Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study

Background: The impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on postoperative recovery needs to be understood to inform clinical decision making during and after the COVID-19 pandemic. This study reports 30-day mortality and pulmonary complication rates in patients with perioperative SARS-CoV-2 infection. Methods: This international, multicentre, cohort study at 235 hospitals in 24 countries included all patients undergoing surgery who had SARS-CoV-2 infection confirmed within 7 days before or 30 days after surgery. The primary outcome measure was 30-day postoperative mortality and was assessed in all enrolled patients. The main secondary outcome measure was pulmonary complications, defined as pneumonia, acute respiratory distress syndrome, or unexpected postoperative ventilation. Findings: This analysis includes 1128 patients who had surgery between Jan 1 and March 31, 2020, of whom 835 (74·0%) had emergency surgery and 280 (24·8%) had elective surgery. SARS-CoV-2 infection was confirmed preoperatively in 294 (26·1%) patients. 30-day mortality was 23·8% (268 of 1128). Pulmonary complications occurred in 577 (51·2%) of 1128 patients; 30-day mortality in these patients was 38·0% (219 of 577), accounting for 81·7% (219 of 268) of all deaths. In adjusted analyses, 30-day mortality was associated with male sex (odds ratio 1·75 [95% CI 1·28–2·40], p\textless0·0001), age 70 years or older versus younger than 70 years (2·30 [1·65–3·22], p\textless0·0001), American Society of Anesthesiologists grades 3–5 versus grades 1–2 (2·35 [1·57–3·53], p\textless0·0001), malignant versus benign or obstetric diagnosis (1·55 [1·01–2·39], p=0·046), emergency versus elective surgery (1·67 [1·06–2·63], p=0·026), and major versus minor surgery (1·52 [1·01–2·31], p=0·047). Interpretation: Postoperative pulmonary complications occur in half of patients with perioperative SARS-CoV-2 infection and are associated with high mortality. Thresholds for surgery during the COVID-19 pandemic should be higher than during normal practice, particularly in men aged 70 years and older. Consideration should be given for postponing non-urgent procedures and promoting non-operative treatment to delay or avoid the need for surgery. Funding: National Institute for Health Research (NIHR), Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, European Society of Coloproctology, NIHR Academy, Sarcoma UK, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research

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

Comparison of dearterialization and hemorrhoidopexy with the standard technique of doppler guided hemorrhoidal artery ligation and hemorrhoidopexy: a prospective randomized controlled trial

Introduction: In this study, we proposed a combined outpatient treatment modality for hemorrhoidal disease. Methods: This study was a prospective non-inferiority randomized controlled trial (RCT). The experimental group included the dearterialization and hemorrhoidopexy under pudendal nerve block, whereas the comparator consisted of the standard doppler guided hemorrhoidal artery ligation and hemorrhoidopexy, under spinal anesthesia. As primary hypothesis we considered the non-inferiority of the proposed modality in terms of the presenting symptom remission rate (non-inferiority margin: 10%). Randomization was based on a 1:1 ratio. Blinding was confined to the patient and the investigator. Results: Overall, 60 patients were enrolled. The primary hypothesis of this RCT (96.7% vs 73.3%) was validated. The experimental group was associated with a lower operation duration and an expedited onset of mobilization and feeding. Moreover, a favorable profile regarding short term morbidity and analgesia was identified. The control group displayed a higher pile recurrence rate and a suboptimal patient satisfaction. A significant effect of the treatment modality in most of the SF-36 components was confirmed. Conclusions: The proposed treatment modality was associated with favorable short and long-term outcomes. Due to specific limitations, further RCTs, with a larger sample size are required.Εισαγωγή: Σε αυτή τη μελέτη προτείναμε μια συνδυασμένη μέθοδο αντιμετώπισης σε εξωτερική βάση των ασθενών με αιμορροϊδική νόσο. Υλικά και Μέθοδοι: Η παρούσα μελέτη σχεδιάστηκε ως μια προοπτική τυχαιοποιημένη μελέτη μη κατωτερότητας. Η πειραματική ομάδα περιλάμβανε την απολίνωση των αιμορροϊδικών αρτηριών και την αιμορροϊδοπηξία σε συνδυασμό με τον αποκλεισμό του αιδοιϊκού νεύρου. Στην ομάδα ελέγχου εφαρμόστηκε η καθιερωμένη τεχνική απολίνωσης των αιμορροϊδικών αρτηριών και αιμορροϊδοπηξίας με χρήση υπερήχου σε συνδυασμό με ραχιαία αναισθησία. Ως πρωτεύον καταληκτικό σημείο ορίστηκε η μη κατωτερότητα της πειραματικής ομάδας όσον αφορά το ποσοστό ύφεσης των συμπτωμάτων (όριο μη κατωτερότητας: 10%). Η τυχαιοποίηση βασιζόταν σε αναλογία 1:1. Τυφλότητα υπήρχε στο επίπεδο του ασθενούς και του ερευνητή. Αποτελέσματα: Συνολικά εντάχθηκαν 60 ασθενείς. Η πρωτεύουσα υπόθεση της μελέτης αυτής επαληθεύθηκε (96.7% έναντι 73.3%). Η πειραματική ομάδα συσχετίστηκε με μικρότερη διάρκεια χειρουργικού χρόνου και έναρξης κινητοποίησης και σίτισης. Επιπλέον, η ομάδα αυτή παρουσίασε καλύτερα αποτελέσματα όσον αφορά τις βραχυπρόθεσμες επιπλοκές και την αναλγησία. Η ομάδα ελέγχου εμφάνισε ένα υψηλότερο ποσοστό υποτροπής των αιμορροϊδικών όζων και χαμηλότερα επίπεδα συνολικής ικανοποίησης των ασθενών. Επίσης, επιβεβαιώθηκε μια σημαντική επίδραση της θεραπευτικής μεθόδου στις περισσότερες συνιστώσες του ερωτηματολογίου SF-36. Συμπεράσματα: Η προτεινόμενη μέθοδος αντιμετώπισης σχετίστηκε με ευνοϊκότερα βραχυπρόθεσμα και μακροπρόθεσμα αποτελέσματα. Λόγω συγκεκριμένων ερευνητικών περιορισμών, απαιτούνται περισσότερες και μεγαλύτερες προοπτικές τυχαιοποιημένες μελέτες

