Risk Factors, Diagnosis and Management of Chyle Leak Following Esophagectomy for Cancers: An International Consensus Statement.

This Delphi exercise aimed to gather consensus surrounding risk factors, diagnosis, and management of chyle leaks after esophagectomy and to develop recommendations for clinical practice. Background: Chyle leaks following esophagectomy for malignancy are uncommon. Although they are associated with increased morbidity and mortality, diagnosis and management of these patients remain controversial and a challenge globally. Methods: This was a modified Delphi exercise was delivered to clinicians across the oesophagogastric anastomosis collaborative. A 5-staged iterative process was used to gather consensus on clinical practice, including a scoping systematic review (stage 1), 2 rounds of anonymous electronic voting (stages 2 and 3), data-based analysis (stage 4), and guideline and consensus development (stage 5). Stratified analyses were performed by surgeon specialty and surgeon volume. Results: In stage 1, the steering committee proposed areas of uncertainty across 5 domains: risk factors, intraoperative techniques, and postoperative management (ie, diagnosis, severity, and treatment). In stages 2 and 3, 275 and 250 respondents respectively participated in online voting. Consensus was achieved on intraoperative thoracic duct ligation, postoperative diagnosis by milky chest drain output and biochemical testing with triglycerides and chylomicrons, assessing severity with volume of chest drain over 24 hours and a step-up approach in the management of chyle leaks. Stratified analyses demonstrated consistent results. In stage 4, data from the Oesophagogastric Anastomosis Audit demonstrated that chyle leaks occurred in 5.4% (122/2247). Increasing chyle leak grades were associated with higher rates of pulmonary complications, return to theater, prolonged length of stay, and 90-day mortality. In stage 5, 41 surgeons developed a set of recommendations in the intraoperative techniques, diagnosis, and management of chyle leaks. Conclusions: Several areas of consensus were reached surrounding diagnosis and management of chyle leaks following esophagectomy for malignancy. Guidance in clinical practice through adaptation of recommendations from this consensus may help in the prevention of, timely diagnosis, and management of chyle leaks.

Ethical Challenges Regarding Cosmetic Surgery in Patients with Body Dysmorphic Disorder.

Body dysmorphic disorder (BDD) is an obsessive-compulsive disease, associated with increased addressability to plastic surgeons; however, as patients perceive body defects due to decreased insight, they are often unsatisfied with their appearance after cosmetic surgery. The purpose of this study is to evaluate the ethical reasoning that should be performed before accepting these patients as cosmetic surgery candidates. We will focus our analysis on three main areas of interest: autonomy, which in these patients is significantly decreased, beneficence as satisfaction, which in these particular patients does not justify performing the intervention, and loyalty, which should render cosmetic procedures immoral in patients with body dysmorphic disorder.

Evaluation of the SF-36 questionnaire for assessment of the quality of life of endometriosis patients undergoing treatment: A systematic review and meta-analysis.

Endometriosis has a negative influence on the physical, psychological, and social aspects of a patient's life; therefore, it affects the health-related quality of life (HRQoL). The current review aimed to investigate the efficiency of a 36-item generic questionnaire survey (SF-36) for patients with endometriosis who were undergoing medical or surgical treatment. A search strategy including the key words 'endometriosis', 'quality of life' (QOL), and 'questionnaire SF-36' was applied using the PubMed/MEDLINE, EMBASE, and Cochrane databases in order to include articles that evaluated the QOL among women with endometriosis using the SF-36. Only articles that included interviews of patients both before and after surgical or medical endometriosis treatment or those articles that compared study groups were considered. The qualitative analysis was based on 37 articles, whereas the quantitative analysis utilized 14 articles. The research participants included 11,101 women, among whom 6,888 patients were diagnosed with endometriosis. The analysis recorded 17 studies dealing with all types of endometriosis, 9 studies dealing with deep infiltrative endometriosis (DIE), and 9 studies dealing with bowel endometriosis or DIE with bowel involvement. QOL was evaluated using only SF-36 in 12 studies that collectively included 1,912 women and using SF-36 in association with other questionnaires in 25 studies that collectively included 8,022 women. For patients with endometriosis, physical functioning [odds ratio (OR), 78.87; 95% confidence interval (CI), 68.97-88.77; I2=98.77%; P≤0.001] was the most affected life parameter. This parameter showed the highest improvement after surgical intervention (OR, 63.39; 95% CI, 48.71-78.07; I2=97.65%; P≤0.001) or hormonal treatment (OR, 38.65; 95% CI, 14.39-62.91; I2=38.65%; P≤0.001). The 36-item survey generic questionnaire seems to be an efficient tool for assessment of the QOL of life of women with endometriosis who are undergoing surgical or medical treatment. It can be applied before and after the procedure, and it can also be used for comparing study groups.

