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Background Endoscopic vacuum therapy (EVT) with or without early surgical closure (ESC) is considered an effective option in the management of pelvic anastomotic leakage. This meta-analysis evaluated the effectiveness of EVT in terms of stoma reversal rate and the added value of ESC. Methods A systematic search of PubMed, MEDLINE, and the Cochrane Library was conducted in November 2021 to identify articles on EVT in adult patients with pelvic anastomotic leakage. The primary outcome was restored continuity rate. Following PRISMA guidelines, a meta-analysis was undertaken using a random-effects model. Results Twenty-nine studies were included, accounting for 827 patients with leakage who underwent EVT. There was large heterogeneity between studies in design and reported outcomes, and a high risk of bias. The overall weighted mean restored continuity rate was 66.8 (95 per cent c.i. 58.8 to 73.9) per cent. In patients undergoing EVT with ESC, the calculated restored continuity rate was 82 per cent (95 per cent c.i. 50.1 to 95.4) as compared to 64.7 per cent (95 per cent c.i. 55.7 to 72.7) after EVT without ESC. The mean number of sponge exchanges was 4 (95 per cent c.i. 2.7 to 4.6) and 9.8 (95 per cent c.i. 7.3 to 12.3), respectively. Sensitivity analysis showed a restored continuity rate of 81 per cent (95 per cent c.i. 55.8 to 99.5) for benign disease, 69.0 per cent (95 per cent c.i. 57.3 to 78.7) for colorectal cancer, and 65 per cent (95 per cent c.i. 48.8 to 79.1) if neoadjuvant radiotherapy was given. Conclusion EVT is associated with satisfactory stoma reversal rates that may be improved if it is combined with ESC.

IntroductionChange in lifestyle and diets is a part of the bariatric surgery process. Preoperative weight loss is still considered obligatory in some programs, but its benefits remain controversial. This study aimed to evaluate the influence of the preoperative weight loss on the postoperative results, in terms of long-term weight loss and perioperative morbidity.Methods.A retrospective review from the prospective collected database was performed. Patients operated for Roux-n-Y Gastric bypass (RYGB) or Sleeve Gastrectomy (SG) as a primary procedure with at least 5 years of follow-up were analysed. Two group of patients were defined depending on if any preoperative weight loss was achieved or not. Patients with 5% or more weight loss were independently evaluated too. Weight loss up to 5 years, nadir weight loss and early postoperative morbidity were analysed.Results.419 Patients were included (225 RYGB and 194 SG), 324 (77.3%) were women, with a mean age of 45.85 years (ranging 15 to 69). 178 patients (42.5%) achieved any weight loss prior to surgery, and just 26 (13.4%) more than 5%. Preoperative weight loss did not correlate with less morbidity, leak o reoperation rate after SG. In the RYGB preoperative weight loss patients showed a trend to higher morbidity.In terms of weight loss, preoperative weight loss patients did not achieve better nadir BMI (27.99kg/m2 vs 28.55kg/m2, p=0.213) nor final BMI (31.56kg/m2 vs 32.04kg/m2, p=0.412). Those results were repeated when RYGB and SG patients were analysed independently. Univariate and multivariate analyses did not find that PWL had any relationship to nadir BMI, final BMI nor postoperative morbidity, leak or reoperation risk.Conclusions.Preoperative weight loss did not correlate to better postoperative results nor to better weight loss results in our series.

Recurrent pyogenic cholangitis is a chronic infection characterized by intrahepatic biliary stones and strictures. Escherichia coli is the commonest infecting organism. This disease is very common in East Asia but infrequent in Western countries, and few reports have been published in European series. The therapeutic approach for hepatolithiasis is highly individual and includes antibiotic therapy, endoscopic and percutaneous biliary drainage with stone removal and dilation of strictures, surgical resection of affected liver segments and liver transplantation. We report two cases of RCP in Chinese patients treated with liver transplantation at our center out of the 34 published in the literature.

