Management of acute diverticulitis with pericolic free gas (ADIFAS). an international multicenter observational study

Background: There are no specific recommendations regarding the optimal management of this group of patients. The World Society of Emergency Surgery suggested a nonoperative strategy with antibiotic therapy, but this was a weak recommendation. This study aims to identify the optimal management of patients with acute diverticulitis (AD) presenting with pericolic free air with or without pericolic fluid. Methods: A multicenter, prospective, international study of patients diagnosed with AD and pericolic-free air with or without pericolic free fluid at a computed tomography (CT) scan between May 2020 and June 2021 was included. Patients were excluded if they had intra-abdominal distant free air, an abscess, generalized peritonitis, or less than a 1-year follow-up. The primary outcome was the rate of failure of nonoperative management within the index admission. Secondary outcomes included the rate of failure of nonoperative management within the first year and risk factors for failure. Results: A total of 810 patients were recruited across 69 European and South American centers; 744 patients (92%) were treated nonoperatively, and 66 (8%) underwent immediate surgery. Baseline characteristics were similar between groups. Hinchey II-IV on diagnostic imaging was the only independent risk factor for surgical intervention during index admission (odds ratios: 12.5, 95% CI: 2.4-64, P =0.003). Among patients treated nonoperatively, at index admission, 697 (94%) patients were discharged without any complications, 35 (4.7%) required emergency surgery, and 12 (1.6%) percutaneous drainage. Free pericolic fluid on CT scan was associated with a higher risk of failure of nonoperative management (odds ratios: 4.9, 95% CI: 1.2-19.9, P =0.023), with 88% of success compared to 96% without free fluid ( P <0.001). The rate of treatment failure with nonoperative management during the first year of follow-up was 16.5%. Conclusion: Patients with AD presenting with pericolic free gas can be successfully managed nonoperatively in the vast majority of cases. Patients with both free pericolic gas and free pericolic fluid on a CT scan are at a higher risk of failing nonoperative management and require closer observation

Infección peritoneal postoperatoria y recurrencia del cáncer colorrectal: estudio de la capacidad de proliferación, migración e invasión de células tumorales in vitro como mecanismos responsables de esta asociación

