Colorectal Surgery

12 months from surgical resection (group A) and patients without or with late distant relapse (group B). RESULTS: Among 635 patients, 86 (13.5%) developed distant disease within 1 year from surgery (group A), and 549 (86.5%) did not (group B). A higher rate of early distant relapse was associated with CEA levels above 3 ng/dL (20% vs 10%, p<0. 001), tumor lying under 5 cm from anal verge (20% vs 9%, p<0.001) and an age less than 63 years (17% vs 11% p¼0.036). Multivariate analysis confirmed this factors to be independently correlated with a higher risk of early metastasis. CONCLUSIONS: Younger age, low tumors and high serum CEA may be associated with unfavorable early oncological outcomes after CRT and surgery for rectal cancer. These clinical factors could be useful to select patients for more aggressive therapeutic strategies.

AimThe Enhanced Recovery After Surgery (ERAS®) 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.MethodAn 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.ResultsOf 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 ...

The mainstay of management for locally advanced rectal cancer is chemoradiotherapy followed by surgical resection. Following chemoradiotherapy, a complete response may be detected clinically and radiologically (cCR) prior to surgery or pathologically after surgery (pCR). We aim to report the overall complete pathological response (pCR) rate and the reliability of detecting a cCR by conventional pre-operative imaging. A pre-planned analysis of the European Society of Coloproctology (ESCP) 2017 audit was performed. Patients treated by elective rectal resection were included. A pCR was defined as a ypT0 N0 EMVI negative primary tumour; a partial response represented any regression from baseline staging following chemoradiotherapy. The primary endpoint was the pCR rate. The secondary endpoint was agreement between post-treatment MRI restaging (yMRI) and final pathological staging. Of 2572 patients undergoing rectal cancer surgery in 277 participating centres across 44 countries, 673 (26...

Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN&#39;s Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with e...

Background An enhanced recovery after surgery (ERAS) protocol was implemented to improve quality and cost effectiveness of surgical care in elective colorectal procedures. Methods A retrospective study was conducted from July 2017 to June 2018. The ERAS protocol was initiated on 9 July 2018 and retrospectively reviewed in July 2019 by chart review, the American College of Surgeons National Surgical Quality Improvement Project database and risk stratification using Clavien–Dindo classification for all elective colorectal procedures. Results A total of 109 patients, 55 (pre-ERAS) and 54 (post-ERAS) are included in the final analysis. There were no differences in complications were recorded ( p = 0.37) and 30-day readmissions ( p = 0.785). The mean hospital stay was 5.89 ± 2.62 days in pre-ERAS and 4.94 ± 2.27 days in post-ERAS group which was statistically significant ( p = 0.047). Conclusions An ERAS protocol for colorectal surgery harmonised perioperative care and decreased length o...

Purpose The aim of this study was to evaluate the impact of various factors on 30-day postoperative morbidity in patients who underwent colorectal surgery (CRS) for colovesical fistula (CVF) in the elective and emergency settings. Methods Patients who underwent CRS for CVF between 2005 and 2013 were identified from the American College of Surgeons National Surgical Quality Improvement Program database by using current procedural terminology codes. Demographics, perioperative, and operative factors were assessed and compared between two groups classified according to the presence or absence of postoperative complications. Results Five hundred twelve patients met the inclusion criteria [mean age of 61.4 (±14.7) years, female 214 (42%)]. Etiology of fistula was diverticulitis [N = 438 (85.5%)], colon cancer [N = 39 (7.6%)], and Crohn's disease [N = 35 (6.8%)]. One hundred fifty-two procedures (29.7%) were performed laparoscopically. In 186 patients (36%), no bladder intervention was performed. One hundred forty-nine patients (29.1%) had at least one postoperative complication. Patients who developed complication were older (P = <0.001), more often female (P = <0.001), hypertensive (P = 0.005), anemic (P = <0.001), preoperatively transfused (P = 0.02), and with class 2-3 wound classification (P = 0.01). Independent risk factors affecting morbidity were increased age [odds ratio (OR) 1.23 (1.03-1.47), P = 0.01], decreased hematocrit level , P < 0.0001], and open approach , P = 0.003]. Conclusions Morbidity for CVF remains high. Lower preoperative hematocrit level and increased age were associated with higher risk of complication. Laparoscopic surgery may be preferable when possible as morbidity is less with this approach.

The aim of this study is to evaluate the impact of concurrent mesh herniorrhaphy on short-term outcomes of colorectal surgery by using a large, nationwide database. METHODS: Patients who underwent simultaneous ventral hernia repair (VHR) and colorectal surgery between 2005 and 2010 were identified from the American College of Surgeons National Surgical Quality Improvement Program. Patients who underwent VHR with mesh repair were case matched with patients who underwent VHR without mesh based on the type of colorectal procedure, diagnosis, and American Society of Anesthesiologists score. RESULTS: Two hundred sixty-two patients who underwent VHR with mesh were case matched with 524 patients who underwent VHR without mesh. Mean operating time was significantly longer in patients who underwent VHR with mesh (195.8 6 98.7 vs 164.3 6 84.4 minutes, P , .001). Postoperative morbidity (P 5 .58), mortality (P 5 .27), superficial surgical site infection (SSI) (P 5 .14), deep SSI (P 5 .38), organ space SSI (P 5 .17), wound disruption (P . .99), reoperation (P 5 .48), and length of hospital stay (P 5 .71) were comparable between the groups. CONCLUSION: The American College of Surgeons National Surgical Quality Improvement Program data suggest that VHR with mesh does not increase 30-day mortality, medical or surgical morbidity in colorectal surgery setting.

