Colorectal neoplastic emergencies in immunocompromised patients: preliminary result from the Web-based International Register of Emergency Surgery and Trauma (WIRES-T trial)

Association of advanced age, neoplastic disease and immunocompromission (IC) may lead to surgical emergencies. Few data exist about this topic. Present study reports the preliminary data from the WIRES-T trial about patients managed for colorectal neoplastic emergencies in immunocompromised patients. The required data were taken from a prospective observational international register. The study was approved by the Ethical Committee with approval n. 17575; ClinicalTrials.gov Identifier: NCT03643718. 839 patients were collected; 753 (80.7%) with mild-moderate IC and 86 (10.3%) with severe. Median age was 71.9 years and 73 years, respectively, in the two groups. The causes of mild-moderate IC were reported such malignancy (753-100%), diabetes (103-13.7%), malnutrition (26-3.5%) and uremia (1-0.1%), while severe IC causes were steroids treatment (14-16.3%); neutropenia (7-8.1%), malignancy on chemotherapy (71-82.6%). Preoperative risk classification were reported as follow: mild-moderate: ASA 1-14 (1.9%); ASA 2-202 (26.8%); ASA 3-341 (45.3%); ASA 4-84 (11.2%); ASA 5-7 (0.9%); severe group: ASA 1-1 patient (1.2%); ASA 2-16 patients (18.6%); ASA 3-41 patients (47.7%); ASA 4-19 patients (22.1%); ASA 5-3 patients (3.5%); lastly, ASA score was unavailable for 105 cases (13.9%) in mild-moderate group and in 6 cases (6.9%) in severe group. All the patients enrolled underwent urgent/emergency surgery Damage control approach with open abdomen was adopted in 18 patients. Mortality was 5.1% and 12.8%, respectively, in mild-moderate and severe groups. Long-term survival data: in mild-moderate disease-free survival (median, IQR) is 28 (10-91) and in severe IC, it is 21 (10-94). Overall survival (median, IQR) is 44 (18-99) and 26 (20-90) in mild-moderate and severe, respectively; the same is for post-progression survival (median, IQR) 29 (16-81) and 28, respectively. Univariate and multivariate analyses showed as the only factor influencing mortality in mild-moderate and severe IC is the ASA score. Colorectal neoplastic emergencies in immunocompromised patients are more frequent in elderly. Sigmoid and right colon are the most involved. Emergency surgery is at higher risk of complication and mortality; however, management in dedicated emergency surgery units is necessary to reduce disease burden and to optimize results by combining oncological and acute care principles. This approach may improve outcomes to obtain clinical advantages for patients like those observed in elective scenario. Lastly, damage control approach seems feasible and safe in selected patients

Textbook outcome in urgent early cholecystectomy for acute calculous cholecystitis: results post hoc of the S.P.Ri.M.A.C.C study

Introduction: A textbook outcome patient is one in which the operative course passes uneventful, without complications, readmission or mortality. There is a lack of publications in terms of TO on acute cholecystitis. Objetive: The objective of this study is to analyze the achievement of TO in patients with urgent early cholecystectomy (UEC) for Acute Cholecystitis. and to identify which factors are related to achieving TO. Materials and methods: This is a post hoc study of the SPRiMACC study. It ́s a prospective multicenter observational study run by WSES. The criteria to define TO in urgent early cholecystectomy (TOUEC) were no 30-day mortality, no 30-day postoperative complications, no readmission within 30 days, and hospital stay ≤ 7 days (75th percentile), and full laparoscopic surgery. Patients who met all these conditions were taken as presenting a TOUEC. Outcomes: 1246 urgent early cholecystectomies for ACC were included. In all, 789 patients (63.3%) achieved all TOUEC parameters, while 457 (36.6%) failed to achieve one or more parameters and were considered non-TOUEC. The patients who achieved TOUEC were younger had significantly lower scores on all the risk scales analyzed. In the serological tests, TOUEC patients had lower values for in a lot of variables than non-TOUEC patients. The TOUEC group had lower rates of complicated cholecystitis. Considering operative time, a shorter duration was also associated with a higher probability of reaching TOUEC. Conclusion: Knowledge of the factors that influence the TOUEC can allow us to improve our results in terms of textbook outcome

Outcomes of elective liver surgery worldwide: a global, prospective, multicenter, cross-sectional study