Background: It has been suggested that patients with a Body Mass Index (BMI) of > 60 kg/m2 should be offered expedited Bariatric Surgery (BS) during the Coronavirus Disease-2019 (COVID-19) pandemic. The main objective of this study was to assess the safety of this approach. Methods: We conducted a global study of patients who underwent BS between 1/05/2020 and 31/10/2020. Patients were divided into three groups according to their preoperative BMI - Group I (BMI60 kg/m2). The effect of preoperative BMI on 30-day morbidity and mortality, procedure choice, COVID-19 specific safety protocols, and comorbidities was assessed. Results: This study included 7084 patients (5197;73.4 % females). The mean preoperative weight and BMI were 119.49 ± 24.4 Kgs and 43.03 ± 6.9 Kg/m2, respectively. Group I included 6024 (85 %) patients, whereas Groups II and III included 905 (13 %) and 155 (2 %) patients, respectively. The 30-day mortality rate was higher in Group III (p = 0.001). The complication rate and COVID-19 infection were not different. Comorbidities were significantly more likely in Group III (p = 70 kg/m2 had a 30-day mortality of 7.7 % (2/26). None of these patients underwent a Roux-en-Y Gastric Bypass. Conclusion: The 30-day mortality rate was significantly higher in patients with BMI > 60 kg/m2. There was, however, no significant difference in complications rates in different BMI groups, probably due to differences in procedure selection.

Background Age ≥ 65 years is regarded as a relative contraindication for bariatric surgery. Advanced age is also a recognised risk factor for adverse outcomes with Coronavirus Disease-2019 (COVID-19) which continues to wreak havoc on global populations. This study aimed to assess the safety of bariatric surgery (BS) in this particular age group during the COVID-19 pandemic in comparison with the younger cohort. Methods We conducted a prospective international study of patients who underwent BS between 1/05/2020 and 31/10/2020. Patients were divided into two groups — patients ≥ 65-years-old (Group I) and patients < 65-years-old (Group II). The two groups were compared for 30-day morbidity and mortality. Results There were 149 patients in Group 1 and 6923 patients in Group II. The mean age, preoperative weight, and BMI were 67.6 ± 2.5 years, 119.5 ± 24.5 kg, and 43 ± 7 in Group I and 39.8 ± 11.3 years, 117.7±20.4 kg, and 43.7 ± 7 in Group II, respectively. Approximately, 95% of patients in Group 1 had at least one co-morbidity compared to 68% of patients in Group 2 (p = < 0.001). The 30-day morbidity was significantly higher in Group I (11.4%) compared to Group II (6.6%) (p = 0.022). However, the 30-day mortality and COVID-19 infection rates were not significantly different between the two groups. Conclusions Bariatric surgery during the COVID-19 pandemic is associated with a higher complication rate in those ≥ 65 years of age compared to those < 65 years old. However, the mortality and postoperative COVID-19 infection rates are not significantly different between the two groups. Graphical abstract

We describe the case of a COVID-19 patient who developed an intestinal ischaemia with thrombotic origin, confirmed by anatomo-pathological examination. A middle-aged woman affected with COVID-19 was evaluated in March 2020. Reverse transcriptase-polymerase chain reaction (RT-PCR) to detect SARS-CoV2 was performed. On the 16th day of being hospitalized, she presented with hemodynamic and respiratory impairment. The physical examination revealed abdominal distension. An urgent abdominal CT scan reported signs of pneumatosis in the distal ileum and ascending colon suggestive of ischaemia (Figure 1D), with mural irregularity predominantly in the ileum. An urgent exploratory laparotomy was performed. Ischaemia of the right colon, as well as patched ischaemia of the distal and middle ileum, was found (Figures 2A & 2B). A right hemicolectomy and resection of the distal-middle ileum with a terminal ileostomy were performed. Pathological examination reported: severe ischaemic colitis, with areas of mucosal necrosis and the presence of abundant small-calibre thrombi in the submucosa and medium-caliber vessels of the mesocolon. Re-examination of the CT scan revealed findings consistent with right lower lobe segmental pulmonary embolism, as well as inferior vena cava filling defects consistent with thrombi. COVID-19 is associated with a large and misleading field of complications, including coagulopathy. The combination of viral injury, cytokine release, and damage-associated molecular patterns induce localized microvascular inflammation, which triggers endothelial activation, leading to vasodilation and prothrombotic conditions. We report this case to alert physicians that they should be vigilant for signs of abdominal thromboembolic complications in patients suffering from COVID-19

