It is time to define an organizational model for the prevention and management of infections along the surgical pathway: a worldwide cross-sectional survey

Background The objectives of the study were to investigate the organizational characteristics of acute care facilities worldwide in preventing and managing infections in surgery; assess participants' perception regarding infection prevention and control (IPC) measures, antibiotic prescribing practices, and source control; describe awareness about the global burden of antimicrobial resistance (AMR) and IPC measures; and determine the role of the Coronavirus Disease 2019 pandemic on said awareness. Methods A cross-sectional web-based survey was conducted contacting 1432 health care workers (HCWs) belonging to a mailing list provided by the Global Alliance for Infections in Surgery. The self-administered questionnaire was developed by a multidisciplinary team. The survey was open from May 22, 2021, and June 22, 2021. Three reminders were sent, after 7, 14, and 21 days. Results Three hundred four respondents from 72 countries returned a questionnaire, with an overall response rate of 21.2%. Respectively, 90.4% and 68.8% of participants stated their hospital had a multidisciplinary IPC team or a multidisciplinary antimicrobial stewardship team. Local protocols for antimicrobial therapy of surgical infections and protocols for surgical antibiotic prophylaxis were present in 76.6% and 90.8% of hospitals, respectively. In 23.4% and 24.0% of hospitals no surveillance systems for surgical site infections and no monitoring systems of used antimicrobials were implemented. Patient and family involvement in IPC management was considered to be slightly or not important in their hospital by the majority of respondents (65.1%). Awareness of the global burden of AMR among HCWs was considered very important or important by 54.6% of participants. The COVID-19 pandemic was considered by 80.3% of respondents as a very important or important factor in raising HCWs awareness of the IPC programs in their hospital. Based on the survey results, the authors developed 15 statements for several questions regarding the prevention and management of infections in surgery. The statements may be the starting point for designing future evidence-based recommendations. Conclusion Adequacy of prevention and management of infections in acute care facilities depends on HCWs behaviours and on the organizational characteristics of acute health care facilities to support best practices and promote behavioural change. Patient involvement in the implementation of IPC is still little considered. A debate on how operationalising a fundamental change to IPC, from being solely the HCWs responsibility to one that involves a collaborative relationship between HCWs and patients, should be opened

It is time to define an organizational model for the prevention and management of infections along the surgical pathway : a worldwide cross-sectional survey

Background The objectives of the study were to investigate the organizational characteristics of acute care facilities worldwide in preventing and managing infections in surgery; assess participants' perception regarding infection prevention and control (IPC) measures, antibiotic prescribing practices, and source control; describe awareness about the global burden of antimicrobial resistance (AMR) and IPC measures; and determine the role of the Coronavirus Disease 2019 pandemic on said awareness. Methods A cross-sectional web-based survey was conducted contacting 1432 health care workers (HCWs) belonging to a mailing list provided by the Global Alliance for Infections in Surgery. The self-administered questionnaire was developed by a multidisciplinary team. The survey was open from May 22, 2021, and June 22, 2021. Three reminders were sent, after 7, 14, and 21 days. Results Three hundred four respondents from 72 countries returned a questionnaire, with an overall response rate of 21.2%. Respectively, 90.4% and 68.8% of participants stated their hospital had a multidisciplinary IPC team or a multidisciplinary antimicrobial stewardship team. Local protocols for antimicrobial therapy of surgical infections and protocols for surgical antibiotic prophylaxis were present in 76.6% and 90.8% of hospitals, respectively. In 23.4% and 24.0% of hospitals no surveillance systems for surgical site infections and no monitoring systems of used antimicrobials were implemented. Patient and family involvement in IPC management was considered to be slightly or not important in their hospital by the majority of respondents (65.1%). Awareness of the global burden of AMR among HCWs was considered very important or important by 54.6% of participants. The COVID-19 pandemic was considered by 80.3% of respondents as a very important or important factor in raising HCWs awareness of the IPC programs in their hospital. Based on the survey results, the authors developed 15 statements for several questions regarding the prevention and management of infections in surgery. The statements may be the starting point for designing future evidence-based recommendations. Conclusion Adequacy of prevention and management of infections in acute care facilities depends on HCWs behaviours and on the organizational characteristics of acute health care facilities to support best practices and promote behavioural change. Patient involvement in the implementation of IPC is still little considered. A debate on how operationalising a fundamental change to IPC, from being solely the HCWs responsibility to one that involves a collaborative relationship between HCWs and patients, should be opened.Peer reviewe

