Elective cancer surgery in COVID-19-free surgical pathways during the SARS-CoV-2 pandemic: An international, multicenter, comparative cohort study

PURPOSE As cancer surgery restarts after the first COVID-19 wave, health care providers urgently require data to determine where elective surgery is best performed. This study aimed to determine whether COVID-19–free surgical pathways were associated with lower postoperative pulmonary complication rates compared with hospitals with no defined pathway. PATIENTS AND METHODS This international, multicenter cohort study included patients who underwent elective surgery for 10 solid cancer types without preoperative suspicion of SARS-CoV-2. Participating hospitals included patients from local emergence of SARS-CoV-2 until April 19, 2020. At the time of surgery, hospitals were defined as having a COVID-19–free surgical pathway (complete segregation of the operating theater, critical care, and inpatient ward areas) or no defined pathway (incomplete or no segregation, areas shared with patients with COVID-19). The primary outcome was 30-day postoperative pulmonary complications (pneumonia, acute respiratory distress syndrome, unexpected ventilation). RESULTS Of 9,171 patients from 447 hospitals in 55 countries, 2,481 were operated on in COVID-19–free surgical pathways. Patients who underwent surgery within COVID-19–free surgical pathways were younger with fewer comorbidities than those in hospitals with no defined pathway but with similar proportions of major surgery. After adjustment, pulmonary complication rates were lower with COVID-19–free surgical pathways (2.2% v 4.9%; adjusted odds ratio [aOR], 0.62; 95% CI, 0.44 to 0.86). This was consistent in sensitivity analyses for low-risk patients (American Society of Anesthesiologists grade 1/2), propensity score–matched models, and patients with negative SARS-CoV-2 preoperative tests. The postoperative SARS-CoV-2 infection rate was also lower in COVID-19–free surgical pathways (2.1% v 3.6%; aOR, 0.53; 95% CI, 0.36 to 0.76). CONCLUSION Within available resources, dedicated COVID-19–free surgical pathways should be established to provide safe elective cancer surgery during current and before future SARS-CoV-2 outbreaks

Elective Cancer Surgery in COVID-19-Free Surgical Pathways During the SARS-CoV-2 Pandemic: An International, Multicenter, Comparative Cohort Study.

PURPOSE: As cancer surgery restarts after the first COVID-19 wave, health care providers urgently require data to determine where elective surgery is best performed. This study aimed to determine whether COVID-19-free surgical pathways were associated with lower postoperative pulmonary complication rates compared with hospitals with no defined pathway. PATIENTS AND METHODS: This international, multicenter cohort study included patients who underwent elective surgery for 10 solid cancer types without preoperative suspicion of SARS-CoV-2. Participating hospitals included patients from local emergence of SARS-CoV-2 until April 19, 2020. At the time of surgery, hospitals were defined as having a COVID-19-free surgical pathway (complete segregation of the operating theater, critical care, and inpatient ward areas) or no defined pathway (incomplete or no segregation, areas shared with patients with COVID-19). The primary outcome was 30-day postoperative pulmonary complications (pneumonia, acute respiratory distress syndrome, unexpected ventilation). RESULTS: Of 9,171 patients from 447 hospitals in 55 countries, 2,481 were operated on in COVID-19-free surgical pathways. Patients who underwent surgery within COVID-19-free surgical pathways were younger with fewer comorbidities than those in hospitals with no defined pathway but with similar proportions of major surgery. After adjustment, pulmonary complication rates were lower with COVID-19-free surgical pathways (2.2% v 4.9%; adjusted odds ratio [aOR], 0.62; 95% CI, 0.44 to 0.86). This was consistent in sensitivity analyses for low-risk patients (American Society of Anesthesiologists grade 1/2), propensity score-matched models, and patients with negative SARS-CoV-2 preoperative tests. The postoperative SARS-CoV-2 infection rate was also lower in COVID-19-free surgical pathways (2.1% v 3.6%; aOR, 0.53; 95% CI, 0.36 to 0.76). CONCLUSION: Within available resources, dedicated COVID-19-free surgical pathways should be established to provide safe elective cancer surgery during current and before future SARS-CoV-2 outbreaks

A Tailored Approach to the Management of Perforations Following Endoscopic Retrograde Cholangiopancreatography and Sphincterotomy