Background Nearly half of all incidental splenectomies caused by iatrogenic splenic injury occur during colorectal surgery. This study evaluates factors associated with incidental splenic procedures during colorectal surgery and their impact on short-term outcomes using a nationwide database. Methods Patients who underwent colorectal resections between 2005 and 2012 were identified from the American College of Surgeons National Surgical Quality Improvement Program database according to Current Procedural Terminology codes. Patients were classified into two groups based on whether they underwent a concurrent incidental splenic procedure at the time of the colorectal procedure. All splenic procedures except a preoperatively intended splenectomy performed in conjunction with colon or rectal resections were considered as incidental. Perioperative and short-term (30 day) outcomes were compared between the groups. Results In total, 93633 patients who underwent colon and/ or rectal resection were identified. Among these, 215 patients had incidental splenic procedures (153 open splenectomy, 17 laparoscopic splenectomy, 36 splenorraphy, and 9 partial splenectomy). Open colorectal resections were associated with a significantly increased likelihood of incidental splenic procedures (OR 6.58, p \ 0.001) compared to laparoscopic surgery. Incidental splenic procedures were associated with increased length of total hospital stay (OR 1.25, p \ 0.001), mechanical ventilation dependency (OR 1.62, p = 0.02), transfusion requirement (OR: 3.84, p \ 0.001), re-operation requirement (OR 1.7, p = 0.005), and sepsis (OR: 2.03, p = 0.001). Short-term advantages of splenic salvage (splenorraphy or partial splenectomy) included shorter length of total hospital stay (p = 0.001) and decreased need for re-operation (p \ 0.001). Conclusions Incidental splenic procedures during colorectal resections are associated with worse short-term outcomes. Use of the laparoscopic technique decreases the need for incidental splenic procedures.

Background Fast-track protocols are followed by an enhanced recovery, early return to bowel function and to complete nutrition, and a reduced hospital stay. Our study was designed to implement fast-track protocol in our university hospital. Methods The 96 consecutive patients with colorectal neoplasm included in the study were randomized in two equal groups: group 1 (FT) included patients undergoing colorectal surgery in a fast-track protocol, and group 2 (C) included patients undergoing colorectal surgery with a conventional care protocol. As with other fast-track protocols, our protocol included carbohydrate fluids load before operation, early mobilization and oral feeding, regular prokinetics, and multimodal postoperative analgesia. Time to restoration of bowel function, to complete mobilization and feeding, length of hospital stay, and incidence of complications and readmissions were monitored. Results Time to mobilization, restoring of bowel function, and complete oral feeding were significantly shorter with fast-track protocol (p = 0.001, p = 0.042, and p = 0.01, respectively). Hospital stay also was shorter in the fast-track group (p = 0.001). The incidence of complications did not significantly differ with the study groups. Conclusions In our study, fast-track protocol resulted in a shorter time to mobilization, complete feeding, and discharge from hospital. Fast-track protocol did not increase the incidence of complications. However, we consider that our data require further confirmation with powered multicenter national studies.

Objectives: The COVID-19 pandemic has emerged as a significant threat to healthcare systems, and has resulted in treatment algorithms being changed in general surgery clinics, as is the case in all other medical disciplines. In the present study we analyze the outcomes of patients who have undergone elective colorectal surgery in our hospital since the COVID-19 outbreak, as well as the precautionary procedural changes that have been made. Methods: The present study evaluates the approaches applied for the treatment of elective colorectal cancer patients in a pandemic hospital. In this cross-sectional study, conducted in a tertiary-level public hospital in Istanbul, Turkey, a retrospective review is made of the files of patients who underwent elective colorectal surgeries between 11.03.2020, as the date on which first case of COVID-19 was officially identified in Turkey, and 01.05.2020, in the general surgery clinic of a tertiary healthcare facility that has been designated a pandemi...

raises interesting observations related to the histopathology of mucocele of the appendix and its management. Our interest in the subject stems from three patients we have been treating for the past two years. The first case involves a mucinous cystadenoma (MCA) in a 42-year-old female with known ulcerative proctocolitis. 2 The lesion was not appreciated on colonoscopy but was noted on a computerized tomographic scan and was treated with a hemicolectomy. The second case is a 57-year-old female who underwent laparoscopic appendectomy for chronic abdominal pain. The computed tomographic scan was suggestive of appendicitis. Following removal, the slightly thickened appendix proved to be a MCA with appendicitis. The third case is 58-year-old white male who underwent an appendectomy for acute appendicitis. The inflamed appendix proved to be a perforated MCA with adenomatous changes extending to the surgical margin. A postoperative colonoscope revealed a large villous lesion in the cecum (Fig. ) and a sessile lesion in the transverse colon. At extended right colectomy, there was no mucinous ascites. The cecal lesion was a villous adenoma with invasive