Background: Surgical site infections (SSIs) remains a concern for surgeons because of the negative impact on outcomes and health care costs. Our purpose was to assess whether topical antibiotics before primary incision closure reduced the rate of SSIs. Methods: Systematic review of MEDLINE/PubMed, Scopus, CINAHL, and Web of Science databases from inception to January 2017. Only randomized controlled trials (RCTs) were retrieved. The primary outcome was the SSI rate. Meta-analysis was complemented with trial sequential analysis (TSA). Results: Thirty-five RCTs (10,870 patients) were included. Only β-lactams and aminoglycosides were used. A substantial reduction of the incidence of SSIs with the application of antibiotic agents before incision closure (risk ratio [RR] 0.49, 95% confidence interval [CI] 0.37-0.64) was found, which remained in the analysis of 12 RCTs after removal of studies of uncertain quality. The use of β-lactams was effective to reduce SSI in elective surgery only (RR 0.33, 95% CI 0.13-0.85). In clean-contaminated fields and as an irrigation solution, β-lactams did not reduce the risk of SSI. Aminoglycosides were not effective (RR 0.74, 95% CI 0.49-1.10). After TSA, the evidence accumulated was far below the optimal information size. The heterogeneity of studies was high and methodological quality of most RCTs included in the meta-analysis was uncertain. Conclusions: Results of this meta-analysis show the data present in the literature are not sufficiently robust and, therefore, the use of topical β-lactams or aminoglycosides before incision closure to reduce SSI cannot be recommended or excluded.

Sleeve gastrectomy (SG) has become one of the most performed bariatric procedures worldwide. Its main weaknesses are weight regain and gastroesophageal reflux disease (GERD). Conversion to Roux-en-Y gastric bypass (RYGB) is considered the gold standard to manage GERD and related symptoms. Retrospective evaluation from a prospective bariatric surgery database of all our institution’s patients converted from SG to RYGB due to GERD between January 2010 and December 2018. Clinical characteristics and workups before SG and before and after RYGB were analyzed. During the study period, 35 patients needed a conversion to RYGB, due to GERD or GERD-related symptoms. Mean age was 48.6 years, 85.7% were women, and mean BMI was 31.4 kg/m2. The interval between SG and RYGB was in a range 7 to 70 months (mean 33 months). All conversions were completed laparoscopically, associating a hiatoplasty in 45.7% of cases. A complete remission of symptoms was observed in 74% of patients, some improvement in 20%, and no relief in 6%. There were 3 cases of hiatal hernia persistence and 2 of recidivism. Only 1 patient presented pathological pHmetry, while moderate esophagitis was demonstrated in 2 patients. Conversion to RYGB was effective in almost all patients. Pathological acid exposure and hiatal hernias seem to be the main findings prior to conversion, justifying an exhaustive examination and aggressive approach to the hiatus. Due to the insufficient correlation between symptoms and findings on morphological and functional tests, actively searching for signs of GERD is advisable.

Background Over the course of the COVID19 pandemic, global healthcare delivery has declined. Surgery is one of the most resource-intensive area of medicine; loss of surgical care has had untold health and economic consequences. Herein, we evaluate resource utilization, outcomes, and healthcare costs associated with unplanned surgery admissions during the height of the pandemic in 2020 versus the same period in 2019. Methods Retrospective analysis on patients ≥18 years admitted from the emergency department to General & Digestive and Gastrointestinal Surgery Services between February and May 2019 and 2020 at our center; clinical outcomes and unadjusted and adjusted per-person healthcare costs were analyzed. Results Consults and admissions to surgery declined between February and May 2020 by 37% and 19%, respectively, relative to the same period in 2019, with even greater relative decline during late March and early April. Time between onset of symptoms to diagnosis increased from 2±3 days 2019 to 5±22 days 2020 (P = 0.01). Overall hospital stay was two days less in 2020 (P = 0.19). Complications (Comprehensive Complication Index 10.3±23.7 2019 vs. 13.9±25.5 2020, P = 0.10) and mortality rates (3% vs. 4%, respectively, P = 0.58) did not vary. Mean unadjusted per-person costs for patients in the 2019 and 2020 cohorts were 5,886.72€±12,576.33€ and 5,287.62±7,220.16€, respectively (P = 0.43). Following multivariate analysis, costs remained similar (4,656.89€±390.53€ 2019 vs. 4,938.54±406.55€ 2020, P = 0.28). Conclusions Healthcare delivery and spending for unplanned general surgery admissions declined considerably due to COVID19. These results provide a small yet relevant illustration of clinical and economic ramifications of this healthcare crisis.