Background: The outcomes of liver surgery worldwide remain unknown. The true population-based outcomes are likely different to those vastly reported that reflect the activity of highly specialized academic centers. The aim of this study was to measure the true worldwide practice of liver surgery and associated outcomes by recruiting from centers across the globe. The geographic distribution of liver surgery activity and complexity was also evaluated to further understand variations in outcomes. Methods: LiverGroup.org was an international, prospective, multicenter, cross-sectional study following the Global Surgery Collaborative Snapshot Research approach with a 3-month prospective, consecutive patient enrollment within January–December 2019. Each patient was followed up for 90 days postoperatively. All patients undergoing liver surgery at their respective centers were eligible for study inclusion. Basic demographics, patient and operation characteristics were collected. Morbidity was recorded according to the Clavien–Dindo Classification of Surgical Complications. Country-based and hospital-based data were collected, including the Human Development Index (HDI). (NCT03768141). Results: A total of 2159 patients were included from six continents. Surgery was performed for cancer in 1785 (83%) patients. Of all patients, 912 (42%) experienced a postoperative complication of any severity, while the major complication rate was 16% (341/2159). The overall 90-day mortality rate after liver surgery was 3.8% (82/2,159). The overall failure to rescue rate was 11% (82/ 722) ranging from 5 to 35% among the higher and lower HDI groups, respectively. Conclusions: This is the first to our knowledge global surgery study specifically designed and conducted for specialized liver surgery. The authors identified failure to rescue as a significant potentially modifiable factor for mortality after liver surgery, mostly related to lower Human Development Index countries. Members of the LiverGroup.org network could now work together to develop quality improvement collaboratives

Diversity and ethics in trauma and acute care surgery teams: results from an international survey

Background Investigating the context of trauma and acute care surgery, the article aims at understanding the factors that can enhance some ethical aspects, namely the importance of patient consent, the perceptiveness of the ethical role of the trauma leader, and the perceived importance of ethics as an educational subject. Methods The article employs an international questionnaire promoted by the World Society of Emergency Surgery. Results Through the analysis of 402 fully filled questionnaires by surgeons from 72 different countries, the three main ethical topics are investigated through the lens of gender, membership of an academic or non-academic institution, an official trauma team, and a diverse group. In general terms, results highlight greater attention paid by surgeons belonging to academic institutions, official trauma teams, and diverse groups. Conclusions Our results underline that some organizational factors (e.g., the fact that the team belongs to a university context or is more diverse) might lead to the development of a higher sensibility on ethical matters. Embracing cultural diversity forces trauma teams to deal with different mindsets. Organizations should, therefore, consider those elements in defining their organizational procedures. Level of evidence Trauma and acute care teams work under tremendous pressure and complex circumstances, with their members needing to make ethical decisions quickly. The international survey allowed to shed light on how team assembly decisions might represent an opportunity to coordinate team member actions and increase performance

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p < 0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p < 0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication

Prospective Observational Study on acute Appendicitis Worldwide (POSAW)

Background: Acute appendicitis (AA) is the most common surgical disease, and appendectomy is the treatment of choice in the majority of cases. A correct diagnosis is key for decreasing the negative appendectomy rate. The management can become difficult in case of complicated appendicitis. The aim of this study is to describe the worldwide clinical and diagnostic work-up and management of AA in surgical departments.Methods: This prospective multicenter observational study was performed in 116 worldwide surgical departments from 44 countries over a 6-month period (April 1, 2016-September 30, 2016). All consecutive patients admitted to surgical departments with a clinical diagnosis of AA were included in the study.Results: A total of 4282 patients were enrolled in the POSAW study, 1928 (45%) women and 2354 (55%) men, with a median age of 29 years. Nine hundred and seven (21.2%) patients underwent an abdominal CT scan, 1856 (43.3%) patients an US, and 285 (6.7%) patients both CT scan and US. A total of 4097 (95.7%) patients underwent surgery; 1809 (42.2%) underwent open appendectomy and 2215 (51.7%) had laparoscopic appendectomy. One hundred eighty-five (4.3%) patients were managed conservatively. Major complications occurred in 199 patients (4.6%). The overall mortality rate was 0.28%.Conclusions: The results of the present study confirm the clinical value of imaging techniques and prognostic scores. Appendectomy remains the most effective treatment of acute appendicitis. Mortality rate is low.</p

Physiological parameters for Prognosis in Abdominal Sepsis (PIPAS) Study : a WSES observational study