Background While laparoscopic approach for right hemicolectomy (LRH) is considered appropriate for the surgical treatment of both malignant and benign diseases of right colon, there is still debate about how to perform the ileo-colic anastomosis. The ColonDxItalianGroup (CoDIG) was designed as a cohort, observational, prospective, multi-center national study with the aims of evaluating the surgeons’ attitude regarding the intracorporeal (ICA) or extra-corporeal (ECA) anastomotic technique and the related surgical outcomes. Methods One hundred and twenty-five Surgical Units experienced in colorectal and advanced laparoscopic surgery were invited and 85 of them joined the study. Each center was asked not to change its surgical habits. Data about demographic characteristics, surgical technique and postoperative outcomes were collected through the official SICE website database. One thousand two hundred and twenty-five patients were enrolled between March 2018 and September 2018. Result...

Gastrointestinal (GI) malignancies account for over a quarter of all new cancer diagnoses worldwide, and pose a significant burden on public health. As endoscopes are improved over the years, upgraded high-definition cameras have allowed for better polyp detection. Due to the absence of symptoms in GI malignancy, lesions are often incidentally detected in various stages by endoscopists. Careful polyp morphology evaluation and classification is paramount when selecting the most appropriate endoscopic (or surgical) resection method. The technique that would allow for an en bloc or R0 resection is preferred (endoscopic submucosal dissection [ESD]), while those that present with lower risk features can be reasonably removed in a piecemeal fashion or hybrid fashion with care in ablating clean margins to decrease recurrence. Although Eastern and European endoscopists have more experience in ESD, this expertise is not widely available in North America. The present study aims to explore the following questions: (1) Is ESD always necessary? (2) In which scenarios are ESD always indicated? (3) Can endoscopic mucosal resection be used to achieve resection goals, since this expertise is more widely available and has an easier learning curve?

In recent years, the Enhanced Recovery After Surgery (ERAS) protocols
have become an evidence-based practice to improve postoperative
recovery, reduce complications, and reduce costs in healthcare. To
summarize data from RCTs and observational studies regarding the
effectiveness of the protocols, especially in colorectal and hepatobiliary
surgery, this meta-analysis is conducted. A secondary type of outcome
examined included; the length of stay in the healthcare facility, resulting
postoperative complications, recovery period, readmission rates, and
overall cost- effectiveness. The findings showed that patients in the ERAS
group have on average 25 percent shorter stay in hospital compared to
those that received standard care. Key ERAS interventions including early
mobilization, optimization of fluid and nutrition management as well as
multimodal analgesia have reduced the physiological stress of surgery
and consequently improved recovery time. In addition, the protocols are
associated with reductions of 15–20 percent in postoperative complications
such as infections and DVT, common issues that delay recovery and
increase healthcare costs. Finally, the meta-analysis also shows that the
protocols have a significant cost saving, and the mean cost per patient
in the ERAS group is around 13 to 15% lower than in the standard care
group, which is primarily due to reduced stays in the healthcare facility
and reduced complications. The beneficial features of ERAS as compared
to the Australian healthcare system, which was one of the first to adopt
ERAS, also indicate a wider range of applicability and a potential cost
advantage, as well as improvement of outcomes. The findings of this
study suggest that the protocols are a widely effective strategy to improve
postoperative recovery and decrease complications, as well as promote cost
efficiencies in high-income as well as low to middle-income countries. The
findings display the ability of the protocols to improve surgical outcomes
across a variety of setting types worldwide.

INTRODUCTION Laparoscopic colorectal surgery, although technically demanding, is an increasingly desirable skill for coloproc-tologists. We believe that trainees with adequate supervision from an experienced trainer may perform these procedures safely with good outcome. PATIENTS AND METHODS Surgical logbooks of two senior trainees were reviewed over a 2-year period. A case note analysis was then undertaken. Patient data were recorded with regards to age, sex, operation type, American Society of Anesthesia (ASA) grade, conversion, length of hospital stay and complications. Lymph node yield, resection margins and grade of total mesorec-tal excision were recorded in oncological procedures. RESULTS Over the 2-year period, trainees were involved in 140 resections (age range, 23-88 years; ASA grades I-III). Seventy patients were male. Trainees were first assistant in at least 20 cases prior to undertaking the procedures themselves. Trainees performed a total of 71 operations. Median hospi...