Correction to: Two years later: Is the SARS-CoV-2 pandemic still having an impact on emergency surgery? An international cross-sectional survey among WSES members

Background: The SARS-CoV-2 pandemic is still ongoing and a major challenge for health care services worldwide. In the first WSES COVID-19 emergency surgery survey, a strong negative impact on emergency surgery (ES) had been described already early in the pandemic situation. However, the knowledge is limited about current effects of the pandemic on patient flow through emergency rooms, daily routine and decision making in ES as well as their changes over time during the last two pandemic years. This second WSES COVID-19 emergency surgery survey investigates the impact of the SARS-CoV-2 pandemic on ES during the course of the pandemic. Methods: A web survey had been distributed to medical specialists in ES during a four-week period from January 2022, investigating the impact of the pandemic on patients and septic diseases both requiring ES, structural problems due to the pandemic and time-to-intervention in ES routine. Results: 367 collaborators from 59 countries responded to the survey. The majority indicated that the pandemic still significantly impacts on treatment and outcome of surgical emergency patients (83.1% and 78.5%, respectively). As reasons, the collaborators reported decreased case load in ES (44.7%), but patients presenting with more prolonged and severe diseases, especially concerning perforated appendicitis (62.1%) and diverticulitis (57.5%). Otherwise, approximately 50% of the participants still observe a delay in time-to-intervention in ES compared with the situation before the pandemic. Relevant causes leading to enlarged time-to-intervention in ES during the pandemic are persistent problems with in-hospital logistics, lacks in medical staff as well as operating room and intensive care capacities during the pandemic. This leads not only to the need for triage or transferring of ES patients to other hospitals, reported by 64.0% and 48.8% of the collaborators, respectively, but also to paradigm shifts in treatment modalities to non-operative approaches reported by 67.3% of the participants, especially in uncomplicated appendicitis, cholecystitis and multiple-recurrent diverticulitis. Conclusions: The SARS-CoV-2 pandemic still significantly impacts on care and outcome of patients in ES. Well-known problems with in-hospital logistics are not sufficiently resolved by now; however, medical staff shortages and reduced capacities have been dramatically aggravated over last two pandemic years

Evolving trends in the management of acute appendicitis during COVID-19 waves. The ACIE appy II study

Background: In 2020, ACIE Appy study showed that COVID-19 pandemic heavily affected the management of patients with acute appendicitis (AA) worldwide, with an increased rate of non-operative management (NOM) strategies and a trend toward open surgery due to concern of virus transmission by laparoscopy and controversial recommendations on this issue. The aim of this study was to survey again the same group of surgeons to assess if any difference in management attitudes of AA had occurred in the later stages of the outbreak. Methods: From August 15 to September 30, 2021, an online questionnaire was sent to all 709 participants of the ACIE Appy study. The questionnaire included questions on personal protective equipment (PPE), local policies and screening for SARS-CoV-2 infection, NOM, surgical approach and disease presentations in 2021. The results were compared with the results from the previous study. Results: A total of 476 answers were collected (response rate 67.1%). Screening policies were significatively improved with most patients screened regardless of symptoms (89.5% vs. 37.4%) with PCR and antigenic test as the preferred test (74.1% vs. 26.3%). More patients tested positive before surgery and commercial systems were the preferred ones to filter smoke plumes during laparoscopy. Laparoscopic appendicectomy was the first option in the treatment of AA, with a declined use of NOM. Conclusion: Management of AA has improved in the last waves of pandemic. Increased evidence regarding SARS-COV-2 infection along with a timely healthcare systems response has been translated into tailored attitudes and a better care for patients with AA worldwide

Goodbye Hartmann trial: a prospective, international, multicenter, observational study on the current use of a surgical procedure developed a century ago

