Η επίδραση των βιολογικών συγκολλητικών στεγανοποιητικών παραγόντων σε πειραματικό μοντέλο διάτρησης εντέρου

Στόχος: Τα τελευταία χρόνια, όλο και περισσότερες χειρουργικές ειδικότητες, με κυμαινόμενη κατάρτιση στη χειρουργική του εντέρου, εμπλέκονται στη λαπαροσκοπική χειρουργική. Ο σκοπός της παρούσας πειραματικής μελέτης ήταν η διερεύνηση της αποτελεσματικότητας της χρήσης TISSEEL™ αντί για τοποθέτηση ραμμάτων σε εντερικές κακώσεις περιορισμένης έκτασης σε επίμυες. Μέθοδος: Είκοσι τέσσερις επίμυες γένους Sprague-Dawley υπεβλήθησαν σε διάτρηση εντέρου περιορισμένης έκτασης και χωρίστηκαν σε τρεις ομάδες: ΡΑΜΜΑ, ΡΑΜΜΑ + TISSEEL™ και TISSEEL™. Μετά την ευθανασία των πειραματόζωων ακολούθησε ιστοπαθολογική ανάλυση. Αποτελέσματα: Το μέσο βάρος των επιμύων ήταν 526 ± 50 gr. Ένα πειραματόζωο παρουσίασε αιματοχεσία την 1η μετεγχειρητική ημέρα. Μετά τη χρήση TISSEEL™ ήταν έκδηλη η ελάττωση της αιμορραγίας στο σημείο της κάκωσης διεγχειρητικά. Στην τρίτη ομάδα επιμύων (TISSEEL™) παρατηρήθηκαν λιγότερες ενδοπεριτοναϊκές συμφύσεις και αιμορραγικές διηθήσεις σε σχέση με τις άλλες δύο ομάδες. Επιπλέον, η ομάδα TISSEEL™ παρουσίασε σχηματισμό θρόμβου στο σημείο της διάτρησης σε σχέση με τις άλλες δύο ομάδες (p=0.042). Η ιστοπαθολογική ανάλυση έδειξε μειωμένη φλεγμονώδη διήθηση (p=0.003), ελαττωμένη ίνωση (p=0.001) και καλύτερη ιστική αναδόμηση (p=0.000) στην ομάδα TISSEEL™ σε σχέση με τις άλλες δύο ομάδες. Συμπέρασμα: Η χρήση TISSEEL™ για την αντιμετώπιση περιορισμένων εντερικών κακώσεων φαίνεται να είναι μια ασφαλής και αποτελεσματική επιλογή. Ωστόσο απαιτούνται περεταίρω πειραματικές και κλινικές μελέτες.Background: During the last decades, surgeons of several specialties, that present different level of expertise in colon handling, have been involved in laparoscopic procedures. The aim of the present experimental study was to investigate the feasibility of TISSEEL™ versus the conventional suture placement technique on confined bowel lesions in rats. Methods: Twenty-four Sprague-Dawley rats underwent confined bowel perforation and were divided into three groups: SUTURE group (sutures were used), SUTURE + TISSEEL™ group (sutures and TISSEEL™ were utilized) and TISSEEL™ group (only TISSEEL™ was used). Blinded histopathologic analysis followed animal sacrifice. Results: The median weight of rats was 526 ± 50 gr. A single animal had hematochezia on the first postoperative day. Cessation of bleeding at the perforation margin was indicated intraoperatively after TISSEEL™ application. Animals in TISSEEL™ group presented less intraperitoneal adhesions and lower hemorrhagic infiltration compared to animals of the two other groups. In addition, animals in TISSEEL™ group showed thrombus formation at the bowel perforation site compared to animals of the two other groups (p=0.042). Histopathologic analysis demonstrated reduced inflammatory reaction (p=0.003), diminished fibrosis (p=0.001) and better tissue regeneration (p=0.000) in the TISSEEL™ group compared to the other two groups. Conclusion: Application of TISSEEL™ at the site perforation was associated with increased regeneration of the intestinal wall and less inflammatory and fibrotic reaction compared to suture placement. However, more experimental and clinical studies should be conducted before implementation in humans

Undifferentiated carcinoma with osteoclast-like giant cells of the pancreas: An individual participant data meta-analysis