Background Ligation of the intersphincteric tract (LIFT), a novel sphincter-saving technique, has been recently described with promising results. Literature data are still scant. In this prospective observational study, we present our experience with this technique. Methods Between October 2010 and April 2011, 18 patients with 'complex' fistulas underwent LIFT. All patients were enrolled in the study after a physical examination including digital examination and proctoscopy. For the purpose of this pilot study, fistulas were classified as complex if any of the following conditions were present: tract crossing more than 30% of the external sphincter, anterior fistula in a woman, recurrent fistula or pre-existing incontinence. Endpoints were healing time, presence of recurrence, faecal incontinence and surgical complications. Results Ten patients were men and 8 were women; mean age was 39 years; minimum follow-up was 4 months. Three patients required drainage seton insertion and delayed LIFT. After LIFT, 1 patient experienced haemorrhoidal thrombosis. At the end of the follow-up, 15 patients (83%) healed with no recurrence. Three patients had persistent symptoms and required further surgical treatment. We did not observe postoperative worsening of continence. Conclusions Results from our pilot study indicate that this novel sphincter-saving approach is effective and safe for treating complex anal fistula.

Following abdominal surgery, transversus abdominis plane (TAP) blocks are frequently used as part of a multimodal anaesthetic regimen. These blocks are traditionally performed by anaesthetists; however, the availability of technical expertise and ultrasound equipment can be limiting factors. A laparoscopic guided TAP block is potentially faster, simpler and safer than alternative techniques. It may also be particularly advantageous in the obese patient where needle placement using a blind technique or ultrasound guidance can be difficult. Since the first published descriptions of a laparoscopic guided TAP block in 2011 , it has been used in colorectal [3-5], gynaecological [6-8], urological 9] and hepatobiliary operations. In Video S1, drawing together the best published evidence, we demonstrate how and why the TAP block can be placed laparoscopically at the conclusion of a laparoscopic surgical procedure.

Recent studies suggest that there is little benefit to routine preoperative staging Ct of the thorax in colorectal cancer. OBJECTIVE: the current study hypothesized that staging Ct of the thorax is not mandated in all patients with colorectal cancer. DESIGN: this study was a tertiary-care center retrospective observational study. Patients with a diagnosis of colon and rectal adenocarcinoma during 2006 to 2011 were included in a hospital database. Demographic, pathological, radiological, survival, and clinical factors were recorded. three hundred eighty-two patients were included in the analysis (234 male, 148 female). INTERVENTIONS: all patients underwent preoperative staging Ct of the thorax to determine the presence of pulmonary metastasis and/or indeterminate lesions. Patients demographics were reviewed, and the factors associated with pulmonary metastasis and indeterminate lesions were evaluated. RESULTS: Distant metastases were evident in 61 patients (16%). Ct scans revealed pulmonary metastasis in 23 patients (6%), and indeterminate lesions in 33 (8.6%). only one-third of pulmonary lesions were evident on chest x-ray. on logistic regression analysis, nodal positivity was associated with an increased risk for pulmonary metastasis (p = 0.03). there was no difference in overall survival between patients with pulmonary metastasis and indeterminate lesions (p = 0.35, Kaplanmeier estimate, log rank analysis). Pulmonary metastasis developed during postoperative surveillance in 7 patients with indeterminate lesions (21.2%). LIMITATIONS: this is a retrospective, single-center study with a relatively small sample size. CONCLUSIONS: Pulmonary metastasis is relatively rare in colorectal cancer, and staging Ct of the thorax may not be mandated in low-risk patients.

The mainstay of management for locally advanced rectal cancer is chemoradiotherapy followed by surgical resection. Following chemoradiotherapy, a complete response may be detected clinically and radiologically (cCR) prior to surgery or pathologically after surgery (pCR). We aim to report the overall complete pathological response (pCR) rate and the reliability of detecting a cCR by conventional pre-operative imaging. A pre-planned analysis of the European Society of Coloproctology (ESCP) 2017 audit was performed. Patients treated by elective rectal resection were included. A pCR was defined as a ypT0 N0 EMVI negative primary tumour; a partial response represented any regression from baseline staging following chemoradiotherapy. The primary endpoint was the pCR rate. The secondary endpoint was agreement between post-treatment MRI restaging (yMRI) and final pathological staging. Of 2572 patients undergoing rectal cancer surgery in 277 participating centres across 44 countries, 673 (26...

Diminutive colon polyps are a common finding during examination of the rectosigmoid. To determine the clinical significance of these, 637 consecutive complete colonoscopies on 526 patients were reviewed. In 430 patients, only adenomatous or hyperplastic polyps 5 mm or smaller were identified in the rectosigmoid colon and removed for pathologic examination. In 156 patients (36.3 percent), additional polyps were identified in the proximal colon. Proximal colon polyps were found in 123 of 382 patients (32.2 percent) with one, 28 of 42 (66.7 percent) patients with two, and five of six patients with three or more rectosigmoid polyps (P < 0.05). Pathologic review revealed 211 patients with only hyperplastic, 179 with adenomatous polyps, and 40 patients with both hyperplastic and adenomatous rectosigmoid polyps. Of these patients, 70 (33.2 percent), 71 (39.7 percent), and 15 (38.0 percent), respectively, had additional proximal colon polyps (P = NS). These data suggest that diminutive rectosigmoid polyps, whether hyperplastic or adenomatous, are associated with proximal colonic neoplasia, with the incidence increasing as the number of rectosigmoid polyps increases. It is suggested that total colonoscopy is indicated for all patients with small polyps of the rectosigmoid colon.