Background: Literature suggests colonic resection and primary anastomosis (RPA) instead of Hartmann's procedure (HP) for the treatment of left-sided colonic emergencies. We aim to evaluate the surgical options globally used to treat patients with acute left-sided colonic emergencies and the factors that leading to the choice of treatment, comparing HP and RPA. Methods: This is a prospective, international, multicenter, observational study registered on ClinicalTrials.gov. A total 1215 patients with left-sided colonic emergencies who required surgery were included from 204 centers during the period of March 1, 2020, to May 31, 2020. with a 1-year follow-up. Results: 564 patients (43.1%) were females. The mean age was 65.9 ± 15.6 years. HP was performed in 697 (57.3%) patients and RPA in 384 (31.6%) cases. Complicated acute diverticulitis was the most common cause of left-sided colonic emergencies (40.2%), followed by colorectal malignancy (36.6%). Severe complications (Clavien-Dindo ≥ 3b) were higher in the HP group (P < 0.001). 30-day mortality was higher in HP patients (13.7%), especially in case of bowel perforation and diffused peritonitis. 1-year follow-up showed no differences on ostomy reversal rate between HP and RPA. (P = 0.127). A backward likelihood logistic regression model showed that RPA was preferred in younger patients, having low ASA score (≤ 3), in case of large bowel obstruction, absence of colonic ischemia, longer time from admission to surgery, operating early at the day working hours, by a surgeon who performed more than 50 colorectal resections. Conclusions: After 100 years since the first Hartmann's procedure, HP remains the most common treatment for left-sided colorectal emergencies. Treatment's choice depends on patient characteristics, the time of surgery and the experience of the surgeon. RPA should be considered as the gold standard for surgery, with HP being an exception

Infected pancreatic necrosis: outcomes and clinical predictors of mortality. A post hoc analysis of the MANCTRA-1 international study

: The identification of high-risk patients in the early stages of infected pancreatic necrosis (IPN) is critical, because it could help the clinicians to adopt more effective management strategies. We conducted a post hoc analysis of the MANCTRA-1 international study to assess the association between clinical risk factors and mortality among adult patients with IPN. Univariable and multivariable logistic regression models were used to identify prognostic factors of mortality. We identified 247 consecutive patients with IPN hospitalised between January 2019 and December 2020. History of uncontrolled arterial hypertension (p = 0.032; 95% CI 1.135-15.882; aOR 4.245), qSOFA (p = 0.005; 95% CI 1.359-5.879; aOR 2.828), renal failure (p = 0.022; 95% CI 1.138-5.442; aOR 2.489), and haemodynamic failure (p = 0.018; 95% CI 1.184-5.978; aOR 2.661), were identified as independent predictors of mortality in IPN patients. Cholangitis (p = 0.003; 95% CI 1.598-9.930; aOR 3.983), abdominal compartment syndrome (p = 0.032; 95% CI 1.090-6.967; aOR 2.735), and gastrointestinal/intra-abdominal bleeding (p = 0.009; 95% CI 1.286-5.712; aOR 2.710) were independently associated with the risk of mortality. Upfront open surgical necrosectomy was strongly associated with the risk of mortality (p < 0.001; 95% CI 1.912-7.442; aOR 3.772), whereas endoscopic drainage of pancreatic necrosis (p = 0.018; 95% CI 0.138-0.834; aOR 0.339) and enteral nutrition (p = 0.003; 95% CI 0.143-0.716; aOR 0.320) were found as protective factors. Organ failure, acute cholangitis, and upfront open surgical necrosectomy were the most significant predictors of mortality. Our study confirmed that, even in a subgroup of particularly ill patients such as those with IPN, upfront open surgery should be avoided as much as possible. Study protocol registered in ClinicalTrials.Gov (I.D. Number NCT04747990)

Global disparities in surgeons’ workloads, academic engagement and rest periods: the on-calL shIft fOr geNEral SurgeonS (LIONESS) study

: The workload of general surgeons is multifaceted, encompassing not only surgical procedures but also a myriad of other responsibilities. From April to May 2023, we conducted a CHERRIES-compliant internet-based survey analyzing clinical practice, academic engagement, and post-on-call rest. The questionnaire featured six sections with 35 questions. Statistical analysis used Chi-square tests, ANOVA, and logistic regression (SPSS® v. 28). The survey received a total of 1.046 responses (65.4%). Over 78.0% of responders came from Europe, 65.1% came from a general surgery unit; 92.8% of European and 87.5% of North American respondents were involved in research, compared to 71.7% in Africa. Europe led in publishing research studies (6.6 ± 8.6 yearly). Teaching involvement was high in North America (100%) and Africa (91.7%). Surgeons reported an average of 6.7 ± 4.9 on-call shifts per month, with European and North American surgeons experiencing 6.5 ± 4.9 and 7.8 ± 4.1 on-calls monthly, respectively. African surgeons had the highest on-call frequency (8.7 ± 6.1). Post-on-call, only 35.1% of respondents received a day off. Europeans were most likely (40%) to have a day off, while African surgeons were least likely (6.7%). On the adjusted multivariable analysis HDI (Human Development Index) (aOR 1.993) hospital capacity > 400 beds (aOR 2.423), working in a specialty surgery unit (aOR 2.087), and making the on-call in-house (aOR 5.446), significantly predicted the likelihood of having a day off after an on-call shift. Our study revealed critical insights into the disparities in workload, access to research, and professional opportunities for surgeons across different continents, underscored by the HDI