La dehiscencia de anastomosis después de cirugía de cáncer colorrectal (CCR) se asocia a una mayor recurrencia tumoral. Sin embargo, los mecanismos responsables de esta asociación son aún desconocidos. En un trabajo previo demostramos que la respuesta inflamatoria y angiogénica secundaria a la infección peritoneal tras cirugía de CCR es mayor que en los pacientes que no presentan ninguna complicación postoperatoria. Esta respuesta amplificada podría tener un efecto negativo en los pacientes con CCR. Otro de los mecanismos que podría explicar esta asociación sería la adquisición de un fenotipo invasivo de células tumorales residuales en presencia de infección. El primer objetivo de este proyecto de investigación fue confirmar nuestros resultados previos y ampliar el estudio a otras citoquinas inflamatorias y angiogénicas. En segundo lugar, investigamos el efecto de la infección peritoneal tras cirugía de CCR sobre la proliferación, migración e invasión de líneas celulares de cáncer in vitro. Se realizó un estudio prospectivo de cohortes con controles apareados en pacientes intervenidos de CCR con intención curativa. Los pacientes que presentaron un absceso intraabdominal o una dehiscencia anastomótica fueron incluidos en el grupo infección. También se seleccionó otro paciente sin ninguna complicación postoperatoria para el grupo control. Las variables de apareamiento fueron sexo, edad, localización tumoral, abordaje quirúrgico, estadio tumoral y tratamiento neoadyuvante en los pacientes con cáncer de recto. Se obtuvieron muestras de sangre y líquido peritoneal antes de la cirugía y al cuarto día postoperatorio o en el momento del diagnóstico de la infección. Se analizaron 43 citoquinas inflamatorias y angiogénicas en las muestras de suero postoperatorias mediante arrays de anticuerpos. Los ensayos in vitro consistieron en el cultivo de células tumorales MDA-MB-231 y SW620 que se trataron con muestras de suero y líquido peritoneal preoperatorias y postoperatorias. Los ensayos de proliferación, migración e invasión realizados se basaron en el método colorimétrico en el cual se utiliza la actividad de la enzima hexosaminidasa como cuantificación del número de células viables. Durante el periodo de estudio, 47 pacientes fueron incluidos en el grupo infección con sus correspondientes controles. Todas las citoquinas analizadas fueron significativamente mayores en el grupo infección. Las muestras de suero postoperatorias de pacientes del grupo infección mostraron un aumento significativo de la proliferación de células MDA-MB-231. Este efecto fue más evidente cuando comparamos la diferencia de proliferación entre muestras postoperatorias y preoperatorias, entre grupos. Además, observamos una mayor inducción de la migración celular en el grupo infección al aplicar muestras de suero postoperatorio aunque no encontramos diferencias de actividad celular invasiva entre grupos. No hallamos diferencias de proliferación celular entre grupos al tratar las células con muestras de líquido peritoneal postoperatorias. Sin embargo, algunas de estas muestras mostraron un efecto citotóxico no relacionado con la presencia de infección. Las muestras postoperatorias de líquido peritoneal del grupo infección mostraron un incremento significativo de la migración de células MDA-MB-231 y de la invasión de células SW620. Este efecto también se observó al comparar las diferencias entre muestras postoperatorias y preoperatorias entre ambos grupos. La supervivencia libre de enfermedad fue significativamente menor en el grupo infección. La infección peritoneal postoperatoria se asoció a recurrencia tumoral. El riesgo de padecer una recurrencia tumoral fue casi tres veces mayor si se sufrió una infección peritoneal postoperatoria en nuestra muestra de pacientes. En conclusión, la expresión de citoquinas inflamatorias y angiogénicas después de cirugía de CCR es mayor en presencia de infección peritoneal. La infección peritoneal postoperatoria estimula la proliferación, migración e invasión de las células tumorales in vitro. Estos mecanismos podrían ser responsables, al menos en parte, de la asociación entre la infección peritoneal y la recurrencia tumoral tras la cirugía del CCR.Anastomotic leakage after colorectal cancer (CRC) surgery is associated with higher tumor recurrence. However, the mechanisms responsible for this association are unknown. In a previous study we showed that inflammatory and angiogenic responses after CRC surgery were higher in patients with postoperative infection than in patients with no postoperative complication. A magnification of these responses could enhance a negative effect in patients with cancer. Another mechanism that would explain this association might be the acquirement of an invasive phenotype of residual tumor cells in the presence of peritoneal infection. The aim of this study was to confirm our previous results and extend the study to other inflammatory and angiogenic cytokines; and investigate the effect of postoperative peritoneal infection after CRC surgery on proliferation, migration, and invasion capacities of tumor cells in vitro. We performed a prospective cohort study with matched controls of patients who underwent elective surgery for CRC with curative intent. Patients who had an intra-abdominal abscess or an anastomotic leak were included in the infection group. For each patient with infection another patient with an uncomplicated postoperative course was selected for the control group. Controls were matched for gender, age, tumor location, surgical approach, tumor stage and neoadjuvant therapy in patients with rectal cancer. Blood and peritoneal fluid samples were collected before surgery and on postoperative day 4 or at the moment a peritoneal infection was diagnosed. We analyzed 43 different inflammatory and/or angiogenic cytokines in the sera of these patients with antibody arrays. In vitro assays on cancer cell lines (MDA-MB-231 and SW620) were performed using preoperative and postoperative serum and peritoneal fluid samples. The assays were performed according to the colorimetric method based on the activity of the lysosomal hexosaminidase enzyme as a measure of the number of viable cells. During the study period, 47 patients were included in the infection group: 34 patients developed an anastomotic leak and 13 patients an intraabdominal abscess. All cytokines tested were significantly induced in the infection group. Postoperative serum samples from patients with peritoneal infection significantly increased proliferation in the MDA-MB-231 cell line compared with controls. This effect was most apparent when comparing the increase in cell proliferation exerted by postoperatory samples respect to preoperatory samples within each group. We also observed a major induction of migration activity with the infection group postoperative serum samples. Cell invasion assays with serum samples did not reveal significant differences between groups. We found no differences in cell proliferation between both groups when cells were treated with peritoneal fluid samples. However, some postoperative peritoneal fluid samples exerted a cytotoxic effect on cell cultures that was not related to the presence of infection. Postoperative peritoneal fluids taken from the infection group rendered a significant increase in the capacity of MDA-MB-231 migration and SW620 invasion capacities. This effect was also apparent when comparing the difference activity between postoperative and preoperative samples in both groups. During follow-up, 12 patients developed tumor recurrence in the infection group and 6 in the control group. Cumulative disease-free survival was significantly lower in patients with postoperative peritoneal infection. The risk of tumor recurrence was almost three times higher if patients suffered a postoperative peritoneal infection in our sample. In conclusion, our results confirm that postoperative peritoneal infection induces a large number of serum cytokines. Furthermore, postoperative peritoneal infection enhances proliferation, migration and invasion capacities of tumor cells in vitro. These mechanisms might be responsible, at least in part, for the association between peritoneal infection and tumor recurrence after CRC surgery