This brief report presents the results of 20 adult and pediatric patients treated with the use of biodegradable SX-Ella biliary stents placed by means of a transhepatic approach for the treatment of benign biliary strictures after liver transplantation. Stent insertions were always feasible (100%), and only 1 case of acute pancreatitis was observed (5%). The overall clinical success rate of the procedure, including anastomotic and nonanastomotic strictures, was 75%, and was higher in the anastomotic stricture group (81.25%) than in the nonanastomotic stricture group (50%).

Laparoscopic single anastomosis duodenoileal bypass with sleeve gastrectomy (SADI-S) is a recently developed one- or two-stage operation based on biliopancreatic diversion that is used to treat morbid obesity. Some midterm outcomes suggest that malabsorption is a possible complication following the procedure. Therefore, conversion to a less malabsorptive procedure may be required. We aim to describe and analyze the outcomes after laparoscopic conversion of SADI-S to non-malabsorptive or less malabsorptive procedures. From January 2015 to April 2017, five patients underwent laparoscopic conversion to single anastomosis duodenojejunal bypass with sleeve gastrectomy (SADJ-S) (video) following SADI-S, and one female patient underwent laparoscopic conversion to gastric bypass (GBP) following SADI-S, after presenting with severe protein-calorie malnutrition, nutritional deficiencies, poor quality of life, or increased number of bowel movements. Mean preoperative BMI was 24.0 kg/m2 (20.4–27.5 kg/m2). Four patients underwent SADI-S to SADJ-S conversions and one underwent a SADI-S to Roux-en-Y duodenojejunal bypass. All cases were performed laparoscopically. No relevant postoperative complications or mortality was reported and the mean hospital stay was 4.6 days. Malabsorptive symptoms resolved in all patients. All patients experienced weight regain. Mean BMI increase was 7.1 kg/m2 (5–10.8 kg/m2). Outcomes of laparoscopic conversion to SADJ-S or GBP after SADI-S were acceptable, showing clinical improvement of malnutrition, nutritional deficiencies, and quality of life in all cases. Weight regain must be advised. These techniques appear feasible and free of severe long-term complications. Further investigation is warranted to understand the best common channel length for patients undergoing SADI-S.

PURPOSE: The introduction of transanal endoscopic or minimally invasive surgery has allowed organ preservation for rectal tumors with good oncological results. Data on functional and quality-of-life (QoL) outcomes are scarce and controversial. This systematic review sought to synthesize fecal continence, QoL, and manometric outcomes after transanal endoscopic microsurgery (TEM) or transanal minimally invasive surgery (TAMIS). METHODS: A systematic review of the literature including Medline, Embase, and the Cochrane Library databases was conducted searching for articles reporting on functional outcomes after TEM or TAMIS between January 1995 and June 2018. The evaluated outcome parameters were pre- and postoperative fecal continence (primary endpoint), QoL, and manometric results. Data were extracted using the same scales and measurement units as from the original study. RESULTS: A total of 29 studies comprising 1297 patients were included. Fecal continence outcomes were evaluated in 23 (79%) studies with a wide variety of assessment tools and divergent results. Ten studies (34%) analyzed QoL changes, and manometric variables were assessed in 15 studies (51%). Most studies reported some deterioration in manometric scores without major QoL impairment. Due to the heterogeneity of the data, it was not possible to perform any pooled analysis or meta-analysis. CONCLUSIONS: These techniques do not seem to affect continence by themselves except in minor cases. The possibility of worsened function after TEM and TAMIS should not be underestimated. There is a need to homogenize or standardize functional and manometric outcomes assessment after TEM or TAMIS.