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Πολυμορφισμοί και έκφραση μεγάλων μη κωδικών RNAs στον οισοφαγικό καρκίνο

Background: Long non-coding RNAs’ HOTAIR rs920778, LINC00951 rs11752942, POLR2E rs3787016, and HULC rs7763881 are progressively reported having a close genetic affinity with esophageal carcinogenesis in the East. Nonetheless, their incidence and malignant potential has only been sparsely investigated in the west. Their correlation with variables already endorsed as significant prognostic factors in terms of staging, guiding treatment and predicting recurrence, metastasis, and survival have also yet to be explored. Aim of the Study: To explore their contribution in esophageal cancer susceptibility and investigate their prognostic value by correlating with clinicopathological and laboratory prognostic markers in esophageal cancer in the West. Materials/Methods: Formalin-fixed paraffin-embedded tissue specimens from 95 consecutive patients operated for esophageal/esophagogastric junction carcinoma during 25/03/2014-25/09/2018 were compared with 121 healthy community controls. Both populations were of European/Greek ancestry. Results: HULC rs7763881 was not detected differently in any of the cancer prognostic subgroups. LINC00951 rs11752942 GG variant was significantly underrepresented in Ca19.9 elevated subgroup. A significantly higher presence of HOTAIR rs920778 TT genotype in esophagogastric junction Siewert I/II adenocarcinoma was demonstrated. HOTAIR TT and T genotypes were significantly associated with prognostic factors as G differentiation grade and SRC status, whereas CT and T genotypes with Ca19.9 elevated patient subgroup. POLR2E rs3787016 C allele and CC genotypes were overrepresented in the control group, and when found in esophageal cancer carriers were associated with earlier disease stages, as well as with minor lymph node involvement and lesser metastatic potential. POLR2E CC and C genotypes were also significantly correlated with histological subtypes such as ESCC, EAC, SRC and Diffuse, as well as with prognostic variables in the form of PNI, LVI, and PVI, whereas CT variant was associated with CEA. Conclusions: LncRNAs’ LINC00951, HOTAIR and POLR2E polymorphisms may genetically influence and as such, may explain a fraction of EC and EAC molecular basis. Therefore, they may hold great potential not only as future therapeutic agents but also as novel markers for predictive analysis of esophageal cancer risk clinical outcome, and survival. Implementation of these genetic models as part of the clinical and pathological risk-assessment process may add to the efficiency and efficacy of the current utilized prognostic models. Prospective multicenter studies with larger sample-size are required to validate these findings.Εισαγωγή: Τα μακρά μη κωδικοποιητικά RNAs και οι πολυμορφισμοί τους HOTAIR rs920778, LINC00951 rs11752942, POLR2E rs3787016 και HULC rs7763881 φαίνεται ότι έχουν στενή γενετική συγγένεια με τη γένεση οισοφαγικού καρκίνου στην Ανατολή. Ωστόσο, η συχνότητα εμφάνισης και το κακόηθες δυναμικό τους έχει σπάνια ερευνηθεί στη Δύση, όπως επίσης και η συσχέτισή τους με μεταβλητές που θεωρούνται σημαντικοί προγνωστικοί παράγοντες όσον αφορά τη σταδιοποίηση, καθοδήγηση της θεραπείας και την πρόβλεψη της υποτροπής, μετάστασης και επιβίωσης. Σκοπός: Η διερεύνηση πιθανής συμβολής τους στον οισοφαγικό