Parastomal hernia repairs: A nationwide cohort study in the Republic of Ireland.

BACKGROUND: In the context of improving colorectal cancer outcomes, post-survivorship quality of life has become an important outcome measure. Parastomal hernias and their associated morbidity remain largely under-reported and under-appreciated. Despite their burden, conservative management is common. This study aims to provide a national overview on the current trends in parastomal hernia repairs (PHRs). METHODS: All PHRs performed in public hospitals across the country between 1/2017 to 7/2022 were identified retrospectively from the National Quality Assurance and Improvement System (NQAIS) database. Anonymised patient characteristics and quality indices were extracted for statistical analysis. RESULTS: A total of 565 PHRs, 64.1 % elective and the remainder emergent, were identified across 27 hospitals. The 8 national colorectal units performed 67.3 % of all repairs. While 42.3 % of PHRs were standalone procedures, reversal of Hartmann's procedure was the commonest simultaneous procedure in the remainder. The median age, ASA and Charlson Co-Morbidity Index were 64 years (19), 3(1) and 3(10) respectively. Mean length of stay (LOS) was 16.25 days (SD = 29.84). Linear regression analysis associated ASA (95 % CI 0.58-16.08, p < 0.035) and emergency admissions (95 % CI 5.86-25.55, P < 0.002) with a significantly longer LOS, with the latter also associated with more frequent emergency re-admissions (95 % CI 0.18-0.82, p < 0.002). CONCLUSION: Patients undergoing emergency PHR were older and significantly more comorbid. Consequently, these patients were subjected to longer hospital stays, more frequent readmissions and overall higher hospital costs. Multidisciplinary perioperative optimisation and standardised referral pathways should underpin the shift towards elective PHRs.

The Complexity of Defining Postoperative Pneumonia After Esophageal Cancer Surgery: A Spectrum of Lung Injury Rather Than a Simple Infective Complication?

OBJECTIVE: To analyze the spectrum of Centers for Disease Control and Prevention (CDC)-defined pneumonia after esophageal cancer surgery. SUMMARY BACKGROUND DATA: Pneumonia is commonly documented after esophageal cancer surgery, and reducing its incidence is central to both ERAS development and to the evidence-base for minimally invasive approaches. The existing definitions of pneumonia based on hospital acquired pneumonia classifications may be suboptimal in this context and merits strict academic scrutiny. METHODS: Patients (2013-2018) treated with curative intent by open surgery were studied. Pneumonia was defined per the CDC definition. Risk factors and associations were analyzed, as was the implications of positive cultures. Multivariable logistic regression examined independently predictive factors of pneumonia and oncologic outcomes. RESULTS: Of 343 patients, 56 (16%) had defined pneumonia, 22 (39%) with positive cultures. Preoperative respiratory disease predicted pneumonia ( P = 0.043). Neoadjuvant therapy was significantly ( P = 0.004) associated with culture negative pneumonia, and age ( P = 0.001) with culture positive pneumonia. In multivariable analysis, pneumonia was associated ( P < 0.05) with respiratory comorbidity, tumor site, and neoadjuvant chemoradiation. Pneumonia did not impact on overall survival (P = 0.807). DISCUSSION: CDC-defined pneumonia occurred in 16% of cases. Culture-negative pneumonia accounted for 61% of cases and was significantly associated with neoadjuvant chemoradiation. Pneumonia as currently defined seems to represent a spectrum of etiology and severity in the post-esoph-agectomy patient, with infection per se rarely proven, suggesting a need to reevaluate its definition, severity classification, and preventive and treatment strategies.

Prospective study of surgical site infections post-open esophageal cancer surgery, and the impact of care bundles.

SSIs represent common infection-related morbidity following major surgery. Modern care bundles have been established as prophylactic measures aimed at preventing SSI occurring postoperatively. SSI incidence and data on common culprit pathogens post-esophagectomy for cancer have not been previously reported. Patients (2013-2018) treated with curative intent were studied. SSI was defined as per the Center for Disease Control (CDC) definition. A care bundle pathway following the National Institute for Clinical Excellence (NICE) guidelines for prevention of SSIs was introduced in 2013 and was audited quarterly. Risk factors and associations of SSIs were analyzed, as was the prevalence of isolated pathogens. Multivariable logistic regression examined independently predictive factors of SSIs and oncologic outcomes. Of 343 patients, 34 (9.9%) developed a postoperative SSI, with a median (range) of 8 (6-17). Quarterly audit carried out over 6 years showed no significant annual variance or trend. The most prevalent pathogen cultured was Methicillin-sensitive Staphylococcus aureus (MSSA) in nine patients (32%) followed by Candida albicans (29%), Escherichia coli (14%), and Enterococcus faecium (11%). SSI was significantly associated with pneumonia (P = 0.001), respiratory failure (P = 0.014), atrial fibrillation (P = 0.004), anastomotic leak (P < 0.001), and in-hospital blood transfusions (P = 0.031). SSI did not impact the overall survival (P = 0.951). SSI rates can be maintained at less than 10% using strict care bundles and regular audit. The most common culprit pathogen is gram-positive MSSA representing 32% of cases. These data are novel and may represent a modern benchmark for SSI post-open esophagectomy for cancer. This study highlights the incidence and associations of SSI post-esophageal cancer surgery.

Early experience with a nutrition and survivorship clinic in esophageal cancer.