Laparoscopic colorectal surgery: current status and implementation of the latest technological innovations.

The introduction of laparoscopy is an example of surgical innovation with a rapid implementation in many areas of surgery. A large number of controlled studies and meta-analyses have shown that laparoscopic colorectal surgery is associated with the same benefits than other minimally invasive procedures, including lesser pain, earlier recovery of bowel transit and shorter hospital stay. On the other hand, despite initial concerns about oncological safety, well-designed prospective randomized multicentre trials have demonstrated that oncological outcomes of laparoscopy and open surgery are similar. Although the use of laparoscopy in colorectal surgery has increased in recent years, the percentages of patients treated with surgery using minimally invasive techniques are still reduced and there are also substantial differences among centres. It has been argued that the limiting factor for the use of laparoscopic procedures is the number of surgeons with adequate skills to perform a laparoscopic colectomy rather than the tumour of patients' characteristics. In this regard, future efforts to increase the use of laparoscopic techniques in colorectal surgery will necessarily require more efforts in teaching surgeons. We here present a review of recent controversies of the use of laparoscopy in colorectal surgery, such as in rectal cancer operations, the possibility of reproducing complete mesocolon excision, and the benefits of intra-corporeal anastomosis after right hemicolectomy. We also describe the results of latest innovations such as single incision laparoscopic surgery, robotic surgery and natural orifice transluminal endoscopic surgery for colon and rectal diseases

Infección peritoneal postoperatoria y recurrencia del cáncer colorrectal: estudio de la capacidad de proliferación, migración e invasión de células tumorales in vitro como mecanismos responsables de esta asociación