BackgroundTiming and adequacy of peritoneal source control are the most important pillars in the management of patients with acute peritonitis. Therefore, early prognostic evaluation of acute peritonitis is paramount to assess the severity and establish a prompt and appropriate treatment. The objectives of this study were to identify clinical and laboratory predictors for in-hospital mortality in patients with acute peritonitis and to develop a warning score system, based on easily recognizable and assessable variables, globally accepted.MethodsThis worldwide multicentre observational study included 153 surgical departments across 56 countries over a 4-month study period between February 1, 2018, and May 31, 2018.ResultsA total of 3137 patients were included, with 1815 (57.9%) men and 1322 (42.1%) women, with a median age of 47years (interquartile range [IQR] 28-66). The overall in-hospital mortality rate was 8.9%, with a median length of stay of 6days (IQR 4-10). Using multivariable logistic regression, independent variables associated with in-hospital mortality were identified: age > 80years, malignancy, severe cardiovascular disease, severe chronic kidney disease, respiratory rate >= 22 breaths/min, systolic blood pressure 4mmol/l. These variables were used to create the PIPAS Severity Score, a bedside early warning score for patients with acute peritonitis. The overall mortality was 2.9% for patients who had scores of 0-1, 22.7% for those who had scores of 2-3, 46.8% for those who had scores of 4-5, and 86.7% for those who have scores of 7-8.ConclusionsThe simple PIPAS Severity Score can be used on a global level and can help clinicians to identify patients at high risk for treatment failure and mortality.Peer reviewe

Prospective Observational Study on acute Appendicitis Worldwide (POSAW)

Acute appendicitis (AA) is the most common surgical disease, and appendectomy is the treatment of choice in the majority of cases. A correct diagnosis is key for decreasing the negative appendectomy rate. The management can become difficult in case of complicated appendicitis. The aim of this study is to describe the worldwide clinical and diagnostic work-up and management of AA in surgical departments.info:eu-repo/semantics/publishedVersio

Exploration of the expression levels of molecules related to the appearance and treatment of breast cancer with a triple negative phenotype