καρκίνο, καθώς και της προγνωστικής τους αξίας μέσω συσχέτισης με κλινικοπαθολογικούς και εργαστηριακούς προγνωστικούς δείκτες. Υλικό/Μέθοδος: Δείγματα ιστού έγκλειστου σε παραφίνη από 95 διαδοχικούς ασθενείς που χειρουργήθηκαν για καρκίνωμα οισοφάγου/οισοφαγογαστρικής συμβολής κατά την περίοδο 25/03/2014-25/09/2018 συγκρίθηκαν με 121 υγιούς μάρτυρες κοινότητας. Και οι δύο πληθυσμοί ήταν ευρωπαϊκής/ελληνικής καταγωγής. Αποτελέσματα: Το HULC rs7763881 δεν ανιχνεύθηκε διαφορετικά σε καμία από τις προγνωστικές υποομάδες καρκίνου. Ο LINC00951 rs11752942 GG γονότυπος βρέθηκε στατιστικώς σημαντικά χαμηλός στην αυξημένη Ca19.9 υποομάδα. Στατιστικώς σημαντικά υψηλότερη παρουσία του ΤΤ γονότυπου του HOTAIR rs920778 αναδείχθη στο αδενοκαρκίνωμα Siewert I/II οισοφαγογαστρικής συμβολής, ενώ οι γονότυποι TT και T συσχετίστηκαν στατιστικώς σημαντικά με προγνωστικούς παράγοντες όπως ο βαθμός διαφοροποίησης G και το SRC, ενώ οι γονότυποι CT και T με την υποομάδα ασθενών αυξημένου Ca19.9 αντιστοίχως. Οι γονότυποι C και CC του POLR2E rs3787016 είχαν αυξημένη συχνότητα στην ομάδα ελέγχου, ενώ όταν βρέθηκαν σε φορείς καρκίνου συσχετίστηκαν με μικρότερα στάδια της νόσου, καθώς και μικρότερη λεμφαδενική διήθηση και μεταστατικό δυναμικό, αλλά και συσχετίστηκαν επίσης στατιστικώς σημαντικά με ιστολογικούς υπότυπους όπως οι ESCC, EAC, SRC και Diffuse, καθώς και με προγνωστικές μεταβλητές όπως τα PNI, LVI και PVI, ενώ ο γονότυπος CT συσχετίστηκε στατιστικώς σημαντικά με το CEA. Συμπεράσματα: Οι lncRNAs πολυμορφισμοί LINC00951, HOTAIR και POLR2E μπορεί να επηρεάσουν γενετικά και κατά συνέπεια να εξηγήσουν ένα τμήμα του μοριακού υπόβαθρου του οισοφαγικού καρκίνου. Μπορούν επομένως δυνητικά να εξελιχθούν σε μελλοντικούς θεραπευτικούς στόχους αλλά και σε βιοδείκτες προγνωστικής ανάλυσης της κλινικής πορείας και έκβασης του οισοφαγικού καρκίνου. Η εφαρμογή αυτών των γενετικών μοντέλων ως μέρος της κλινικής και τελικής ιστοπαθολογικής διαδικασίας σταδιοποίησης μπορεί να αυξήσει την αποτελεσματικότητα των τρέχοντων χρησιμοποιούμενων προγνωστικών μοντέλων αξιολόγησης και εκτίμησης κινδύνου στον οισοφαγικό καρκίνο. Απαιτούνται προοπτικές πολυκεντρικές μελέτες με μεγαλύτερο μέγεθος δείγματος για την επικύρωση των ευρημάτων της παρούσας αυτής ερευνητικής μελέτης

An extraordinary rare anastomotic band causing food bolus obstruction following uneventful minimally invasive esophagectomy: endoscopic treatment

The most common long-term complication post esophagectomy implicating the esophagogastric anastomosis is stricture-induced stenosis leading to late postoperative dysphagia. Herein, we present a case of a male patient readmitted to our Upper Gastrointestinal Department due to a food bolus obstruction through an anastomotic epithelial band arisen from a prior esophagogastric anastomosis performed 5 months earlier. A band transection in between two hemostatic clips placed on both sides of the band, followed by a release and fragmentation of the foreign body into several pieces led to its final transoral removal endoscopically. The patient experienced a direct resolution of his dysphagia and discharged on the same day. At 6 months follow-up, he remains symptom-free. In conclusion, endoscopic state-of-the-art techniques when combined with standard hemostatic surgical principles in a minimally invasive manner are excellent tools for the management of post-esophagectomy syndromes