Markers of hyperglycemia in the vitreous humor. A systematic review and meta-analysis.

BACKGROUND: Vitreous humor has been extensively used in forensic practice to assess hyperglycemia after death. The results from different articles, for various hyperglycemia markers are highly variable, and a systematic analysis of the results from studies currently used in forensic practice as landmarks has not yet been performed. Therefore, we aimed to evaluate to usefulness and limits of using the values of vitreous glucose, lactic acid, beta-hydroxybutyrate, and 1,5 Anhydro-d-glucitol to detect postmortem hyperglycemia. MATERIALS AND METHODS: For this purpose, we performed a systematic review and a meta-analysis using the random-effects model to identify the threshold values and average differences for the markers mentioned above in the vitreous humor of diabetic versus nondiabetic subjects. RESULTS: We included eleven studies in the meta-analysis and found the following mean differences between the diabetic and nondiabetic groups: for glucose - 91.4 mg/dl, for lactate - 34.17 mg/dl, for the Traub formula - 111 mg/dl, for fructosamine - 0.71 mmol/L, for beta-hydroxybutyrate - 36.55 mg/dl and 1,5 Anhydro-d-glucitol - -15.2 mg/dl. We also gave practical recommendations, based on the range of values and 95% confidence intervals in normal subjects and controls to identify antemortem hyperglycemia and evaluated, whenever possible, threshold values for fatal diabetes. CONCLUSIONS: Glucose, Traub formula, fructosamine, and beta-hydroxy-butyrate can be used to detect postmortem hyperglycemia with some limitations; 1,5 Anhydro-d-glucitol can only be used to suggest the absence of a hyperglycemic status before death.

European Society of Coloproctology guidance on the use of mesh in the pelvis in colorectal surgery.

This is a comprehensive and rigorous review of currently available data on the use of mesh in the pelvis in colorectal surgery. This guideline outlines the limitations of available data and the challenges of interpretation, followed by best possible recommendations.

Accuracy of the Demirjian's method for assessing the age in children, from 1973 to 2020. A meta-analysis.

One of the most common ways to assess the age in subadults using dental records is the Demirjian method. As the number of the studies using this method increased significantly in the recent years, and as their results were often conflicting, we investigated the accuracy of the method. We performed a systematic review and meta-analysis of observational studies obtained from Pubmed, using a random-effects model with the DerSimonian-Laird estimator, and raw mean difference for effect size measure. Prediction intervals (at 95%) were used to assess the presence of significant statistical differences between chronological and dental age. Our meta-analysis showed that Demirijan's method overestimated dental age by 0.48 years in girls and 0.51 in boys. Depending on the location and sex, in girls the smallest average overestimation was found in Asia (except India), with a value of 0.36 years, and the largest overestimation in Turkey/Arabia, with a value of 0.66 years. In boys, the smallest average overestimation was found in India (0.45 years), but Asia (except India), Africa - both with 0.46 years and Oceania - with 0.47 years were close, while the largest overestimation was found in Turkey/Arabia, with an average value of 0.63 years. The Demirjian method overestimated the age by about half a year for both sexes. Even if there are some geographical/ethnic differences, they are rather small, making the method useful irrespective of the ethnic profile of the subjects.

Age Estimation Using the Cameriere Methods of Open Apices: A Meta-Analysis.