AIM: Angiogenesis plays a critical role in the growth and proliferation of cancer cells. In breast cancer it is mediated by the vascular endothelial growth factor (VEGF) signalling axis. Furthermore, it is regulated by different proangiogenic factors, such as heparin- binding – EGF- like growth factor (HB-EGF) and platelet – derived growth factor – CC (PDGF-CC) in addition to co – receptors, such as neuropilin – 1 (NRP-1), which are implicated in the prognosis and therapy of breast cancer patients. The purpose of the present study is to determine the expression of the aforementioned angiogenic factors in the systemic circulation of women with early breast cancer and the correlation with body mass index (BMI), menopausal status, histological types and molecular subtypes of breast cancer. PATIENTS AND METHOD: The study cohort consisted of 205 premenopausal and postmenopausal patients with early breast cancer and 31 healthy donors. We assessed the serum levels of VEGF, HB-EGF, PDGF -CC and NRP-1 and investigated the potential associations with clinical and histopathological parameters. RESULTS: VEGF serum levels were significantly higher in patients with invasive carcinoma in comparison to patients with ductal carcinoma in situ. PDGF-CC serum levels were significantly higher in patients with molecular subtype of LumB (Her2-) in comparison to patients with triple negative molecular subtype. Moreover, we observed a different expression of most biomarkers between overweight/obese and normal weight patients among the breast cancer molecular subtypes. Specifically, overweight/obese patients with triple negative breast cancer exhibited significantly higher HB-EGF serum levels in comparison to normal weight patients. CONCLUSION: The serum levels of angiogenic factors are associated with molecular subtypes of breast cancer. Moreover, some of these angiogenic factors are affected by the histological type, the ΒΜΙ and the menopausal status of patients with breast cancer. The current study suggests a potential interaction of obesity and HB-EGF in breast cancer and specifically in triple negative molecular subtype. Further studies could enhance our findings and designate these factors as prognostic biomarkers in breast cancer and especially in triple negative breast cancer (TNBC). ΣΚΟΠΟΣ: Η αγγειογένεση εμπλέκεται στην ανάπτυξη και στον πολλαπλασιασμό των καρκινικών κυττάρων. Στον καρκίνο του μαστού ελέγχεται από τον σηματοδοτικό άξονα του αγγειακού ενδοθηλιακού αυξητικού παράγοντα (VEGF). Επιπλέον ελέγχε¬ται από διάφορους προαγγειογενετικούς παράγοντες στους οποίους περιλαμβά¬νεται ο επιδερμικός αυξητικός παράγοντας συνδεδεμένος με ηπαρίνη (HB-EGF) και ο αυξητικός παράγοντας των αιμοπεταλίων – CC (PDGF-CC), καθώς επίσης και συνυποδοχείς όπως η νευροπιλίνη -1 (NRP-1) οι οποίοι εμπλέκο¬νται προγνωστικά και θεραπευτικά στους ασθενείς με καρκίνο μαστού. Σκοπός της παρούσας μελέτης αποτελεί ο προσδιορισμός της έκφρασης των προαναφερθέντων αγγειογενετικών παραγόντων στη συστηματική κυκλοφορία γυναικών με πρωτοεμφανιζόμενο καρκίνο μαστού και η συσχέτιση τους με τον δείκτη μάζας σώματος (ΔΜΣ), το εμμηνορρυσιακό status, τους ιστολογικούς τύπους και τους μοριακούς υπότυπους του καρκίνου του μαστού. ΑΣΘΕΝΕΙΣ ΚΑΙ ΜΕΘΟΔΟΣ: Στη μελέτη συμπεριελήφθησαν 205 προεμμηνοπαυ-σιακές και μετεμμηνοπαυσιακές γυναίκες με πρώιμο καρκίνο του μαστού και 31 υγιείς μάρτυρες. Μετρήθηκαν τα επίπεδα έκφρασης στον ορό των αγγειογενετικών παραγόντων VEGF, HB-EGF, PDGF-CC και την NRP-1 και διερευνήθηκε η πιθανή συσχέτιση τους με κλινικές και ιστοπαθολογικές παραμέτρους. ΑΠΟΤΕΛΕΣΜΑΤΑ: Τα επίπεδα του VEGF ήταν σημαντικά υψηλότερα στις ασθενείς με διηθητικό καρκίνωμα συγκριτικά με τις ασθενείς με in situ πορογενές καρκί-νωμα. Τα επίπεδα στον ορό του PDGF-CC ήταν σημαντικά υψηλότερα στις ασθενείς με τον μοριακό υπότυπο LumB (Her2-) συγκριτικά με τις ασθενείς με τριπλά αρνητικό καρκίνο του μαστού. Επιπλέον παρατηρήθηκε διαφορετική έκφραση στα επίπεδα των περισσότερων βιοδεικτών μεταξύ υπέρβαρων/παχύσαρκων και φυσιολογικoύ βάρους ασθενών ανάμεσα στους μοριακούς υπότυπους του καρκίνου του μαστού. Τα επίπεδα στον ορό του HB-EGF, όσο αφορά τον τριπλά αρνητικό καρκίνο του μαστού ήταν σημαντικά υψηλότερα στις υπέρβαρες/παχύσαρκες ασθενείς συγκριτικά με τις ασθενείς με φυσιολογικό βάρος σώματος. ΣΥΜΠΕΡΑΣΜΑ: Τα επίπεδα των αγγειογενετικών παραγόντων στον ορό σχετίζονται με τους μοριακούς υπότυπους του καρκίνου του μαστού. Επίσης μερικοί από αυτούς τους αγγειογενετικούς παράγοντες επηρεάζονται από τον ιστολογικό τύπο, τον ΔΜΣ και το εμμηνορρυσιακό status των ασθενών με καρκίνο του μαστού. Η παρούσα μελέτη προτείνει μια πιθανή αλληλεπίδραση της παχυσαρκίας και του HB-EGF στον καρκίνο του μαστού και ειδικότερα στον τριπλά αρνητικό μοριακό υπότυπο. Περαιτέρω μελέτες θα μπορούσαν να ενισχύσουν τα ευρήματα μας και να αναδείξουν τα μόρια αυτά ως προγνωστικούς βιοδείκτες στον καρκίνο του μαστού και ιδιαίτερα στον τριπλά αρνητικό καρκίνο του μαστού