Microvessel Density in Patients with Cutaneous Melanoma: An Up-to-Date Systematic Review and Meta-Analysis

Background. We conducted a meta-analysis, in order to appraise the effect of microvessel density (MVD) on the survival of patients with cutaneous melanoma. Methods. This study was conducted according to the PRISMA guidelines and the Cochrane Handbook for Systematic Reviews of Interventions. A systematic literature search in electronic databases (MEDLINE, Web of Science, and Cochrane Central Register of Controlled Clinical Trials) was performed. Fixed Effects or Random Effects model was used, based on the Cochran Q test. Results. In total 9 studies (903 patients) were included. Pooled HR for overall survival (OS) and disease-free survival (DFS) were 2.62 (95% CI: 0.71–9.60, p=0.15) and 2.64 (95% CI: 0.82–8.47, p=0.10), respectively. Odds ratios of overall survival between high and low MVD groups, at 12 (1.45, 95% CI: 0.16–13.24), 36 (2.93, 95% CI: 0.63–13.59), and 60 (4.09, 95% CI: 0.85–19.77) months did not reach statistical significance. Significant superiority of low MVD group, in terms of DFS, at all time intervals (OR: 4.69, p<0.0001; OR: 2.18, p=0.004; OR: 7.46, p=0.01, resp.) was documented. Discussion. MVD does not affect the HR of OS and DFS. A strong correlation with DFS rates at 12, 36, and 60 months was recorded

Laparoscopic Gastric Plication versus Laparoscopic Sleeve Gastrectomy: An Up-to-Date Systematic Review and Meta-Analysis

Introduction. A meta-analysis was conducted in order to provide an up-to-date comparison of laparoscopic sleeve gastrectomy (LSG) and laparoscopic gastric plication (LGP) for morbid obesity. Materials and Methods. The PRISMA guidelines and the Cochrane Handbook for Systematic Reviews of Interventions were used for the conduction of this study. A systematic literature search was performed in the electronic databases (MEDLINE, CENTRAL, and Web of Science and Scopus). The fixed effects or random effects model was used according to the Cochran Q test. Results. Totally, 12 eligible studies were extracted. LSG displayed a statistically significant lower rate of overall complications (OR: 0.35; 95% CI: 0.17, 0.68; p=0.002) and a sustainable higher %EWL through all time endpoints (OR: 4.86, p=0.04; OR: 7.57, p<0.00001; and OR: 13.74; p<0.00001). There was no difference between the two techniques in terms of length of hospital stay (p=0.16), operative duration (p=0.81), reoperation rate (p=0.51), and cost (p=0.06). Conclusions. LSG was demonstrated to have a lower overall complications and a higher weight loss rate, when compared to LGP. Further RCTs of a higher methodological quality level, with a larger sample size, are required in order to validate these findings

An Appendiceal Carcinoid Tumor within an Amyand’s Hernia Mimicking an Incarcerated Inguinal Hernia

Introduction. We report the case of an appendiceal carcinoid tumor within an Amyand’s hernia, presenting as an incarcerated right inguinal hernia. Presentation of Case. A 52-year-old male presented in the emergency department due to a persistent right inguinal pain. Clinical examination revealed a tender right groin mass. Laboratory tests revealed leukocytosis and an increased serum CRP. Under the diagnosis of an incarcerated right inguinal hernia, an emergency operation was taken. Intraoperatively, an inflamed appendix and a part of the cecum were found in the hernia sac. The operation was completed with an appendectomy and a modified Bassini hernia repair. Histological examination revealed a carcinoid tumor, resulting in the performance of a right hemicolectomy. Discussion. Amyand’s hernia is estimated to account for 0.4% to 0.6% of all inguinal hernias. Coexistence of an Amyand’s hernia and a neoplasia is quite rare. Carcinoids are the most frequent tumors found in the appendix, with the size of the primary tumor to be considered the most important prognostic factor and the basis upon which the operative plan is decided. Conclusion. A malignancy of the appendix should always be in the differential diagnosis of a right inguinal mass, in order to provide optimum surgical treatment

The use of over-the-scope clip in the treatment of persistent staple line leak after re-sleeve gastrectomy: Review of the literature

Staple line leak after sleeve gastrectomy (SG) is a severe complication associated with increased mortality rates and the potential need for reoperation. We report the successful management of a re-SG staple line leak with the use of an endoscopic over-the-scope clip