PURPOSE: To evaluate the actual variability of the mean difference between chronological and dental age using the Cameriere method of open apices and to test its accuracy in variable age groups. METHOD: We selected studies that contained data about the mean, standard deviation, and number of cases for chronological age, dental age and gender. We used a random-effects model. Statistical significance was estimated, at a p < 0.05, using prediction intervals. For the analysis of publication bias we used the funnel plot and Egger's regression test for plot asymmetry. I2 was used to test the presence of heterogeneity between studies. The Z test was used to test for statistical differences between subgroups, with p < 0.05 being considered statistically significant. We also used 95% for confidence intervals and prediction intervals. RESULTS: In boys, the average difference between chronological and dental age was 0.44 (0.26-0.63) years, while in girls the average difference between chronological and dental age was 0.34 (0.19-0.49) years. In the 6-7 years age group and in the 14-15 years age group, there was a statistically significant difference between dental and chronological age. Our study shows that the Cameriere method is useful for estimating the chronological age, with errors of less than one year. CONCLUSIONS: The Cameriere method of evaluating dental age using open apices is sufficiently accurate for forensic practice, at least in the 7-14 age-interval.

Patient-Reported Outcome Measures in Colorectal Surgery: Construction of Core Measures Using Open-Source Research Method.

Purpose. The primary aim of the study was to review the existing literature about patient-reported outcome measures (PROMs) in colorectal cancer and IBD. The secondary aim was to present a road map to develop a core outcome set via opinion gathering using social media. Method. This study is the first step of a three-step project aimed at constructing simple, applicable PROMs in colorectal surgery. This article was written in a collaborative manner with authors invited both through Twitter via the #OpenSourceResearch hashtag. The 5 most used PROMs were presented and discussed as slides/images on Twitter. Inputs from a wide spectrum of participants including researchers, surgeons, physicians, nurses, patients, and patients' organizations were collected and analyzed. The final draft was emailed to all contributors and 6 patients' representatives for proofreading and approval. Results. Five PROM sets were identified and discussed: EORTC QLQ-CR29, IBDQ short health questionnaire, EORTC QLQ-C30, ED-Q5-5L, and Short Form-36. There were 315 tweets posted by 50 tweeters with 1458 retweets. Awareness about PROMs was generally limited. The general psycho-physical well-being score (GPP) was suggested and discussed, and then a survey was conducted in which more than 2/3 of voters agreed that GPP covers the most important aspects in PROMs. Conclusion. Despite the limitations of this exploratory study, it offered a new method to conduct clinical research with opportunity to engage patients. The general psycho-physical well-being score suggested as simple, applicable PROMs to be eventually combined procedure-specific, disease-specific, or symptom-specific PROMs if needed.

Age in the Time of COVID-19: An Ethical Analysis.

Despite using a myriad of methods to combat the spread of COVID-19, the healthcare systems (especially the intensive care units) have been overwhelmed, showing an outpaced capacity of available beds and ventilators. Choosing the right criteria to allocate the scarce ICU seems very challenging, being necessary a rapid, uncomplicated and universally accepted tool for patients' triage regarding access to lifesaving resources; one such criterion, which generates intense debates, is age. Under certain circumstances, it might seem appropriate to choose to treat a young over an old patient. The main advantage of this approach is the potential for long-term survival, implying an equal right to reach an advanced age. Many authors have given moral reasons to support it, mainly based on utilitarian ethics or on distributive justice. However, there are numerous counterarguments to this approach, which we will summarize in this article. We will show that age should never be used as a unique criterion for withholding/not initiating life-saving procedures, even in pandemics or cases in which healthcare resources are extremely scarce. This approach is based on fundamental Codes of Ethics, such as the WMA Code of Ethics or the Oath of Hippocrates and all physicians treating patients should obey them.

Design and validation of a patient-reported outcome measure scale in acute pancreatitis: the PAN-PROMISE study.