BACKGROUND: Despite advances in surgical approaches, emergency colorectal surgery has high mortality and morbidity. OBJECTIVE: We aimed to create a simple and distinctive scoring system, for predicting mortality among patients undergoing emergency colorectal surgery. DESIGN AND SETTING: Prediction model development study based on retrospective data-gathering. METHODS: Patients who underwent emergency colorectal surgery between March 2014 and December 2016 at a single tertiary-level referral center were included in our study. Patient demographics, comorbidities, type of surgery, etiology and laboratory and radiological findings were collected retrospectively and analyzed. A new clinical score (named the Numune emergency colorectal resection score) was constructed from the last logistic regression model, in which one point was assigned for the presence of each predictive factor. RESULTS: 138 patients underwent emergency colorectal surgery. These comprised 64 males (46.4%) and 74 females (53.6%), with a mean age of 64 years. Multivariate analysis revealed that blood urea nitrogen level > 65 mg/dl (odds ratio, OR: 8.03; 95% confidence interval, CI: 2.16-15.77), albumin level < 0.7 mg/ dl (OR: 4.43; 95% CI: 1.96-14.39) and American Society of Anesthesiologists score ≥ 3 (OR: 3.47; 95% CI: 0.81-9.18) were associated with postoperative complications. The Numune score was graded from I to III. The risk of mortality was found to be 63.2% in the group with grade III, which accounted for 35.2% of the subjects. There were 37 postoperative deaths. CONCLUSIONS: Surgeons need scoring systems, especially to predict postoperative mortality. We propose the Numune emergency colorectal resection score for emergency surgical procedures as a practical, usable and effective system for predicting postoperative morbidity.

To the Editor-We thank the readers for their comments and suggestions on our recently published retrospective National Cancer Database review. Regarding assessment of surgical technique, specifically total mesocolic excision (TME), we accept that TME is not recorded in the To the Editor-We read with great interest the article entitled "Omission of Adjuvant Chemotherapy Is Associated With Increased Mortality in Patients With T3N0 Colon Cancer With Inadequate Lymph Node Harvest." 1 Although the results of the study were impressive, we feel that there are some points that must be clarified. First of all, the authors did not fully elucidate their surgical technique. If they performed total mesocolic excision (TME) and retrieved a suboptimal number of lymph nodes and thus added chemotherapy, then their surgery and overall management should be considered inadequate. If they did not perform TME, then their surgical management is questionable from the beginning, depending on the latest findings and superior outcomes about TME in colon cancer. It may also be worthwhile to say that reaching clearcut conclusions based on such a wide database (ie, National Cancer Database) that involves a wide variety of clinical approaches might be erroneous. This is especially true for surgical techniques that cannot be standardized in large databases.

Objective: We aimed to identify the ratio of Surgical Site Infection (SSI) and also the validity of the National Nosocomial Infection Surveillance (NNIS) and Study on the Efficacy of Nosocomial Infection Control (SENIC) risk indexes in colorectal surgery, among Turkish population. Background: Some problems have been reported with the power of NNIS risk index to predict the risk of surgical site infection. We aimed to validate theNNIS and SENIC risk indexes in colorectal surgery. Methods: Between January 2003 and December 2006, surgical site ınfection surveillance was performed to 107 patients who undergo colorectal surgery with NNIS and SENIC risk scales. The mean patient age was 48 years (range, 17 to 86), and 61.7% of the group (66) was female. For this patient cohort, 6 (5.6%) were diagnosed with incisional SSI. While the mean Body Mass Index (BMI) of all patients was 26.6; mean value of BMI among the patiens with SSI was 27.8.Results: 6 insicional surgical site infection were observed during the study. According to Receiver Operating Characteric (ROC) curve analyze neither NNIS with avalue of 0.70, nor SENIC with a value of 0.67 are perfect risk indexes. Conclusion: As a result both NNIS and SENIC ıs a good risk indexes but not perfect. Scarcely when NNIS and SENIC is used together to predict the SSI they forecast the development of infection better. But there is a lot of other factors that effect the development of SSI, so for excellent surveillance risk index those factors known by everyone must be added to risk index scales.

Aim: To compare the outcome of early versus delayed temporary ileostomy reversal in colorectal anastomosis. Design: Randomized control clinical trials Place & period of the study: Surgical Unit 1 of the Services Hospital in Lahore from December 2017 to June 2018. Methods: A total of 176 patients, undergoing distal colorectal resections were divided randomly into group A; ileostomy reversal in less than 2 weeks after primary surgery and group B; ileostomy reversal after 8 weeks of primary surgery was followed for 4 weeks to access wound infection, abdominal pain, anastomotic leak, soreness and gut material discharge through the wound. Results: The average age of patients was 40.48+13.13years [range 18-60] in group A. In group B, the average age of patients was 41.92+14.08 [range 18 – 60]. Post-operative wound infection occurred in group A were 12 (13.63%) and in group B 8 (9.09%) while anastomotic leakage observed in 7 (8%) of group A patients and 4 (4.5%) of group B patients. Calcul...