La dehiscencia de anastomosis después de cirugía de cáncer colorrectal (CCR) se asocia a una mayor recurrencia tumoral. Sin embargo, los mecanismos responsables de esta asociación son aún desconocidos. En un trabajo previo demostramos que la respuesta inflamatoria y angiogénica secundaria a la infección peritoneal tras cirugía de CCR es mayor que en los pacientes que no presentan ninguna complicación postoperatoria. Esta respuesta amplificada podría tener un efecto negativo en los pacientes con CCR. Otro de los mecanismos que podría explicar esta asociación sería la adquisición de un fenotipo invasivo de células tumorales residuales en presencia de infección. El primer objetivo de este proyecto de investigación fue confirmar nuestros resultados previos y ampliar el estudio a otras citoquinas inflamatorias y angiogénicas. En segundo lugar, investigamos el efecto de la infección peritoneal tras cirugía de CCR sobre la proliferación, migración e invasión de líneas celulares de cáncer in vitro. Se realizó un estudio prospectivo de cohortes con controles apareados en pacientes intervenidos de CCR con intención curativa. Los pacientes que presentaron un absceso intraabdominal o una dehiscencia anastomótica fueron incluidos en el grupo infección. También se seleccionó otro paciente sin ninguna complicación postoperatoria para el grupo control. Las variables de apareamiento fueron sexo, edad, localización tumoral, abordaje quirúrgico, estadio tumoral y tratamiento neoadyuvante en los pacientes con cáncer de recto. Se obtuvieron muestras de sangre y líquido peritoneal antes de la cirugía y al cuarto día postoperatorio o en el momento del diagnóstico de la infección. Se analizaron 43 citoquinas inflamatorias y angiogénicas en las muestras de suero postoperatorias mediante arrays de anticuerpos. Los ensayos in vitro consistieron en el cultivo de células tumorales MDA-MB-231 y SW620 que se trataron con muestras de suero y líquido peritoneal preoperatorias y postoperatorias. Los ensayos de proliferación, migración e invasión realizados se basaron en el método colorimétrico en el cual se utiliza la actividad de la enzima hexosaminidasa como cuantificación del número de células viables. Durante el periodo de estudio, 47 pacientes fueron incluidos en el grupo infección con sus correspondientes controles. Todas las citoquinas analizadas fueron significativamente mayores en el grupo infección. Las muestras de suero postoperatorias de pacientes del grupo infección mostraron un aumento significativo de la proliferación de células MDA-MB-231. Este efecto fue más evidente cuando comparamos la diferencia de proliferación entre muestras postoperatorias y preoperatorias, entre grupos. Además, observamos una mayor inducción de la migración celular en el grupo infección al aplicar muestras de suero postoperatorio aunque no encontramos diferencias de actividad celular invasiva entre grupos. No hallamos diferencias de proliferación celular entre grupos al tratar las células con muestras de líquido peritoneal postoperatorias. Sin embargo, algunas de estas muestras mostraron un efecto citotóxico no relacionado con la presencia de infección. Las muestras postoperatorias de líquido peritoneal del grupo infección mostraron un incremento significativo de la migración de células MDA-MB-231 y de la invasión de células SW620. Este efecto también se observó al comparar las diferencias entre muestras postoperatorias y preoperatorias entre ambos grupos. La supervivencia libre de enfermedad fue significativamente menor en el grupo infección. La infección peritoneal postoperatoria se asoció a recurrencia tumoral. El riesgo de padecer una recurrencia tumoral fue casi tres veces mayor si se sufrió una infección peritoneal postoperatoria en nuestra muestra de pacientes. En conclusión, la expresión de citoquinas inflamatorias y angiogénicas después de cirugía de CCR es mayor en presencia de infección peritoneal. La infección peritoneal postoperatoria estimula la proliferación, migración e invasión de las células tumorales in vitro. Estos mecanismos podrían ser responsables, al menos en parte, de la asociación entre la infección peritoneal y la recurrencia tumoral tras la cirugía del CCR.Anastomotic leakage after colorectal cancer (CRC) surgery is associated with higher tumor recurrence. However, the mechanisms responsible for this association are unknown. In a previous study we showed that inflammatory and angiogenic responses after CRC surgery were higher in patients with postoperative infection than in patients with no postoperative complication. A magnification of these responses could enhance a negative effect in patients with cancer. Another mechanism that would explain this association might be the acquirement of an invasive phenotype of residual tumor cells in the presence of peritoneal infection. The aim of this study was to confirm our previous results and extend the study to other inflammatory and angiogenic cytokines; and investigate the effect of postoperative peritoneal infection after CRC surgery on proliferation, migration, and invasion capacities of tumor cells in vitro. We performed a prospective cohort study with matched controls of patients who underwent elective surgery for CRC with curative intent. Patients who had an intra-abdominal abscess or an anastomotic leak were included in the infection group. For each patient with infection another patient with an uncomplicated postoperative course was selected for the control group. Controls were matched for gender, age, tumor location, surgical approach, tumor stage and neoadjuvant therapy in patients with rectal cancer. Blood and peritoneal fluid samples were collected before surgery and on postoperative day 4 or at the moment a peritoneal infection was diagnosed. We analyzed 43 different inflammatory and/or angiogenic cytokines in the sera of these patients with antibody arrays. In vitro assays on cancer cell lines (MDA-MB-231 and SW620) were performed using preoperative and postoperative serum and peritoneal fluid samples. The assays were performed according to the colorimetric method based on the activity of the lysosomal hexosaminidase enzyme as a measure of the number of viable cells. During the study period, 47 patients were included in the infection group: 34 patients developed an anastomotic leak and 13 patients an intraabdominal abscess. All cytokines tested were significantly induced in the infection group. Postoperative serum samples from patients with peritoneal infection significantly increased proliferation in the MDA-MB-231 cell line compared with controls. This effect was most apparent when comparing the increase in cell proliferation exerted by postoperatory samples respect to preoperatory samples within each group. We also observed a major induction of migration activity with the infection group postoperative serum samples. Cell invasion assays with serum samples did not reveal significant differences between groups. We found no differences in cell proliferation between both groups when cells were treated with peritoneal fluid samples. However, some postoperative peritoneal fluid samples exerted a cytotoxic effect on cell cultures that was not related to the presence of infection. Postoperative peritoneal fluids taken from the infection group rendered a significant increase in the capacity of MDA-MB-231 migration and SW620 invasion capacities. This effect was also apparent when comparing the difference activity between postoperative and preoperative samples in both groups. During follow-up, 12 patients developed tumor recurrence in the infection group and 6 in the control group. Cumulative disease-free survival was significantly lower in patients with postoperative peritoneal infection. The risk of tumor recurrence was almost three times higher if patients suffered a postoperative peritoneal infection in our sample. In conclusion, our results confirm that postoperative peritoneal infection induces a large number of serum cytokines. Furthermore, postoperative peritoneal infection enhances proliferation, migration and invasion capacities of tumor cells in vitro. These mechanisms might be responsible, at least in part, for the association between peritoneal infection and tumor recurrence after CRC surgery