OBJECTIVE: This study aimed to develop and validate a patient-reported outcome measure (PROM) in acute pancreatitis (AP) as an endpoint centred on the patient. DESIGN: A PROM instrument (PAtieNt-rePoRted OutcoMe scale in acute pancreatItis, an international proSpEctive cohort study, PAN-PROMISE scale) was designed based on the opinion of patients, professionals and an expert panel. The scale was validated in an international multicentre prospective cohort study, describing the severity of AP and quality of life at 15 days after discharge as the main variables for validation. The COSMIN (COnsensus-based Standards for the selection of health status Measurement INstruments) methodology was applied. Both the design and validation stages considered the content and face validity of this new instrument; the metric properties of the different items, reliability (reproducibility and internal consistence), the construct, structural and criterion validity, responsiveness and interpretability of this scale. RESULTS: PAN-PROMISE consists of a seven-item scale based on the symptoms that cause the most discomfort and concern to patients with AP. The validation cohort involved 15 countries, 524 patients. The intensity of symptoms changed from higher values during the first 24 hours to lower values at discharge and 15 days thereafter. Items converged into a unidimensional ordinal scale with good fit indices. Internal consistency and split-half reliability at discharge were adequate. Reproducibility was confirmed using test-retest reliability and comparing the PAN-PROMISE score at discharge and 15 days after discharge. Evidence is also provided for the convergent-discriminant and empirical validity of the scale. CONCLUSION: The PAN-PROMISE scale is a useful tool to be used as an endpoint in clinical trials, and to quantify patient well-being during the hospital admission and follow-up. TRIAL REGISTRATION NUMBER: NCT03650062.

Management of intra-abdominal-infections: 2017 World Society of Emergency Surgery guidelines summary focused on remote areas and low-income nations.

BACKGROUND: Most remote areas have restricted access to healthcare services and are too small and remote to sustain specialist services. In 2017, the World Society of Emergency Surgery (WSES) published guidelines for the management of intra-abdominal infections. Many hospitals, especially those in remote areas, continue to face logistical barriers, leading to an overall poorer adherence to international guidelines. METHODS: The aim of this paper is to report and amend the 2017 WSES guidelines for the management of intra-abdominal infections, extending these recommendations for remote areas and low-income countries. A literature search of the PubMed/MEDLINE databases was conducted covering the period up until June 2020. RESULTS: The critical shortages of healthcare workers and material resources in remote areas require the use of a robust triage system. A combination of abdominal signs and symptoms with early warning signs may be used to screen patients needing immediate acute care surgery. A tailored diagnostic step-up approach based on the hospital's resources is recommended. Ultrasound and plain X-ray may be useful diagnostic tools in remote areas. The source of infection should be totally controlled as soon as possible. CONCLUSIONS: The cornerstones of effective treatment for intra-abdominal infections in remote areas include early diagnosis, prompt resuscitation, early source control, and appropriate antimicrobial therapy. Standardization in applying the guidelines is mandatory to adequately manage intra-abdominal infections.

2020 update of the WSES guidelines for the management of acute colonic diverticulitis in the emergency setting.

Acute colonic diverticulitis is one of the most common clinical conditions encountered by surgeons in the acute setting. An international multidisciplinary panel of experts from the World Society of Emergency Surgery (WSES) updated its guidelines for management of acute left-sided colonic diverticulitis (ALCD) according to the most recent available literature. The update includes recent changes introduced in the management of ALCD. The new update has been further integrated with advances in acute right-sided colonic diverticulitis (ARCD) that is more common than ALCD in select regions of the world.

Changes in disease burden in Poland between 1990-2017 in comparison with other Central European countries: A systematic analysis for the Global Burden of Disease Study 2017.