Background: The management of endoscopic retrograde cholangiopancreatography (ERCP)-related perforations remains controversial. The aim of the study was to determine the incidence of perforations following ERCP, their characteristics, operative and non-operative management options and clinical outcome. Methods: A retrospective review of ERCP-related perforations, during a 21-year period, was performed. Each perforation was categorized into types I to IV according to the location, mechanism and radiographic evaluation of the injury. Comparisons were made between patients treated operatively and non-operatively. Results: Forty-four perforations (0. 4%) occurred in 9,880 procedures. They were mainly caused by the passage of the endoscope (type I) in 7 (16%) and sphincterotomy (type II) in 30 (68%) patients. The management was non-operative in 32 (72%) and operative in 12 patients. In multivariate analysis, only the type of perforation (type I: endoscope-related) was found significant for predicting operative treatment. The hospital stay was longer for patients requiring an operation (median, 24 vs 9 days). The overall mortality was 2/44 (4. 5%). There was no death in the non-operative group. Conclusions: The need for immediate operative intervention should be based on the type of injury and clinical findings. Patients with type I perforations should be treated surgically and primary repair should be tried. Patients with type II injuries may be treated initially non-operatively. Delayed operative intervention will be required in a minority of these patients. © 2011 The Society for Surgery of the Alimentary Tract

Seronegative cat-scratch disease diagnosed by PCR detection of Bartonella henselae DNA in lymph node samples

Cat scratch disease (CSD), the typical clinical manifestation of Bartonella infections usually follows a typical benign self-limited course. Nevertheless, a variety of unusual clinical manifestations and confusing imaging features can lead to misinterpretations and render the disease a diagnostic dispute. Routine laboratory tests exhibit varying reported sensitivity and are usually unhelpful in diagnosis, as serology fails in terms of specificity and/or sensitivity. Herein we report a case of seronegative Bartonella infection presenting as symptomatic suppurative lymphadenitis with abscess formation, which was surgically drained. Diagnosis was established by PCR analysis from lymph nodes samples obtained during the procedure. PCR detection of specific DNA fragments from lymph node biopsy provides a sensitive detection of disease. The technique should be considered for patients with suspected CSD and negative serology, since serological assays exhibit low sensitivity. In ambiguous cases, surgical exploration may provide tissue for diagnosis; it is well tolerated and affords improved recovery. © 2012 Elsevier Editora Ltda.

Esophagopericardial fistula as a rare complication after total gastrectomy for cancer

Background: Esophagopericardial fistula is a rare but life-threatening complication of benign, malignant or traumatic esophageal disease. It is most commonly associated with benign etiology and carries a high mortality rate which increases with delay in diagnosis. Case presentation: We present a case of an esophagopericardial fistula as a rare complication in a 53-year-old male patient, 7 months after total gastrectomy for an adenocarcinoma of the esophagogastric junction. Conclusion: The prognosis of esophagopericardial fistula is poor, especially when it is associated with malignancy. © 2009 Dafnios et al; licensee BioMed Central Ltd

Safety and efficacy of extending a previous endoscopic sphincterotomy for the treatment of retained or recurrent common bile duct stones

Background The aim of the study was to evaluate the safety and efficacy of extending a previous endoscopic sphincterotomy (ES) in patients with retained or recurrent common bile duct (CBD) stones. Methods Between 2001 and 2013, extension of a previous ES, for known or suspected CBD stones, was performed in 118 patients (m/f, 53/65) with a median age of 74 (range: 31-91) years (group A). During the same period, ES was performed in 1064 patients with suspected or known choledocholithiasis (group B). The efficacy and complications of the extension (group A) were analyzed and a comparison was made between groups regarding complications. Results Bile duct cannulation was straightforward in all patients in group A, while it was considered difficult in 49% of patients in group B. Complete clearance was achieved in 76/97 patients (78%) with CBD stones, after a mean of 1.18 attempts per patient. Mechanical lithotripsy was required in 10% of patients. After extension, immediate bleeding occurred in 24 patients (20%), which stopped spontaneously in 9 (37%) and endoscopic hemostasis was required in the remainder. Complications were more frequent in group B (5.3% vs. 0.8%, P=0.031), but there was no significant difference for any individual complication. Immediate bleeding was more common in group B (29% vs. 20%, P=0.035), but there was no difference in clinical bleeding. Conclusion Extension of a previous ES seems to be a simple, effective and safe technique, allowing stone clearance in nearly 80% of patients; it is thus recommended in patients with CBD stones after ES. © 2018 Hellenic Society of Gastroenterology