Laparoscopic treatment for perforated duodenal ulcer

Clinica de Chirurgie 2, UMF “Victor Babeș” Timișoara, Clinica de Chirurgie, UMF ”Carol Davila”, București, Clinica de Chirurgie 2, UMF ”Grigore T Popa”, Iași, Clinica de Chirurgie 2, Facultatea de Medicină, Universitatea ”Ovidius”, Constanța, Clinica de Chirurgie 2, Facultatea de Medicina, Sibiu, Clinica de Chirurgie 1, UMF ”Iuliu Hațieganu”, Cluj- Napoca, Departamentul de Chirurgie I, Facultatea de Medicină, UMF Craiova, România, Al XII-lea Congres al Asociației Chirurgilor „Nicolae Anestiadi” din Republica Moldova cu participare internațională 23-25 septembrie 2015Introducere: Acest studiu retrospectiv evaluează rezultatele tratamentului laparoscopic în ulcerul duodenal perforat și este realizat în 7 spitale cu experiență în chirurgia laparoscopica din România. Material și metode: Între anii 2006 și 2013, 297 pacienți (48 femei, 249 bărbați) cu vârste cuprinse între 18 și 77 ani au fost supuși intervenției chirurgicale laparoscopice pentru ulcer duodenal perforat, cu utilizarea a 3 (61%), 4 (29%) sau 5 (10%) trocare. Șaizeci și doi (21%) dintre pacienți au prezentat o formă ușoară, 190 (64,1%) au prezentat o formă moderată și 45 (14,9%) o formă severă de peritonită. Procedurile utilizate au fost: sutura simplă – 118 (39,8%) pacienți, sutura cu epiplonoplastie – 176 (59,5%), doar epiplonoplastie – 1 (0,3%) pacient, excizie și sutură – 1 (0,3%) pacient. Rezultate: Durata intervențiilor a fost între 30 și 120 minute, cu o medie de 65 minute. Mortalitatea a fost nulă. Complicații: infecții parietale – 3 (1%), fistule duodenale – 3 (1%), abcese abdominale – 2 (0,6%), hemoragii digestive – 1 (0,3%) și stenoza duodenală – 1 (0,3%). Durata medie de spitalizare – 5,5 zile. În comparație cu tehnica clasica, pacienții au necesitat mai puține analgetice și antibiotice, cu 80% mai puține pansamente și au avut cu 70% mai puține infecții parietale în evoluția postoperatorie. Concluzii: Tratamentul laparoscopic pentru ulcerul duodenal perforat, este recomandat chiar și în cazurile cu peritonită severă, evoluția postoperatorie fiind cu mai puține complicații și cu o recuperare mai rapidă fața de procedura clasică. Aceast abord poate fi considerat “standard de aur” în tratamentul ulcerului duodenal perforat.Introduction: This retrospective study evaluates results of the laparoscopic treatment of perforated duodenal ulcer obtained in 7 centers with experience in laparoscopic surgery from Romania. Material and methods: A total of 297 (48 women and 249 men) patients with perforated duodenal ulcer underwent laparoscopic intervention between 2006 and 2013, with ages 18 to 77 years. Three (61%), 4 (29%) or 5 (10%) trocars were used. In 62 patients (21%) was diagnosed mild form of peritonitis, in 190 (64.1%) – moderate and in 45 (14.9%) – severe peritonitis. Types of repair used in this study: simple suture – 118 (39.8%) patients, suture with omental patch – 176 (59.5%), only sutured omental patch – 1 (0.3%), excision and suture – 1 (0.3%) patient. Results: Operation time was between 30 and 120 min, with average of 65 min. Mortality rate was zero. Complications: parietal infections – 3 (1%), duodenal fistula – 3 (1%), intraabdominal abscesses – 2 (0.6%), digestive bleeding – 1 (0.3%) and duodenal stenosis – 1 (0.3%). Average length of hospital stay – 5.5 days. Patients treated using laparoscopic technique needed less analgesics, antibiotics, 80% less dressing procedures and had 70% less surgical site infections in comparison to traditional operation. Conclusions: Laparoscopic treatment of perforated duodenal ulcer can be recommended even for patients with severe peritonitis. This treatment is associated with fewer complications and more rapid recovery than traditional intervention. Laparoscopic repair can be considered “gold standard” in the treatment of perforated duodenal ulcer

