperative complications and reinterventions were investigated. RESULTS: Of the 55 patients allocated to group A, 3 experienced anastomotic leakage compared with 4 in group B. The patients with GI experienced a lower severity of anastomotic leakage and shorter hospitalization compared with the patients in group B. None of the patients with GI and anastomotic leakage required laparotomy to treat the dehiscence. CONCLUSIONS: The use of GI in laparoscopic rectal resections in patients at medium risk for anastomotic leakage was useful because it allowed for the avoidance of stoma creation in all of the patients, thus reducing the number of stomas performed, improving the quality of life of the patients and preserving, in most cases, the benefits gained by laparoscopy.

One-step laparoscopic and endoscopic treatment of gallbladder and common bile duct stones: our experience of the last 9 years in a retrospective study.

The optimal timing and best method for removal of common bile duct stones (CBDS) associated with gallbladder stones (GBS) is still controversial. The aim of this study is to investigate the outcomes of a single-step procedure combining laparoscopic cholecystectomy (LC), intraoperative cholangiography (IOC), and endoscopic retrograde cholangiopancreatography (ERCP). Between January 2003 and January 2012, 1972 patients underwent cholecystectomy at our hospital. Of those, 162 patients (8.2%; male/female 72/90) presented with GBS and suspected CBDS. We treated 54 cases (Group 1) with ERCP and LC within 48 to 72 hours. In 108 patients (Group 2) we performed LC with IOC and, if positive, was associated with IO-ERCP and sphincterotomy. In Group 1, a preoperative ERCP and LC were completed in 50 patients (30%). In four cases (2%), an ERCP and endobiliary stents were performed without cholecystectomy and then patients were discharged because of the severity of clinical conditions and advanced American Society of Anesthesiologists score (III to IV). Two months later a preoperative ERCP and removal of biliary stents were performed followed by LC 48 to 72 hours later. In Group 2, the IOC was performed in all cases and CBDS were extracted in 94 patients (87%). In two cases, the laparoscopic choledochotomy was necessary to remove large stones. In another two cases, an open choledochotomy was performed to remove safely the stones with T-tube drainage. In three cases, conversion was necessary to safely complete the procedure. The mean operative time was 95 minutes (range, 45 to 150 minutes) in Group 1 and 130 minutes (range, 50 to 300 minutes) in Group 2. The mean hospital stay was 6.5 days (range, 4 to 21 days) in Group 1 and 4.7 days (range, 3 to 14 days) in Group 2. Five cases (two in Group 2 and three in Group 1) presented with CBDS at 12 to 18 months after surgery. They were treated successfully with a second ERCP. There was no perioperative mortality. Our experience suggests that when clinically and technically feasible, a single-stage approach combining LC, IOC, and ERCP to the patients diagnosed with chole-choledocholithiasis is indicated. The IO-ERCP with CBDS extraction is a safe and effective method with low risk of postoperative pancreatitis. One-step treatment is more comfortable for the patient and also reduces the mean hospital stay.

[Adult ileocaecal and colic invagination: a case report]. / Invaginazione ileo-colica nell'adulto: a proposito di un caso clinico.

Intestinal invagination or intussusception is the telescoping of a segment of the intestinal tract into an adjacent one. In most cases the invagination is ileocolic, consisting of the small intestine penetrating into the colon through the ileocaecal valve; in other cases it could be ileoileal or colocolic. It is a common entity in paediatric subjects, especially in the first two years of life (90-95% of cases), but is a rare condition in the adult where it accounts for only 5-10% of all intestinal invaginations and around 1% of all intestinal occlusions. We report a case observed in a 65-year-old patient. The patient underwent ileo-caeco-colic resection. Histological examination of the specimen showed an ulcerated submucosal intestinal lipoma. Computed tomography is the most accurate imaging technique for intestinal invagination. The recommended treatment of adult intestinal invagination is surgical resection of the intestinal segments involved.

Gallstone ileus: a case report and review of the literature.

Gallstone ileus is a rare complication of gallstone disease, accounting for 1-4% of all bowel obstructions. The phisiopathology is related to the presence of a bilio-enteric fistula. Cholecistoenteric fistulae occur in fewer than 1% of patients with gallstone. We present the case of an 83-years-old woman, complaining of acute abdominal pain, vomiting and mechanical obstruction at admission. She reported a past history of hypertension, recent miocardial ischaemia, diverticular disease and cholelithiasis. A CT scan revealed aerobilia, gastric and duodenal dilatation and a gallstone impacted just beyond the duodeno-jejunal junction. An exploratory supraumbilical laparotomy was performed: revealing a 4-cm gallstone impacted just caudal to the Treitz ligament. We then performed an enterolithotomy. According to the literature, enterolithotomy is the most commonly used surgical technique, whereas enterolithotomy combined with cholecistectomy and fistulectomy is indicated only in selected cases. The clinical presentation depends on impaction site and generally includes abdominal pain, nausea and vomiting. Some cases may present haematemesis due to mucosal erosion. The gold-standard investigation technique is CT scan.