Anastomosis configuration and technique following ileocaecal resection for Crohn's disease: a multicentre study

A limited ileocaecal resection is the most frequently performed procedure for ileocaecal CD and different anastomotic configurations and techniques have been described. This manuscript audited the different anastomotic techniques used in a national study and evaluated their influence on postoperative outcomes following ileocaecal resection for primary CD. This is a retrospective, multicentre, observational study promoted by the Italian Society of Colorectal Surgery (SICCR), including all adults undergoing elective ileocaecal resection for primary CD from June 2018 May 2019. Postoperative morbidity within 30 days of surgery was the primary endpoint. Postoperative length of hospital stay (LOS) and anastomotic leak rate were the secondary outcomes. 427 patients were included. The side to side anastomosis was the chosen configuration in 380 patients (89%). The stapled anastomotic (n = 286; 67%), techniques were preferred to hand-sewn (n = 141; 33%). Postoperative morbidity was 20.3% and anastomotic leak 3.7%. Anastomotic leak was independent of the type of anastomosis performed, while was associated with an ASA grade ≥ 3, presence of perianal disease and ileocolonic localization of disease. Four predictors of LOS were identified after multivariate analysis. The laparoscopic approach was the only associated with a reduced LOS (p = 0.017), while age, ASA grade ≥ 3 or administration of preoperative TPN were associated with increased LOS. The side to side was the most commonly used anastomotic configuration for ileocolic reconstruction following primary CD resection. There was no difference in postoperative morbidity according to anastomotic technique and configuration. Anastomotic leak was associated with ASA grade ≥ 3, a penetrating phenotype of disease and ileo-colonic distribution of CD

National variations in perioperative assessment and surgical management of Crohn's disease: a multicentre study

Aim: Crohn's disease (CD) requires a multidisciplinary approach and surgery should be undertaken by dedicated colorectal surgeons with audited outcomes. We present a national, multicentre study, with the aim to collect benchmark data on key performance indicators in CD surgery, to highlight areas where standards of CD surgery excel and to facilitate targeted quality improvement where indicated. Methods: All patients undergoing ileocaecal or redo ileocolic resection in the participating centres for primary and recurrent CD from June 2018 to May 2019 were included. The main objective was to collect national data on hospital volume and practice variations. Postoperative morbidity was the primary outcome. Laparoscopic surgery and stoma rate were the secondary outcomes. Results: In all, 715 patients were included: 457 primary CD and 258 recurrent CD with a postoperative morbidity of 21.6% and 34.7%, respectively. Laparoscopy was used in 83.8% of primary CD compared to 31% of recurrent CD. Twenty-five hospitals participated and the total number of patients per hospital ranged from 2 to 169. Hospitals performing more than 10 primary CD procedures per year showed a higher adoption of laparoscopy and bowel sparing surgery. Conclusions: There is significant heterogeneity in the number of CD surgeries performed per year nationally in Italy. Our data suggest that high-volume hospitals perform more complex procedures, with a higher adoption of bowel sparing surgery. The rate of laparoscopy in high-volume hospitals is higher for primary CD but not for recurrent CD compared with low-volume hospitals

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

Is CA 19-9 a screening marker?

CA 19-9 a screening marke

Cancer of the Exocrine Pancreas: Surgery and Multimodal Treatment

The optimal management of pancreatic ductal carcinoma remains poorly defined. Radical resection is possible in about 20\u201330% of patients, with an overall 5-year survival rate of only 20% [1]. In recent years, perioperative morbidity and mortality have significantly decreased, and different clinical trials have suggested an important role for adjuvant therap

SILS cholecystectomy, early experience of a single institution: pilot study of 21 cases.

Many surgeons have attempted to reduce the number and the size of ports in laparoscopic cholecystectomy to decrease parietal trauma and pain, and to improve cosmetic results. We report a series of laparoscopic cholecystectomies using a single-port technique (SILS) through an umbilical incision in a pilot group of 21 cases. Our goal was to validate and develop the single-port access as a viable option. All the operations were performed using an umbilical SILS port (Ethicon). Most reported techniques utilize special purpose-made instruments. This article provides a stepwise description of the procedure using all straight instruments. No special reticulating instruments or flexible telescopes were used. We report our early difficulties and concerns about the procedure and propose solutions to the problems. Patients' request for improved cosmesis impels surgeons toward the application of SILS, but the true advantage of the technique should be assessed by more evidences. For this reason, we are planning a single-institution, prospective randomized controlled trial to compare postoperative pain, operating time and cosmetic result between one port and standard laparoscopic surgery