Chronic HBV carrier is estimated more than three & half million in Korea and around 8-10% of these carriers will be chronic hepatopathies. Since the licensure of an inactivated hepatitis B vaccine, H-B Vax is recommended for immunization of infants, children & adults who are exposed to high risk of hepatitis B imfection. H-B Vax (Merck) was introduced in Korea in July 1982 as a commercial base. Subseqhently Pasteur Vaccine in Aug. 1982, and currently Hepavax B, Green Cross Co., Korea in Oct. 1983 are also available here and this time HBV vaccination is widely administered. The authors studied on immune response of healthy adults to HB vaccine at the six months after 3 times injection and they also observed the immune response in neonates to HB vaccine & HBIG. Further follow up studies on antibody response after HB vaccination will be carried out in future in addition to this preliminary report. And further prevention of hepatitis B infection will be expected by active vaccination program at highly contaminated areas.

CT colonography, also called virtual colonoscopy, was introduced about a decade ago, has made great progress over the years, and is becoming more popular. With the advent of CT scanners and computer software, the examination is performed more quickly and with less patient radiation exposure providing the radiologist with data that allow for accurate polyp detection using both two-and three-dimensional imaging. In this article we will review the technical basics of CT colonography, its current indications, and performance.

AimThe Enhanced Recovery After Surgery (ERAS®) 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.MethodAn 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.ResultsOf 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 ...

Aim: This single-center retrospective study aimed to evaluate the rate of protective ileostomy closure in patients with rectosigmoid junction/rectal cancer and to investigate the factors that prevent ileostomy reversal. Material and Method: Patients with rectal cancer treated with/without neoadjuvant chemoradiotherapy were included in this study. All were treated with anterior rectal resection and temporary protective ileostomy creation. Decision for ileostomy closure was brought upon predefined ileostomy closure protocol. Results: Total number of 115 patients (17 with rectosigmoid junction and 98 with rectal cancer) were operated. Neoadjuvant chemoradiotherapy was conducted in 90 of them. Ileostomy closure rate was 73.9%. Mean time for stoma closure in patients with chemoradiotherapy conduction was 227.8 days, while in the rest, time was shorter (168.3 days), without statistical difference. Multivariate analysis revealed that endoscopic examination of the anastomosis during its creation was independent prognostic factor that affected ileostomy closure. More than one quarter of the patients with protective ileostomy experienced non-closure of their stoma due to various events after index rectal cancer surgery. Endoscopic examination of the anastomosis during its creation presented as independent factor affecting ileostomy closure.

Introduction: Caecal bascule, a rare variant of caecal volvulus, accounts
for <2% of large bowel obstructions and 5-20% of caecal volvuli. Unlike
classic volvulus, it lacks axial twisting and results from an antero-medial
folding of the caecum, leading to obstruction. Presentation typically
includes nausea, vomiting, abdominal pain, distension, and constipation.
Prompt diagnosis is critical to prevent ischaemia or perforation. This report
presents an 85-year-old female with a small bowel obstruction secondary
to caecal bascule.
Case Presentation: An 85-year-old female presented with a 2-day history
of worsening right-lower-quadrant pain, nausea, and mild appetite loss,
but no vomiting or fever. Examination revealed abdominal tenderness
and mild distension without rigidity. Imaging identified distal ileal
obstruction and a flipped, dilated caecum consistent with caecal bascule.
Conservative management failed, prompting surgical intervention. A
laparoscopy converted to laparotomy revealed a caecal bascule with
ischaemic mucosa. Right hemicolectomy with ileocolic anastomosis was
performed. Postoperative ileus required parenteral nutrition, but recovery
was prompt and the patient was discharged by day 10. Histopathology
showed obstruction and ischaemia with incidental appendiceal mucinous
adenoma without malignancy. Follow-up revealed no complications.

This study looked at the Perioperative Antibiotic Prophylaxis (PAP) practice among 22 colorectal surgeons in Bahrain by way of a hand delivered questionnaire. Fourteen surgeons completed responses. For PAP, all fourteen used intravenous (IV) antibiotics in combination with mechanical bowel cleansing. Four (28.5%) used combined oral and IV PAP. One used IV antibiotics only. None used oral PAP alone nor used oral PAP combined with mechanical cleansing. Ten (71%) stated their PAP method was inherited from their training and was not evidence based. Seven (50%) said that they were open to changing their PAP methods after reading an evidence based review.