Undifferentiated carcinoma with osteoclast-like giant cells (UC-OGCs) of the pancreas is a rare neoplasm that accounts for less than 1% of all pancreatic malignancies. The aim of this study was to review the literature regarding UC-OGC, and to highlight its biological behavior, clinicopathologic characteristics, prognosis, and therapeutic options. A systematic review of the literature in PubMed/Medline and Scopus databases was performed (last search October 31st, 2023) for articles concerning pancreatic UC-OGC in the adult population. Fifty-seven studies met the inclusion criteria, involving 69 patients with a male-to-female ratio of 1.1:1 and a mean age of 62.96. Main symptoms included abdominal pain (33.3%), jaundice (14.5%), weight loss (8.7%), while fourteen patients (20.3%) were asymptomatic. Surgical resection was performed in 88.4% of cases. Survival rates at one, three, and five years were 58%, 44.7%, and 37.3% respectively. Sex, age, size (cut-off of 4 cm), location, and adjuvant treatment did not significantly affect patient survival. UC-OGC of the pancreas is a rare subtype of undifferentiated pancreatic carcinoma with a better prognosis than conventional pancreatic ductal adenocarcinoma or undifferentiated carcinoma without giant cells. The establishment of a dedicated patient registry is imperative to further delineate the optimal treatment for this uncommon clinical entity

Pediatric trauma and emergency surgery: an international cross-sectional survey among WSES members

Background: In contrast to adults, the situation for pediatric trauma care from an international point of view and the global management of severely injured children remain rather unclear. The current study investigates structural management of pediatric trauma in centers of different trauma levels as well as experiences with pediatric trauma management around the world. Methods: A web-survey had been distributed to the global mailing list of the World Society of Emergency Surgery from 10/2021-03/2022, investigating characteristics of respondents and affiliated hospitals, case-load of pediatric trauma patients, capacities and infrastructure for critical care in children, trauma team composition, clinical work-up and individual experiences with pediatric trauma management in response to patients´ age. The collaboration group was subdivided regarding sizes of affiliated hospitals to allow comparisons concerning hospital volumes. Comparable results were conducted to statistical analysis. Results: A total of 133 participants from 34 countries, i.e. 5 continents responded to the survey. They were most commonly affiliated with larger hospitals (> 500 beds in 72.9%) and with level I or II trauma centers (82.0%), respectively. 74.4% of hospitals offer unrestricted pediatric medical care, but only 63.2% and 42.9% of the participants had sufficient experiences with trauma care in children ≤ 10 and ≤ 5 years of age (p = 0.0014). This situation is aggravated in participants from smaller hospitals (p < 0.01). With regard to hospital size (≤ 500 versus > 500 in-hospital beds), larger hospitals were more likely affiliated with advanced trauma centers, more elaborated pediatric intensive care infrastructure (p < 0.0001), treated children at all ages more frequently (p = 0.0938) and have higher case-loads of severely injured children < 12 years of age (p = 0.0009). Therefore, the majority of larger hospitals reserve either pediatric surgery departments or board-certified pediatric surgeons (p < 0.0001) and in-hospital trauma management is conducted more multi-disciplinarily. However, the majority of respondents does not feel prepared for treatment of severe pediatric trauma and call for special educational and practical training courses (overall: 80.2% and 64.3%, respectively). Conclusions: Multi-professional management of pediatric trauma and individual experiences with severely injured children depend on volumes, level of trauma centers and infrastructure of the hospital. However, respondents from hospitals at all levels of trauma care complain about an alarming lack of knowledge on pediatric trauma management

Correction to: Two years later: Is the SARS-CoV-2 pandemic still having an impact on emergency surgery? An international cross-sectional survey among WSES members

Background: The SARS-CoV-2 pandemic is still ongoing and a major challenge for health care services worldwide. In the first WSES COVID-19 emergency surgery survey, a strong negative impact on emergency surgery (ES) had been described already early in the pandemic situation. However, the knowledge is limited about current effects of the pandemic on patient flow through emergency rooms, daily routine and decision making in ES as well as their changes over time during the last two pandemic years. This second WSES COVID-19 emergency surgery survey investigates the impact of the SARS-CoV-2 pandemic on ES during the course of the pandemic. Methods: A web survey had been distributed to medical specialists in ES during a four-week period from January 2022, investigating the impact of the pandemic on patients and septic diseases both requiring ES, structural problems due to the pandemic and time-to-intervention in ES routine. Results: 367 collaborators from 59 countries responded to the survey. The majority indicated that the pandemic still significantly impacts on treatment and outcome of surgical emergency patients (83.1% and 78.5%, respectively). As reasons, the collaborators reported decreased case load in ES (44.7%), but patients presenting with more prolonged and severe diseases, especially concerning perforated appendicitis (62.1%) and diverticulitis (57.5%). Otherwise, approximately 50% of the participants still observe a delay in time-to-intervention in ES compared with the situation before the pandemic. Relevant causes leading to enlarged time-to-intervention in ES during the pandemic are persistent problems with in-hospital logistics, lacks in medical staff as well as operating room and intensive care capacities during the pandemic. This leads not only to the need for triage or transferring of ES patients to other hospitals, reported by 64.0% and 48.8% of the collaborators, respectively, but also to paradigm shifts in treatment modalities to non-operative approaches reported by 67.3% of the participants, especially in uncomplicated appendicitis, cholecystitis and multiple-recurrent diverticulitis. Conclusions: The SARS-CoV-2 pandemic still significantly impacts on care and outcome of patients in ES. Well-known problems with in-hospital logistics are not sufficiently resolved by now; however, medical staff shortages and reduced capacities have been dramatically aggravated over last two pandemic years