BACKGROUND: Systematic collection of mortality/morbidity data over time is crucial for monitoring trends in population health, developing health policies, assessing the impact of health programs. In Poland, a comprehensive analysis describing trends in disease burden for major conditions has never been published. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) provides data on the burden of over 300 diseases in 195 countries since 1990. We used the GBD database to undertake an assessment of disease burden in Poland, evaluate changes in population health between 1990-2017, and compare Poland with other Central European (CE) countries. METHODS: The results of GBD 2017 for 1990 and 2017 for Poland and CE were used to assess rates and trends in years of life lost (YLLs), years lived with disability (YLDs), disability-adjusted life years (DALYs). Data came from cause-of-death registration systems, population health surveys, disease registries, hospitalization databases, and the scientific literature. Analytical approaches have been used to adjust for missing data, errors in cause-of-death certification, and differences in data collection methodology. Main estimation strategies were ensemble modelling for mortality and Bayesian meta-regression for disability. RESULTS: Between 1990-2017, age-standardized YLL rates for all causes declined in Poland by 46.0% (95% UI: 43.7-48.2), YLD rates declined by 4.0% (4.2-4.9), DALY rates by 31.7% (29.2-34.4). For both YLLs and YLDs, greater relative declines were observed for females. There was a large decrease in communicable, maternal, neonatal, and nutritional disease DALYs (48.2%; 46.3-50.4). DALYs due to non-communicable diseases (NCDs) decreased slightly (2.0%; 0.1-4.6). In 2017, Poland performed better than CE as a whole (ranked fourth for YLLs, sixth for YLDs, and fifth for DALYs) and achieved greater reductions in YLLs and DALYs than most CE countries. In 2017 and 1990, the leading cause of YLLs and DALYs in Poland and CE was ischaemic heart disease (IHD), and the leading cause of YLDs was low back pain. In 2017, the top 20 causes of YLLs and YLDs in Poland and CE were the same, although in different order. In Poland, age-standardized DALYs from neonatal causes, other cardiovascular and circulatory diseases, and road injuries declined substantially between 1990-2017, while alcohol use disorders and chronic liver diseases increased. The highest observed-to-expected ratios were seen for alcohol use disorders for YLLs, neonatal sepsis for YLDs, and falls for DALYs (3.21, 2.65, and 2.03, respectively). CONCLUSIONS: There was relatively little geographical variation in premature death and disability in CE in 2017, although some between-country differences existed. Health in Poland has been improving since 1990; in 2017 Poland outperformed CE as a whole for YLLs, YLDs, and DALYs. While the health gap between Poland and Western Europe has diminished, it remains substantial. The shift to NCDs and chronic disability, together with marked between-gender health inequalities, poses a challenge for the Polish health-care system. IHD is still the leading cause of disease burden in Poland, but DALYs from IHD are declining. To further reduce disease burden, an integrated response focused on NCDs and population groups with disproportionally high burden is needed.

Preoperative factors associated with prolonged postoperative in-hospital length of stay in patients with Crohn's disease undergoing intestinal resection or strictureplasty.

PURPOSE: To investigate factors that influence postoperative in-hospital length of stay (LOS) in patients with Crohn's disease (CD) undergoing bowel surgery. Furthermore, the study aimed to evaluate LOS as a surrogate for postoperative outcome. METHODS: This is a multicentre retrospective cohort study. Inclusion criteria were adult patients with CD who underwent bowel surgery with either anastomosis or stricturoplasty. All timings of surgeries were included regardless of the method of access to the abdominal cavities. Patients with stoma were excluded. Demographic data, preoperative medications, previous operations for CD, preoperative sepsis, and operation were recorded. Primary outcome was LOS while secondary outcome variable was postoperative complications. RESULTS: A total of 449 patients who underwent abdominal surgery for CD were included. Of the 449 patients, 265 were female (59%). Median age was 37 years (IQR = 20), median LOS was 7 days (IQR = 6). Patients with longer LOS had higher rates of re-laparotomy/re-laparoscopy (45/228 (19.7%) versus 9/219 (4.1%) p = 0.01). In multivariate analysis, age (OR = 1.024 [CI 95% 1.007-1.041], p = 0.005), preoperative intra-abdominal abscess (OR = 0.39 [CI 95% 0.185-0.821], p = 0.013), and previous laparotomy/laparoscopy (OR = 0.57 [CI 95% 0.334-0.918], p = 0.021) were associated with prolonged LOS. LOS correlated with postoperative complications after adjustment for age, gender, previous laparotomy/laparoscopy, and preoperative intra-abdominal abscesses (OR = 1.28 [CI 95% 1.199-1.366], p < 0.0001). CONCLUSION: Age, preoperative intra-abdominal abscess, and previous laparotomy/laparoscopy significantly prolonged LOS. LOS correlated with postoperative complications and can therefore be used in epidemiological or register-based studies as a surrogate for postoperative outcome.