Objective: One of the most critical parameters of the ERAS protocol is perioperative fluid management. Goal-directed fluid therapy has advantages in this respect. We aimed to observe whether the epidural analgesia has an effect on intraoperative fluid replacement and postoperative recovery in patients who underwent major abdominal surgery in this study. Methods: Forty-six patients who underwent elective laparoscopic colon surgery under general anesthesia, aged 18-75, ASA I-III, were included in the study. The patients were divided into two groups as those who received epidural analgesia and those who did not receive epidural analgesia (intravenous, IV analgesia group). Goal-directed fluid therapy was arranged with Pleth Variability Index (PVI) monitoring in both groups. Results: There was no difference in the amount of the fluid administered and the hemodynamic parameters between the groups. Intraoperative PVI trend significantly decreased in the epidural group while it was stable in the IV analgesia group. (p=0.03). Body temperature was significantly lower at the end of the surgery compared to the beginning of the epidural analgesia group (p<0.001). But no significant change n body temperature was observed in the IV analgesi group (p=0.182). There was no difference between groups in terms of hospital length of stay, postoperative complications, and clinical recovery time. The administration of epidural analgesia does not have an advantage in comparison to the IV analgesia group in terms of targeted fluid therapy and the postoperative process and recovery time in laparoscopic colorectal surgery performed under general anesthesia. More detailed evaluations are needed for the effectiveness of PVI in intraoperative fluid therapy optimization.

Introduction Early rehabilitation programs have become an important focus of perioperative management after colorectal surgery with aims of improving patient care, reducing complication rates, and shortening hospital stay following colorectal surgery. The aim of this study is to evaluate the efficacy and safety of Yogic Breathing and Manual Diaphragm Release Technique in early rehabilitation of patients following surgery to remove colorectal cancer. Methods A total of 40 patients with colorectal cancer who underwent colorectal resection were randomly assigned to receive either the experimental protocol (experimental group, EG: n 20 average age 66,5 years) or the stansard postoperative care (standard group, SG: n 20 average age 66 years). In all subjects, postoperative outcomes after seven sessions were: peripheral oxygen saturation of capillary blood hemoglobin (SpO2), heart rate (HR), Activities of Daily Living (ADL), Short-Form 12 (SF-12) questionnaire, Visual Analogue Scale (VAS)...

Recent studies suggest that there is little benefit to routine preoperative staging Ct of the thorax in colorectal cancer. OBJECTIVE: the current study hypothesized that staging Ct of the thorax is not mandated in all patients with colorectal cancer. DESIGN: this study was a tertiary-care center retrospective observational study. Patients with a diagnosis of colon and rectal adenocarcinoma during 2006 to 2011 were included in a hospital database. Demographic, pathological, radiological, survival, and clinical factors were recorded. three hundred eighty-two patients were included in the analysis (234 male, 148 female). INTERVENTIONS: all patients underwent preoperative staging Ct of the thorax to determine the presence of pulmonary metastasis and/or indeterminate lesions. Patients demographics were reviewed, and the factors associated with pulmonary metastasis and indeterminate lesions were evaluated. RESULTS: Distant metastases were evident in 61 patients (16%). Ct scans revealed pulmonary metastasis in 23 patients (6%), and indeterminate lesions in 33 (8.6%). only one-third of pulmonary lesions were evident on chest x-ray. on logistic regression analysis, nodal positivity was associated with an increased risk for pulmonary metastasis (p = 0.03). there was no difference in overall survival between patients with pulmonary metastasis and indeterminate lesions (p = 0.35, Kaplanmeier estimate, log rank analysis). Pulmonary metastasis developed during postoperative surveillance in 7 patients with indeterminate lesions (21.2%). LIMITATIONS: this is a retrospective, single-center study with a relatively small sample size. CONCLUSIONS: Pulmonary metastasis is relatively rare in colorectal cancer, and staging Ct of the thorax may not be mandated in low-risk patients.

Background: Fast-track program has been applied in several surgical fields. However, currently many surgical patients are elderly over 70 years of age, and discussion about the application of such protocols for elderly patients is inadequate. Materials and methods: The present study was designed to consider the safety and feasibility of application of a fast-track program after colorectal surgery in elderly patients. A total of 76 elderly patients with colorectal cancer who underwent laparoscopic colorectal resection were randomly assigned to receive either the fast-track care program (n ¼ 40) or the conventional perioperative care protocol (control group, n ¼ 36). The fast track protocol included no preoperative mechanical bowel irrigation, immediate oral alimentation and earlier postoperative ambulation exercise. The length of postoperative hospital stay, the length of time to regain bowel function and the rate of postoperative complications were compared between the two groups. Results: The length of time to regain bowel function, including the passage of flatus [32 (24e40) h vs 42 (32e52) h], and to start a liquid diet (13 [10e16] h v/s 43 [36e50] h) were significantly shorter in patients receiving the fast track care protocol compared with those receiving the conventional care protocol. A shorter duration of postoperative hospital stay was recorded in patients receiving the fast-track program than in those receiving conventional care [6 (5e7) days v/s 9.5 (7e12) days]. A reduced percentage of patients who developed general complications was also observed in the fast-track group (5.0% v/s 18%). Conclusion: Fast-track after laparoscopic colorectal surgery can be safely applied in carefully selected elderly patients older than age 70 years. The fast-track recovery program resulted in a more rapid postoperative recovery, earlier discharge from hospital and fewer general complications compared with a conventional postoperative protocol.

