Percutaneous management of acute necrotizing pancreatitis

OBJECTIVES: The study aims to evaluate the efficacy of percutaneous necrosectomy (PN) performed under ultrasound control and of endoscopic necrosectomy through secondary sinus track (ENTSST) using nephroscope and cystoscope.MATERIAL AND METHOD: Puncture of fluid collections in the pancreas was performed under ultrasonographic control to 23 patients with acute necrotizing pancreatitis (ANP). ENTSST using nephroscope and cystoscope was performed to 47 patients after open or percutaneous necrosectomy and persistent sepsis (without satellite collection of CT).RESULTS: Seventeen patients (74%) treated with percutaneous necrosectomy recovered without open surgery. Two of this group died. The average hospital stay was 42 days. Twenty-three patients required an average of two (range 1-4) ENTSST.CONCLUSIONS: Based on our initial results we believe that the percutaneous necrosectomy and ENTSST in well selected patients might be the better choice than open necrosectomy and postoperative lavage. Common solution for these methods has not been reached yet

An international assessment of the adoption of enhanced recovery after surgery (ERAS (R)) principles across colorectal units in 2019-2020

Aim The Enhanced Recovery After Surgery (ERAS (R)) Society guidelines aim to standardize perioperative care in colorectal surgery via 25 principles. We aimed to assess the variation in uptake of these principles across an international network of colorectal units. Method An online survey was circulated amongst European Society of Coloproctology members in 2019-2020. For each ERAS principle, respondents were asked to score how frequently the principle was implemented in their hospital, from 1 ('rarely') to 4 ('always'). Respondents were also asked to recall whether practice had changed since 2017. Subgroup analyses based on hospital characteristics were conducted. Results Of hospitals approached, 58% responded to the survey (195/335), with 296 individual responses (multiple responses were received from some hospitals). The majority were European (163/195, 83.6%). Overall, respondents indicated they 'most often' or 'always' adhered to most individual ERAS principles (18/25, 72%). Variability in the uptake of principles was reported, with universal uptake of some principles (e.g., prophylactic antibiotics; early mobilization) and inconsistency from 'rarely' to 'always' in others (e.g., no nasogastric intubation; no preoperative fasting and carbohydrate drinks). In alignment with 2018 ERAS guideline updates, adherence to principles for prehabilitation, managing anaemia and postoperative nutrition appears to have increased since 2017. Conclusions Uptake of ERAS principles varied across hospitals, and not all 25 principles were equally adhered to. Whilst some principles exhibited a high level of acceptance, others had a wide variability in uptake indicative of controversy or barriers to uptake. Further research into specific principles is required to improve ERAS implementation

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)

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

Background Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide.Methods A multimethods analysis was performed as part of the GlobalSurg 3 study-a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital.Findings Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3.85 [95% CI 2.58-5.75]; p<0.0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63.0% vs 82.7%; OR 0.35 [0.23-0.53]; p<0.0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer.Interpretation Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised

Recurrent pilonidal disease - individualization and pathogenesis-oriented surgery

INTRODUCTIONRecurrence after pilonidal disease surgery are common and difficult to treat. Many options are proposed including cleft lift procedure, Karydakis flap and advanced flaps. The aim of the study is to present and analyze our experience with individualized pathogenesis-based surgery of recurrent pilonidal disease. METHODSFor a 10-year period (2009-2019) patients with recurrent pilonidal disease were operated by authors. RESULTSThe healing time in 60 patients was 14-40 days. 22 patients had concomitant hidradenitis suppurativa in gluteal and/or inguinal regions. In 51 patients modified Karydakis operation was performed. In 9 patients complex advanced flaps were used. General or spinal anesthesia is used. In all patients perioperative antibiotics were administered and closed suction drains were used. Major complications occurred in 7 patients – 3 postoperative hematoma formation and 4 partial wound dehiscence managed conservatively. All patients are recurrence free. CONCLUSIONThe main issues in surgery of recurrent pilonidal disease is to avoid repeated procedures, to prevent new recurrence and to have acceptable functional and cosmetic results. Radical surgery with individualization following principles of cleft lift and avoiding of midline suture lines leads to best results and patient satisfaction. According to our experience and literature, we propose tailored radical surgical treatment of recurrent pilonidal disease:(1) recurrence after primary midline closure or pit piking (Bascom 1), or multiple incisions with midline sinus tract or wound with limited lateral extension – Bascom cleft lift procedure or modified Karydakis flap; (2) recurrence after lay open techniques – Karydakis or advanced flap; (3) recurrence with gluteal extension or combination with hidradenitis suppurativa – advanced flap with avoiding of midline suture line - “modified cleft lift”. &nbsp

A case of sclerosing mesenteritis mimic mesenteric tumour with small bowel obstruction. a difficult diagnosis

Sclerosing mesenteritis is a rare medical condition, affecting radix mesenterii. Its initial clinical appearance is very atypical. Pathological finding was non-specific and in most cases is associated with inflammatory process. Currently there is no imaging method confirming the diagnosis, which requires in most patients to make laparotomy with biopsy from the changed tissue. At least six months of conservative therapy are needed for the patient to become asymptomatic. The material presents our experience with a patient and brief literature review. Scripta Scientifica Medica 2010;42(2):101-10

Surgical Treatment of Pancreatic Pseudocysts - Indications and Choice Between a Drainage Procedure and Pancreatic Resection