Outcomes after resection of locally advanced or borderline resectable pancreatic cancer after neoadjuvant therapy

BACKGROUND: Neoadjuvant treatment frequently is performed in unresectable/borderline resectable pancreatic cancer. The aim of this study was to retrospectively compare postoperative outcomes and survival of patients who underwent pancreatectomy after neoadjuvant treatment for locally advanced/borderline resectable pancreatic cancer (neoadjuvant treatment group) with those of patients with resectable disease who underwent upfront surgery. METHODS: Between 2000 and 2008, there were 403 patients who underwent pancreatic cancer resection, 41 (10.1%) patients after neoadjuvant treatment for initially unresectable tumors and 362 (89.9%) patients had upfront surgery. Univariate and multivariable analyses were performed. RESULTS: Mortality/morbidity rates were similar in the 2 groups. Nodal metastases were significantly lower in the neoadjuvant treatment group (31.7% vs 86.2%; P < .001). A complete pathologic response was observed in 13.6% after neoadjuvant treatment. Median disease-specific survival from resection was 35 and 27 months in the neoadjuvant treatment and upfront groups, respectively (P = .74). In the neoadjuvant treatment group survival rates were similar in N0/N1 patients. CONCLUSIONS: Postoperative mortality and morbidity do not significantly increase after neoadjuvant treatment. Neoadjuvant treatment in locally advanced pancreatic cancer can lead to an objective pathologic response, but this does not significantly improve survival after resection

Evaluation of a Predictive Model for Pancreatic Fistula Based on Amylase Value in Drains: A Prospective Study on 231 Consecutive Patients

Background The assessment of amylase value in drains (AVD) has been proposed as a predictor of pancreatic fistula (PF) after standard pancreatic resection. Nevertheless this model has never been validated. Objective To evaluate the accuracy of an AVD-based model in predicting PF after pancreatic resection. Methods We included 158 patients (68%) who underwent PD and 73 (32%) who underwent DP. AVD was prospectively measured in postoperative days (POD) 1. Patients with AVD &gt;5,000 U/L in POD 1 underwent further AVD measurement in POD 5 according to the model proposed by Molinari et al. [1]. Results The rate of PF was 25% and 59% after PD and DP respectively. Blood transfusions (odds ratio (OR)=6.9, P=0.004), a “soft” pancreatic texture (OR=10.8, P&lt;0.0001) and the AVD model (OR=38.7, P&lt;0.0001) were independent predictors of PF after PD. The median AVD in POD 1 was significantly higher after DP respect of PD (9,320 U/L versus 3,250 U/L, P&lt;0.0001).  The area under the receiving characteristic curve (ROC) was 0.892 (P&lt;0.0001) for AVD in POD 1 after PD and 0.726 (P=0.001) after DP. The sensitivity and specificity of AVD-based model in patients who underwent PD were 55% and 97%, respectively. The sensitivity and specificity of AVD predictive model in patients who underwent DP were 70% and 97%. For PD group we tested a new model considering a cut-off of 2,000 U/L for POD 1 AVD (sensitivity 90% and specificity 75%) and 200 U/L for POD 5 AVD (sensitivity 89% and specificity 85%). The new model showed a sensitivity and specificity in predicting PF after PD of 78% and 95% respectively. Conclusion Although the specificity of the AVD-based model previously proposed is high, its sensibility does not allow a safe PF prediction. A POD 1 AVD cut-off of 2,000 U/L considerably increases the accuracy of this model in patients who underwent PD

The determinant factors of recurrence following resection for ductal pancreatic cancer.

Long-term survival for patients with pancreatic carcinoma is low, even following resection. Most patients who undergo curative treatment, develop recurrence usually at the same site of resection or in the liver. Failure seals the fate of the patient. Local recurrence occurs frequently; however, it is rarely a direct cause of death. In fact, most patients die from distant metastases. From a clinical point of view, it is important to distinguish recurrence from relapse. In fact, recurrence can be recognized as the reappearance of the disease in the surgical bed, often due to inadequate surgical clearance. On the other hand, the concept of relapse should be much more related to the appearance of the disease in a distant site. Both underestimated staging of the diagnosis and the biological features of the tumor can cause relapse. Up to now, there have only been a few reviews on the incidence and pattern of failure following resection. Detailed knowledge of the recurring sites of pancreatic carcinoma and study of the factors influencing disease-free survival are significant in developing neoadjuvant, surgical and adjuvant treatment. The aim of this review is to point out the major factors most commonly identified as determinants of both recurrence and relapse