State of the art of enhanced recovery after surgery (ERAS) protocols in esophagogastric cancer surgery: the Western experience

Data de publicació electrònica: 21-06-2022Enhanced recovery after surgery (ERAS) programs provide a framework to standardize care processes and improve outcomes. The results of this multimodal and multidisciplinary approach based on actions focused on reducing physiological surgical stress in the preoperative, intraoperative, and postoperative periods are beneficial in reducing morbidity and hospital stay, without increasing readmissions across different surgical settings. The implementation of ERAS in resection procedures of esophageal and gastric cancer has been challenging due to the complexity of these surgical techniques and the high risk of complications. Despite the limited evidence of ERAS in esophagectomy operations, systematic reviews and meta-analysis have confirmed a reduction of pulmonary complications and hospital stay without increasing readmissions. In gastrectomy operations, the implementation of ERAS reduces the use of nasogastric tubes and intraabdominal drains, facilitates early diet, and reduces the length of hospital stay, without increasing complications. There is, however, wide heterogeneity and absence of standardization in the number and definition of the ERAS components. The development of ERAS consensus guidelines including procedure-specific components may reduce this variability. Regardless growing evidence of the effectiveness of ERAS, the adherence rate is still low. The commitment of the multidisciplinary team and leadership is critical in the application and refinement of ERAS protocols in parallel with periodic audits. Pre- and post-habilitation methods are emerging concepts to be incorporated in ERAS protocols

Global attitudes in the management of acute appendicitis during COVID-19 pandemic: ACIE Appy Study

Background: Surgical strategies are being adapted to face the COVID-19 pandemic. Recommendations on the management of acute appendicitis have been based on expert opinion, but very little evidence is available. This study addressed that dearth with a snapshot of worldwide approaches to appendicitis. Methods: The Association of Italian Surgeons in Europe designed an online survey to assess the current attitude of surgeons globally regarding the management of patients with acute appendicitis during the pandemic. Questions were divided into baseline information, hospital organization and screening, personal protective equipment, management and surgical approach, and patient presentation before versus during the pandemic. Results: Of 744 answers, 709 (from 66 countries) were complete and were included in the analysis. Most hospitals were treating both patients with and those without COVID. There was variation in screening indications and modality used, with chest X-ray plus molecular testing (PCR) being the commonest (19\ub78 per cent). Conservative management of complicated and uncomplicated appendicitis was used by 6\ub76 and 2\ub74 per cent respectively before, but 23\ub77 and 5\ub73 per cent, during the pandemic (both P < 0\ub7001). One-third changed their approach from laparoscopic to open surgery owing to the popular (but evidence-lacking) advice from expert groups during the initial phase of the pandemic. No agreement on how to filter surgical smoke plume during laparoscopy was identified. There was an overall reduction in the number of patients admitted with appendicitis and one-third felt that patients who did present had more severe appendicitis than they usually observe. Conclusion: Conservative management of mild appendicitis has been possible during the pandemic. The fact that some surgeons switched to open appendicectomy may reflect the poor guidelines that emanated in the early phase of SARS-CoV-2