Anal fistulas comprise a disease spectrum ranging from simple submucosal fistula tracts to extrasphincteric fistulas with multiple tracts. A large variety of treatment options exist for the diverse clinical presentations. The first surgical treatments used sacrificed the anal sphincter and are often associated with significant comorbidities such as high incontinence rates and alteration of anal sphincter anatomy [1]. Therefore, more modern surgical approaches are focused on sparing the sphincter. These surgical treatments include closure of the fistula tract with plugs, fibrin glue or clips, and obliteration of the fistula tract with diathermy or with fistula tract laser closure (FiLaCTM) [2, 3]. FiLaCTM is one of the newest procedures designed to treat complex anal fistulas, sealing the fistula lumen by means of diode laser energy. Whether the internal orifice needs to be closed before FiLaCTM is performed remains unclear [4, 5]. For this technique, the laser fiber is introduced in...

Background: Nowadays colo-rectal laparoscopic surgery has shown its advantages in terms of reduced post-operative pain, earlier recovery of intestinal peristalsis and shorter hospital stay. Few studies reported results of laparoscopic surgery in complicated diverticulitis. The aim of this study was to analyze the results of laparoscopic sigmoidectomy in patients with fistulized sigmoiditis. Methods: The authors retrospectively reviewed 16 patients operated on for fistulized sigmoidectomy between 1992 and 2003, in a series of 247 laparoscopic colectomies. Eleven patients presented with colo-vesical fistula, 4 with colo-vaginal and one with colo-cutaneous fistula, and all were caused by sigmoiditis. The procedure always consisted in coelioscopic sigmoidectomy with stapled transanal suture and eventually closure of the cystic or vaginal orifice. Results: Mean age was 60 years (range: 39 to 78 years). Mean number of diverticulitis crises before operation was 3 (range: 1 to 5). Mean time between the last crisis and operation was 46 weeks (range: 2 to 250 weeks).Three cases (18.7%) were converted in the three first years of experience. Reason to conversion was necessary intestinal resection, splenectomy and wound of anterior rectum. The mean operating time was 172 min (range: 100 to 280 min). Mean hospitalization stay was 5.7 days (3-12 days). Mortality rate was 0%. Postoperative morbidity (12.5%) consisted in one pulmonary infection and one splenectomy. Long-term follow-up demonstrated no diverticultis recurrence and one incisional hernia. In experimented hands, laparoscopic sigmoidectomy may be a safe and effective procedure for fistulized sigmoiditis.

Background: Incidence of serious complications after MH has remained high despite considerable improvement in mortality rates over last two decades and it has significant negative impact on post-operative survival and quality of life in patients undergoing MH. No risk model is currently available to identify those patients at higher risk of major complications after MH. Methods: Prospective recruitment of patients undergoing MH for various indications was performed. Pre-operative clinical and laboratory data including liver stiffness and indocyanine green retention at 15 min (ICG-R15) were analyzed to identify independent risk factors for major complications, defined as >Grade II complications according to Clavien-Dindo classification during the 90-day post-operative period. A nomogram was built with only pre-operative predictors and validated by Heat map plot. Results: Complications observed after 164 MHs (56.7% men, median age-62 years) were Grade I (12.8%), Grade II (39%), Grade IIIa (9.8%), Grade IIIb (17.1%), Grade IVa (0.6%), Grade IVb (0%) and Grade V (2.4%) with 49 patients (29.9%) developing major complications. Three preoperative parameters: patient's age, ICG-R15, and extent of liver resection, were identified and internally validated by bootstrap as independent predictors of major complications after MH. A nomogram (Figure1) built with these three factors demonstrated a good discriminatory performance with area under receiver operating curve of 0.76 and an excellent Goodness-of-fit in Heat map plot. Conclusions: This novel and simple nomogram accurately predicts major complications in a patient undergoing MH. This allows pre-operative identification of patients at risk and may influence decision making for surgical intervention.

Background and objectives It is increasingly accepted that quality of colon cancer surgery might be secured by combining volume standards with audit implementation. However, debate remains about other structural factors also influencing this quality, such as hospital teaching status. This study evaluates short-term outcomes after colon cancer surgery of patients treated in general, teaching or academic hospitals. Methods All patients (n = 23,593) registered in the Dutch Colorectal Audit undergoing colon cancer surgery between 2011 and 2014 were included. Patients were divided into groups based on teaching status of their hospital. Main outcome measures were serious complications, failure to rescue (FTR) and 30-day or in-hospital mortality. Multivariate logistic regression models on these outcome measures and with hospital teaching status as primary determinant were used, adjusted for case-mix, year of surgery and hospital volume. Results Patients treated in teaching and academic hospitals showed higher adjusted serious complication rates, compared to patients treated in general hospitals (odds ratio 1.25 95% ). However, patients treated in teaching hospitals had lower adjusted FTR rates than patients treated in general hospitals (OR 0.63 [0.44-0.89]). However, for all outcomes there was considerable between-hospitals variation within each type of teaching status. Conclusion On average, patients treated in general hospitals had lower serious complication rates, but patients treated in teaching hospitals had more favorable FTR rates. Given the hospital variation within each hospital teaching type, it is possible to deliver excellent care regardless of the hospital teaching type.