Goodbye Hartmann trial: a prospective, international, multicenter, observational study on the current use of a surgical procedure developed a century ago

Background: Literature suggests colonic resection and primary anastomosis (RPA) instead of Hartmann's procedure (HP) for the treatment of left-sided colonic emergencies. We aim to evaluate the surgical options globally used to treat patients with acute left-sided colonic emergencies and the factors that leading to the choice of treatment, comparing HP and RPA. Methods: This is a prospective, international, multicenter, observational study registered on ClinicalTrials.gov. A total 1215 patients with left-sided colonic emergencies who required surgery were included from 204 centers during the period of March 1, 2020, to May 31, 2020. with a 1-year follow-up. Results: 564 patients (43.1%) were females. The mean age was 65.9 ± 15.6 years. HP was performed in 697 (57.3%) patients and RPA in 384 (31.6%) cases. Complicated acute diverticulitis was the most common cause of left-sided colonic emergencies (40.2%), followed by colorectal malignancy (36.6%). Severe complications (Clavien-Dindo ≥ 3b) were higher in the HP group (P < 0.001). 30-day mortality was higher in HP patients (13.7%), especially in case of bowel perforation and diffused peritonitis. 1-year follow-up showed no differences on ostomy reversal rate between HP and RPA. (P = 0.127). A backward likelihood logistic regression model showed that RPA was preferred in younger patients, having low ASA score (≤ 3), in case of large bowel obstruction, absence of colonic ischemia, longer time from admission to surgery, operating early at the day working hours, by a surgeon who performed more than 50 colorectal resections. Conclusions: After 100 years since the first Hartmann's procedure, HP remains the most common treatment for left-sided colorectal emergencies. Treatment's choice depends on patient characteristics, the time of surgery and the experience of the surgeon. RPA should be considered as the gold standard for surgery, with HP being an exception

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

Synthetic or biologic mesh for the abdominal wall reconstruction in contaminated surgical fields? A meta-analysis of randomized controlled trials and observational cohort studies.

Mesh utilization for abdominal wall reconstruction in contaminated (CDC class > I) surgical fields is still a challenge for most surgeons worldwide. During recent years, the quandary has shifted from the mesh employment or not, to the selection of the optimal mesh type. The present meta-analysis demonstrated lower recurrence rates for synthetic mesh compared to biologic mesh, while SSIs were similar among the two groups. In addition, length of hospital stay and overall hospital cost were significantly lower for synthetic mesh, while all other outcomes (hematomas, seromas, SSOs, readmissions and reoperations) were similar compared to synthetic mesh. Therefore, synthetic mesh seems to be a safe and effective option for abdominal wall reconstruction in contaminated fields compared to biologic mesh, but also emerging outcomes from biosynthetic mesh use in such wounds should always be considered

Could FiLaC™ be the revolution in the treatment of anal fistulas? A systematic review of observational studies and proportional meta-analysis.

Purpose: Anal fistula disease still impairs the quality of life of thousands of patients. Despite its efficacy, the traditional surgical treatment with fistulotomy presents high rates of fecal incontinence due to division of the external sphincter. Therefore, new sphincter preserving techniques, like Fistula Laser Closure (FiLaC™), that include surgical interventions combined to new technologies and biomaterials have risen. The aim of the present meta-analysis is to present the efficacy and the safety of FiLaC™ in the management of anal fistula disease. Methods: The present proportional meta-analysis was designed using the PRISMA and AMSTAR guidelines. We searched Medline, Scopus, Clinicaltrials.gov, EMBASE, Cochrane Central Register of Controlled Trials CENTRAL and Google Scholar databases from inception until November 2019. Results: Overall, eight studies were included that recruited 476 patients. The pooled success rate of the technique was 63% (95% CI = 50 to 75). The pooled complication rate was 8% (95 CI = 1 to 18). 66% of the patients suffered from a transphincteric type of anal fistula, while 60% of patients had undergone a previous surgical intervention, mainly a seton (54%). The majority of the patients suffered from a cryptoglandular fistula. Operation time and follow-up period were described for each study. Conclusion: FiLaC™ seems to be an efficient therapeutic option for perianal fistula disease with an adequate level of safety, that preserves quality of life for patients. Nevertheless, randomized trials need to be designed for the comparison of FiLaC™ with the most common procedures for the management of anal fistulas