Ενδείξεις νεοεπικουρικής χημειοθεραπείας στον εξαιρέσιμο καρκίνο του παγκρέατος

Ο καρκίνος του παγκρέατος θεωρείται παγκοσμίως μία από τις πλέον θανατηφόρες μορφές καρκίνων, ενώ η 5 ετής επιβίωση παραμένει χαμηλή και ανέρχεται στο 9% για όλα τα στάδια της νόσου. Η νόσος παρουσιάζει γεωγραφική κατανομή και διακυμαίνεται μεταξύ των πληθυσμών και των φύλων. Στην αύξηση της επίπτωσης της νόσου στον γενικό πληθυσμό, πέραν από τους γενετικούς παράγοντες έχουν συμβάλλει σημαντικά η έκθεση σε διάφορους χημικούς παράγοντες, το κάπνισμα, ο σακχαρώδης διαβήτης και η παχυσαρκία. Σημαντικό ρόλο στη πρώιμη διάγνωση της νόσου διαδραματίζουν η αξονική τομογραφία και το ενδοσκοπικό υπερηχογράφημα. Όμως παρά την βελτίωση των διαγνωστικών μέσων, οι περισσότεροι ασθενείς προσέρχονται με μεταστατική νόσο παρουσιάζοντας υψηλή αντίσταση στην χημειοθεραπεία. Περίπου το 20% των ασθενών με πορογενές αδενοκαρκίνωμα παγκρέατος διαγιγνώσκεται με εξαιρέσιμη ή οριακά εξαιρέσιμη νόσο. Παρά ταύτα η μόνη θεραπευτική προσέγγιση η οποία συμβάλλει στην αύξηση της επιβίωσης αποτελεί η χειρουργική εξαίρεση, ακολουθούμενη από επικουρική χημειοθεραπεία. Βέβαια η χειρουργική εξαίρεση δεν αρκεί και γι΄αυτό απαιτείται να επιτευχθεί πλήρης εκτομή της νόσου ( R0 εκτομή ), χωρίς παρουσία μικροσκοπικής νόσου. Επίσης από το σύνολο των ασθενών που θα υποβληθούν σε παγρεατεκτομή, μόνο οι μισοί θα λάβουν επικουρική χημειοθεραπεία και σε αυτό συμβάλλει η αυξημένη επίπτωση των μετεγχειρητικών επιπλοκών. Αν και η αποδεκτή θεραπεία για τον καρκίνο του παγκρέατος είναι η χειρουργική με την εφαρμογή επικουρικής χημειοθεραπείας, τις τελευταίες δεκαετίες έχουν γίνει πολλές κλινικές μελέτες για τον έλεγχο της αποτελεσματικότητας της νεοεπικουρικής χημειοθεραπείας στον εξαιρέσιμο καρκίνο του παγκρέατος. Οι μελέτες αυτές έχουν δείξει πως με την νεοεπικουρική χημειοθεραπεία αυξάνεται ο αριθμός των ασθενών που θα επωφεληθούν από την χημειοθεραπεία προεγχειρητικά , βελτιώνεται η συνολική επιβίωση των ασθενών, αυξάνεται το ποσοστό των R0 εκτομών, γίνεται πιο αποτελεσματικά η διάχυση της χημειοθεραπείας μέσω του ακέραιου αγγειακού δικτύου, αποστειρώνεται τοπικά το χειρουργικό πεδίο προλαμβάνοντας την διασπορά της νόσου διεγχειρητικά και μειώνεται η επίπτωση του παγκρεατικού συριγγίου.Pancreatic cancer is globally considered one of the most deadly cancers, while the 5 - year survival rate remains low and achieves 9% for all stages of disease. The disease expounds geographical distribution and varies among populations and genders. Apart from the genetic factors, the exposure to chemicals, cigarette, diabetes mellitus and obesity have greatly contributed to the increase in the impact of the disease among general population. The computed tomography (CT) and endoscopic ultrasound (EUS) play an important role in the early diagnosis of the disease. However, in spite of the improvement of diagnostic imaging, most of the patients in admission have metastatic disease, presenting high resistance in cancer chemotherapy. Approximately 20% of the patients with pancreatic ductal adenocarcinoma have resectable or borderline resectable disease. Albeit the only treatment that contributes to augment survival is surgical resection followed by adjuvant chemotherapy. Certainly surgical excision is not sufficient, so it demands that a complete resection of disease (R0 resection) should be accomplished , without microscopic disease. Moreover only half of the patients who undergo pancreatectomy actually receive adjuvant chemotherapy and heightened effect of post – surgical complications contributes to this. Although the appropriate treatment for pancreatic cancer is surgical resection with adjuvant chemotherapy, during the last two decades, many clinical trials have been performed , for the assessment of the response of resectable pancreatic cancer to neoadjuvant chemotherapy. These clinical trials have shown that neoadjuvant chemotherapy can increase the number of patients who can be benefited from chemotherapy preoperatively, the overall survival of patients is improved , the percentage of R0 resections is increased , the delivery of chemotherapy becomes more effective (through intact vascular network) the surgical field is locally sterilized preventing disease’s diaspora and the incidence of pancreatic fistula is decreased