Introduction: Pancreatic pseudocysts mostly occur as a consequence of acute pancreatitis. However, they can also occur in the setting of chronic pancreatitis, postoperatively, or after a pancreatic trauma. Pseudocysts may be asymptomatic or may present with a variety of symptoms such as pain, satiety, nausea and vomiting, upper gastrointestinal bleeding, etc. In 33% of the cases, pancreatic pseudocysts disappear spontaneously. Most of the persistent pseudocysts require treatment because of the occurrence of symptoms, increase in size, and the impossibility for the differentiation of the malignant process or due to the development of complications (bleeding, hemorrhage, rupture or compression of the stomach, duodenum or bile ducts). Aim: The aim of this paper is to investigate the experience of the Clinic in the treatment of pancreatic pseudocysts and to determine, on this basis, the indications for surgery and the factors influencing the choice of a specific surgical strategy. Materials and Methods: In KOCHPH, University Hospital `Alexandrovska`, a retrospective study was carried out. It covered the period 1999 - 2015 and included 213 patients who underwent surgery for pancreatic pseudocysts. Clinicopathological material (size, number and arrangement of pseudocysts, type and duration of the symptoms, data from the imaging tests and type of applied treatment) was analyzed by various statistical methods using SPSS-19. Results: 36 pancreatocystogastrostomies, 28 pancreatocystojejunostomies, 21 pancreatocystoduodenostomies, and 3 pancreatowirsungojejunostomies were performed. External drainage was carried out in 33 patients. The applied resections were: 44 distal pancreatic resections, 6 pancreatoduodenectomies, 9 cystic extirpations, and 8 cystoresections. In some cases, combined surgical procedures were performed. Conclusions: Surgery remains the primary method of choice in the treatment of pancreatic pseudocysts with a high success rate - in 91-100% of cases. The choice of a particular surgical strategy depends on the location, number and size of the pseudocysts, presence and type of complications, and the stated changes in the area of the pancreas, as well as the relations with the surrounding tissues and organs. Therefore, the precise diagnostic process and individualized approach to treatment are the basis for achieving optimal and lasting postoperative results

Gastrointestinal Stromal Tumors of Pancreas and Duodenum - Challenges in Their Diagnosis and Surgical Treatment

Introduction: Although gastrointestinal stromal tumors (GIST) are the most common mesenchymal tumors of the gastrointestinal tract, they constitute less than 1% of all cancers of the digestive tube. Only 4-5% of these are located in the duodenum and GISTs in the pancreas, omentum and retroperitoneum are extremely rare. Diagnosis of pancreatic or duodenal GIST is often difficult because formation resembles pancreatic cancer clinically or on the imaging tests.Aim: The aim of this paper is to make a detailed review of the literature regarding the surgical treatment of duodenal and pancreatic GISTs and to present the observed cases in our practice comparing them with the patients with other locations of the process. Materials and Methods: A retrospective study covering the period 2005 - 2015 was carried out in the University Hospital `Alexandrovska`. It included 50 patients who underwent surgery for GIST. Two of patients were diagnosed with duodenal GIST, and in one case - GIST arising from the left pancreas was found. In cases with a pancreatic tumor location, a distal pancreatectomy with splenectomy was performed. A partial resection of the duodenum and a pancreatoduodenectomy were carried out respectively, in the cases of duodenal GIST. Literature review was made on the basis of recent publications referenced in Medline, PubMed and Google scholar. Results and Conclusions: GISTs, and in particular those with pancreatic and duodenal localization, may have varying malignant potential. Surgical removal of the tumor in clear resection margins is the only method providing a cure. Sometimes, this can be achieved through a relatively limited resection in tight. In most cases, however, a pancreatoduodenectomy needs to be done given the mistaken interpretation of the tumor as pancreatic cancer and due to the anatomical connection between the pancreas, the duodenum, and the bile ducts

Patients with Crohn's disease have longer post-operative in-hospital stay than patients with colon cancer but no difference in complications' rate

BACKGROUNDRight hemicolectomy or ileocecal resection are used to treat benign conditions like Crohn's disease (CD) and malignant ones like colon cancer (CC).AIMTo investigate differences in pre- and peri-operative factors and their impact on post-operative outcome in patients with CC and CD.METHODSThis is a sub-group analysis of the European Society of Coloproctology's prospective, multi-centre snapshot audit. Adult patients with CC and CD undergoing right hemicolectomy or ileocecal resection were included. Primary outcome measure was 30-d post-operative complications. Secondary outcome measures were post-operative length of stay (LOS) at and readmission.RESULTSThree hundred and seventy-five patients with CD and 2,515 patients with CC were included. Patients with CD were younger (median = 37 years for CD and 71 years for CC (P < 0.01), had lower American Society of Anesthesiology score (ASA) grade (P < 0.01) and less comorbidity (P < 0.01), but were more likely to be current smokers (P < 0.01). Patients with CD were more frequently operated on by colorectal surgeons (P < 0.01) and frequently underwent ileocecal resection (P < 0.01) with higher rate of de-functioning/primary stoma construction (P < 0.01). Thirty-day post-operative mortality occurred exclusively in the CC group (66/2515, 2.3%). In multivariate analyses, the risk of post-operative complications was similar in the two groups (OR 0.80, 95%CI: 0.54-1.17; P = 0.25). Patients with CD had a significantly longer LOS (Geometric mean 0.87, 95%CI: 0.79-0.95; P < 0.01). There was no difference in re-admission rates. The audit did not collect data on post-operative enhanced recovery protocols that are implemented in the different participating centers.CONCLUSIONPatients with CD were younger, with lower ASA grade, less comorbidity, operated on by experienced surgeons and underwent less radical resection but had a longer LOS than patients with CC although complication's rate was not different between the two groups