Surgeons’ practice and preferences for the anal fissure treatment: results from an international survey

The best nonoperative or operative anal fissure (AF) treatment is not yet established, and several options have been proposed. Aim is to report the surgeons' practice for the AF treatment. Thirty-four multiple-choice questions were developed. Seven questions were about to participants' demographics and, 27 questions about their clinical practice. Based on the specialty (general surgeon and colorectal surgeon), obtained data were divided and compared between two groups. Five-hundred surgeons were included (321 general and 179 colorectal surgeons). For both groups, duration of symptoms for at least 6 weeks is the most important factor for AF diagnosis (30.6%). Type of AF (acute vs chronic) is the most important factor which guide the therapeutic plan (44.4%). The first treatment of choice for acute AF is ointment application for both groups (59.6%). For the treatment of chronic AF, this data is confirmed by colorectal surgeons (57%), but not by the general surgeons who prefer the lateral internal sphincterotomy (LIS) (31.8%) (p = 0.0001). Botulin toxin injection is most performed by colorectal surgeons (58.7%) in comparison to general surgeons (20.9%) (p = 0.0001). Anal flap is mostly performed by colorectal surgeons (37.4%) in comparison to general surgeons (28.3%) (p = 0.0001). Fissurectomy alone is statistically significantly most performed by general surgeons in comparison to colorectal surgeons (57.9% and 43.6%, respectively) (p = 0.0020). This analysis provides useful information about the clinical practice for the management of a debated topic such as AF treatment. Shared guidelines and consensus especially focused on operative management are required to standardize the treatment and to improve postoperative results

Evaluation of a quality improvement intervention to reduce anastomotic leak following right colectomy (EAGLE): pragmatic, batched stepped-wedge, cluster-randomized trial in 64 countries

Background Anastomotic leak affects 8 per cent of patients after right colectomy with a 10-fold increased risk of postoperative death. The EAGLE study aimed to develop and test whether an international, standardized quality improvement intervention could reduce anastomotic leaks. Methods The internationally intended protocol, iteratively co-developed by a multistage Delphi process, comprised an online educational module introducing risk stratification, an intraoperative checklist, and harmonized surgical techniques. Clusters (hospital teams) were randomized to one of three arms with varied sequences of intervention/data collection by a derived stepped-wedge batch design (at least 18 hospital teams per batch). Patients were blinded to the study allocation. Low- and middle-income country enrolment was encouraged. The primary outcome (assessed by intention to treat) was anastomotic leak rate, and subgroup analyses by module completion (at least 80 per cent of surgeons, high engagement; less than 50 per cent, low engagement) were preplanned. Results A total 355 hospital teams registered, with 332 from 64 countries (39.2 per cent low and middle income) included in the final analysis. The online modules were completed by half of the surgeons (2143 of 4411). The primary analysis included 3039 of the 3268 patients recruited (206 patients had no anastomosis and 23 were lost to follow-up), with anastomotic leaks arising before and after the intervention in 10.1 and 9.6 per cent respectively (adjusted OR 0.87, 95 per cent c.i. 0.59 to 1.30; P = 0.498). The proportion of surgeons completing the educational modules was an influence: the leak rate decreased from 12.2 per cent (61 of 500) before intervention to 5.1 per cent (24 of 473) after intervention in high-engagement centres (adjusted OR 0.36, 0.20 to 0.64; P &lt; 0.001), but this was not observed in low-engagement hospitals (8.3 per cent (59 of 714) and 13.8 per cent (61 of 443) respectively; adjusted OR 2.09, 1.31 to 3.31). Conclusion Completion of globally available digital training by engaged teams can alter anastomotic leak rates. Registration number: NCT04270721 (http://www.clinicaltrials.gov)