Anatomical variants of renal veins: A meta-analysis of prevalence.

The main aim of this article is to establish the actual prevalence of renal vein variations (circumaortic renal vein, retroaortic renal vein, double renal vein), and to increase awareness about them. To this purpose, we have performed a meta-analysis of prevalence, using the MetaXL package, We included 105 articles in the final analysis of prevalence, of which 88 contained data about retroaortic renal vein, 84 - about circumaortic renal vein, and 51 - about multiple renal veins. The overall prevalence for retroaortic renal vein was 3% (CI:2.4-3.6%), for circumaortic renal vein - 3.5% (CI:2.8-4.4%), and for multiple renal veins - 16.7% (14.3-19.2%), much higher on the right 16.6 (14.2-19.1%) than on the left side 2.1 (1.3-3.2%). The results were relatively homogenous between studies, with only a minor publication bias overall.

Retrocaval ureter: a meta-analysis of prevalence.

INTRODUCTION: Retrocaval ureter is a congenital abnormality of the right ureter, which has been shown, in rare cases to cause clinical symptoms, mainly due to the development of ureterohydronephrosis. PURPOSE: The purpose of this article is to identify the prevalence of the retrocaval ureter, and to emphasize its clinical and surgical importance. DESIGN: A meta-analysis of prevalence, on cases obtained from PubMed, Web of Science, and Scopus databases. RESULTS: A total number of 13 studies contained data that allowed us to estimate the prevalence of the retrocaval ureter, which was identified overall in 9 cases, out of 18,493 subjects. The overall prevalence of retrocaval ureter was 0.13%, with a 95% confidence interval between 0.06 and 0.27%. There was no publication bias, all studies being under the funnel. CONCLUSIONS: The overall prevalence of retrocaval ureter is 0.13%. Even if this is obviously a rare condition, its presence must be suspected by practitioners, especially in the presence of urological symptoms without a clear cause.

Duplication and transposition of inferior vena cava: A meta-analysis of prevalence.

OBJECTIVE: The primary aim of this article was to establish the actual prevalence of transposition and duplication of the inferior vena cava and to increase awareness about them. METHODS: A meta-analysis of prevalence was conducted of cases obtained from PubMed, Web of Science, and Scopus databases. RESULTS: A total of 48 studies contained data that allowed us to estimate the prevalence of these variants (39 for duplication and 32 for transposition). The overall prevalence of duplication was 0.7%, with a 95% confidence interval between 0.5% and 0.9%; for transposition, the prevalence was 0.3%, with a 95% confidence interval between 0.2% and 0.5%. The publication bias was minimal. Duplication prevalence was significantly higher in anatomy studies compared with imaging and surgery studies; for transposition, there were no statistically significant differences by detection technique. CONCLUSIONS: The overall prevalence of duplication of the inferior vena cava is 0.7%; for transposition, it is 0.3%. Even if they are obviously rare conditions, their presence must be suspected by practitioners as they can have important clinical consequences, may require changes in the surgery protocol, or can be associated with other congenital abnormalities.

The moral status of cerebral organoids.

Organoids are 3D biological structures constructed from stem cells in vitro. They partially mimic the function of real organs. Although the number of articles detailing this technology has increased in recent years, papers debating their ethical issues are few. In addition, many of such articles outline a mere summary of potential ethical concerns associated with organoids, although some have focused on consciousness assessment or organoid use in cystic fibrosis treatment. This article seeks to evaluate the moral status of cerebral organoids and to determine under which conditions their use should be allowed from a bioethical standpoint. We will present an overview of recent steps in developing highly advanced cerebral organoids, followed by an analysis of their ethics based on three factors: human origin, a specific biological threshold (which, once crossed, grants an entity moral status), and the potential to generate human beings. We will also make practical recommendations for researchers working in this biological field.