Improved cure rates in esophageal cancer care have increased focus on health-related quality of life (HRQL) in survivorship. To optimize recovery after esophagectomy, particularly nutritional well-being, a personalized multidisciplinary survivorship clinic was established at this center. Assessments at 6 and 12 months postoperatively include validated European Organization for the Research and Treatment of Cancer (EORTC) symptom and health-related quality of life (HRQL) questionnaires, functional status review, anthropometry, and biochemical screening for micronutrient deficiencies. 75 patients, at a mean age of 63 years, 84% male, 85% with adenocarcinoma, and 73% receiving multimodal therapy were included. Mean preoperative body mass index (BMI) was 27.5 (4.3) kg m -2. 6- and 12-month assessments were completed by 66 (88%) and 37 (93%) recurrence-free patients, respectively. Mean body weight loss at 6 months was 8.5 ± 6.6% and at 12 months 8.8 ± 7.3%. Of the 12-month cohort, micronutrient deficiency was present in 27 (79.4%) preoperatively and 29 (80.6%) after 1 year (P = 0.727), most commonly iron deficiency (preoperative: 16 [43.2%] and postoperative: 17 [45.9%] patients, P = 0.100). 26 (70.3%) of these patients also had clinically significant dumping syndrome persisting to 12 months after surgery. We describe a novel follow-up support structure for esophageal cancer patients in the first year of survivorship. This may serve as an exemplar model with parallel application across oncological care.

Advances in anti-viral immune defence: revealing the importance of the IFN JAK/STAT pathway.

Interferon-alpha (IFN-α) is a potent anti-viral cytokine, critical to the host immune response against viruses. IFN-α is first produced upon viral detection by pathogen recognition receptors. Following its expression, IFN-α embarks upon a complex downstream signalling cascade called the JAK/STAT pathway. This signalling pathway results in the expression of hundreds of effector genes known as interferon stimulated genes (ISGs). These genes are the basis for an elaborate effector mechanism and ultimately, the clearance of viral infection. ISGs mark an elegant mechanism of anti-viral host defence that warrants renewed research focus in our global efforts to treat existing and emerging viruses. By understanding the mechanistic role of individual ISGs we anticipate the discovery of a new "treasure trove" of anti-viral mediators that may pave the way for more effective, targeted and less toxic anti-viral therapies. Therefore, with the aim of highlighting the value of the innate type 1 IFN response in our battle against viral infection, this review outlines both historic and recent advances in understanding the IFN-α JAK/STAT pathway, with a focus on new research discoveries relating to specific ISGs and their potential role in curing existing and future emergent viral infections.

Objective improvement with coronary anastomosis simulation training: meta-analysis.

BACKGROUND: Coronary artery anastomosis training and assessment are vital for patient safety and for conferring a prognostic benefit. A systematic review and meta-analysis were performed to analyse the impact of simulation on coronary anastomosis proficiency in terms of time taken and skill score. METHODS: This review was conducted in accordance with PRISMA guidelines, searching PubMed, Embase and Cochrane databases on 10 October 2020, using the terms 'Coronary anastomosis simulation' or 'vascular anastomosis simulation' and 'anastomosis simulation'. Studies included had objective measurement of scores of before and after simulation. Meta-analysis was performed using RevMan, version 5.4 (Cochrane Library). RESULTS: From a pool of 1687 articles, 12 articles evaluating the use of simulation in teaching coronary anastomosis were identified, with objective scores at baseline and after simulation. The 12 papers included 274 subjects. Data on 223 subjects could be extracted for analysis in performing coronary anastomosis in a simulated environment. Eight trials evaluated improvement in time and 12 trials evaluated performance using an objective evaluation score. In comparison with no formal simulation training, simulation was associated with improved skill in a five-point scale (standardized mean difference 1.68 (95 per cent c.i. 1.23 to 2.13; P < 0.001)) and time (mean difference 205.9 s (95 per cent c.i. 133.62 to 278.18; P < 0.001)) in trials included in the meta-analysis. Furthermore, novice cardiothoracic surgeons benefited more from simulation as regards time improvement compared with senior cardiothoracic surgeons (293 versus 120 s improvement; P = 0.003). Fidelity of simulator did not have a significant effect on rates of improvement. CONCLUSION: Simulation-based training in coronary anastomosis is associated with improved time efficiency and overall performance in comparison with no intervention. Further studies are necessary to determine the optimum timing of trainees progressing from simulation training to live operating.

Perioperative haematological outcomes following total knee arthroplasty in haemophiliacs.

PURPOSE: Patients with haemophilia suffer from recurrent joint haemarthrosis. This can progress to symptomatic arthropathy commonly affecting the knee. While modern coagulation strategies have reduced those proceeding to end-stage arthropathy, total knee arthroplasty (TKA) remains the optimal treatment for some patients. Despite innovation in perioperative haematological management, concerns about the potential for excessive haemorrhage still exist. The aim of this study is to quantify immediate postoperative blood loss and haematological complications in haemophiliacs following TKA. METHODS: A retrospective study of patients with haemophilia types A or B who underwent a TKA over a 12-year period at a single institution was conducted. These patients were compared to both a non-haemophiliac control group and to published standards in non-haemophiliacs undergoing TKA. RESULTS: Twenty-one TKA procedures in 18 patients (72% haemophilia A, 28% haemophilia B) were suitable for inclusion with a mean age of 44 years. The mean haemoglobin drops at 24 and 48 h postoperatively were 2.7 g/dl and 3.8 g/dl respectively. There was no significant difference in haemoglobin drop at 48 h postoperatively when compared to the non-haemophiliac control group (P = 0.2644). There were no immediate perioperative complications and two patients (9.6%) required postoperative transfusion. CONCLUSION: Haemophiliacs undergoing a unilateral primary TKA in a specialised tertiary referral centre appear to have comparable rates of perioperative blood loss when compared to both a non-haemophiliac control group as and published haemostatic standards in non-haemophiliac patients following TKA. Perioperative management with expert orthopaedic and haematological input is recommended to optimise outcomes in this complex patient group.