Postoperative outcomes in oesophagectomy with trainee involvement

BACKGROUND: The complexity of oesophageal surgery and the significant risk of morbidity necessitates that oesophagectomy is predominantly performed by a consultant surgeon, or a senior trainee under their supervision. The aim of this study was to determine the impact of trainee involvement in oesophagectomy on postoperative outcomes in an international multicentre setting. METHODS: Data from the multicentre Oesophago-Gastric Anastomosis Study Group (OGAA) cohort study were analysed, which comprised prospectively collected data from patients undergoing oesophagectomy for oesophageal cancer between April 2018 and December 2018. Procedures were grouped by the level of trainee involvement, and univariable and multivariable analyses were performed to compare patient outcomes across groups. RESULTS: Of 2232 oesophagectomies from 137 centres in 41 countries, trainees were involved in 29.1 per cent of them (n = 650), performing only the abdominal phase in 230, only the chest and/or neck phases in 130, and all phases in 315 procedures. For procedures with a chest anastomosis, those with trainee involvement had similar 90-day mortality, complication and reoperation rates to consultant-performed oesophagectomies (P = 0.451, P = 0.318, and P = 0.382, respectively), while anastomotic leak rates were significantly lower in the trainee groups (P = 0.030). Procedures with a neck anastomosis had equivalent complication, anastomotic leak, and reoperation rates (P = 0.150, P = 0.430, and P = 0.632, respectively) in trainee-involved versus consultant-performed oesophagectomies, with significantly lower 90-day mortality in the trainee groups (P = 0.005). CONCLUSION: Trainee involvement was not found to be associated with significantly inferior postoperative outcomes for selected patients undergoing oesophagectomy. The results support continued supervised trainee involvement in oesophageal cancer surgery

Association of mechanical bowel preparation with oral antibiotics and anastomotic leak following left sided colorectal resection:an international, multi-centre, prospective audit

Introduction: The optimal bowel preparation strategy to minimise the risk of anastomotic leak is yet to be determined. This study aimed to determine whether oral antibiotics combined with mechanical bowel preparation (MBP+Abx) was associated with a reduced risk of anastomotic leak when compared to mechanical bowel preparation alone (MBP) or no bowel preparation (NBP). Methods: A pre-planned analysis of the European Society of Coloproctology (ESCP) 2017 Left Sided Colorectal Resection audit was performed. Patients undergoing elective left sided colonic or rectal resection with primary anastomosis between 1 January 2017 and 15 March 2017 by any operative approach were included. The primary outcome measure was anastomotic leak. Results: Of 3676 patients across 343 centres in 47 countries, 618 (16.8%) received MBP+ABx, 1945 MBP (52.9%) and 1099 patients NBP (29.9%). Patients undergoing MBP+ABx had the lowest overall rate of anastomotic leak (6.1%, 9.2%, 8.7% respectively) in unadjusted analysis. After case-mix adjustment using a mixed-effects multivariable regression model, MBP+Abx was associated with a lower risk of anastomotic leak (OR 0.52, 0.30–0.92, P = 0.02) but MBP was not (OR 0.92, 0.63–1.36, P = 0.69) compared to NBP. Conclusion: This non-randomised study adds ‘real-world’, contemporaneous, and prospective evidence of the beneficial effects of combined mechanical bowel preparation and oral antibiotics in the prevention of anastomotic leak following left sided colorectal resection across diverse settings. We have also demonstrated limited uptake of this strategy in current international colorectal practice

Evaluating the incidence of pathological complete response in current international rectal cancer practice

The mainstay of management for locally advanced rectal cancer is chemoradiotherapy followed by surgical resection. Following chemoradiotherapy, a complete response may be detected clinically and radiologically (cCR) prior to surgery or pathologically after surgery (pCR). We aim to report the overall complete pathological response (pCR) rate and the reliability of detecting a cCR by conventional pre-operative imaging.A pre-planned analysis of the European Society of Coloproctology (ESCP) 2017 audit was performed. Patients treated by elective rectal resection were included. A pCR was defined as a ypT0 N0 EMVI negative primary tumour; a partial response represented any regression from baseline staging following chemoradiotherapy. The primary endpoint was the pCR rate. The secondary endpoint was agreement between post-treatment MRI restaging (yMRI) and final pathological staging.Of 2572 patients undergoing rectal cancer surgery in 277 participating centres across 44 countries, 673 (26.2%) underwent chemoradiotherapy and surgery. The pCR rate was 10.3% (67/649), with a partial response in 35.9% (233/649) patients. Comparison of AJCC stage determined by post-treatment yMRI with final pathology showed understaging in 13% (55/429) and overstaging in 34% (148/429). Agreement between yMRI and final pathology for T-stage, N-stage, or AJCC status were each graded as 'fair' only (n = 429, Kappa 0.25, 0.26 and 0.35 respectively).The reported pCR rate of 10% highlights the potential for non-operative management in selected cases. The limited strength of agreement between basic conventional post-chemoradiotherapy imaging assessment techniques and pathology suggest alternative markers of response should be considered, in the context of controlled clinical trials