Povidone iodine (PVI) is a widely used antiseptic solution among surgeons. A meta-analysis based on randomized controlled trials (RCTs) was conducted to establish whether application of PVI before wound closure could reduce surgical site infection (SSI) rates. Systematic review of MEDLINE/PubMed, Scopus, CINAHL, and Web of Science databases from inception to September 2017, with no language restrictions. Only RCTs were retrieved. The primary outcome was the SSI rate. Meta-analysis was complemented with trial sequential analysis (TSA). A total of 7601 patients collected from 16 RCTs were analyzed. A reduction in overall SSI rate was found (RR 0.64, 95% CI 0.48–0.85, P = 0.002, I2 = 65%), which was attributed to patients undergoing elective operations (n = 2358) and mixed elective/urgent operations (n = 2019). When RCTs of uncertain quality (n = 9) were excluded, the use of PVI before wound closure (n = 4322 patients) was not associated with a significant reduction of SSI (RR 0.81, 95% CI 0.55–1.20, P = 0.29, I2 = 51%) and was only significant in clean wounds (RR 0.25, 95% CI 0.09–0.70, P = 0.008, I2 = 0%). For the primary outcome, the TSA calculation using a relative risk reduction of 19% and an 11% proportion of control event rate (CER) with 51% of I2, the accrued information size (n = 4322) was 32.8% of the estimated optimal information size (n = 13,148). There is no conclusive evidence for a strong recommendation of topical PVI before wound closure to prevent SSI.

Resumen Introduccion Tras la introduccion del abordaje laparoscopico en la cirugia adrenal, esta tecnica se ha convertido en el estandar de referencia para el tratamiento de las enfermedades quirurgicas adrenales. A pesar de ello, los estudios comparativos con el abordaje abierto son escasos, y no se conoce el impacto que las tecnicas laparoscopicas pueden haber tenido en su tratamiento. Objetivo Evaluar la experiencia en cirugia adrenal durante un periodo de 14 anos, antes y despues de la introduccion de la adrenalectomia laparoscopica, y analizar la influencia de esta tecnica en el abordaje quirurgico de las enfermedades adrenales. Pacientes y metodo Entre enero de 1990 y junio de 2004 se realizo una adrenalectomia en 78 pacientes. En el periodo 1990-1998 se efectuo una adrenalectomia abierta en 24 pacientes, mientras que entre 1999 y 2004 se realizaron 53 abordajes por via laparoscopica y 1 por via abierta. Los datos del grupo abierto fueron revisados retrospectivamente, y los del grupo laparoscopico fueron registrados prospectivamente en la base de datos de cirugia laparoscopica avanzada del Hospital de Sant Pau. Resultados La edad media de los grupos de adrenalectomia abierta y laparoscopica fue, respectivamente, de 47 (rango, 16-75) y 49 anos (rango, 17-77) (p = NS). La distribucion por indicaciones de la cirugia fueron similares en ambos periodos en cuanto a hiperaldosteronismo primario, hipercortisolismo y feocromocitoma, con un incremento significativo de los casos indicados por malignidad (1 frente a 4) o incidentaloma (2 frente a 13) (p Conclusiones El abordaje laparoscopico ha favorecido una mejoria de los resultados quirurgicos inmediatos (tiempo operatorio, morbilidad y estancia hospitalaria). Es evidente el incremento en el numero de adrenalectomias, especialmente respecto a los incidentalomas, debido a las mejores exploraciones diagnosticas y la disponibilidad de un abordaje menos agresivo.

Laparoscopic splenectomy (LS) has been demonstrated as an effective and safe treatment for hematological disorders requiring spleen removal, especially in cases of normal-sized spleens. However, although results are promising, long-term outcome data are lacking. We reviewed our clinical experience with LS in a series of 255 cases, with particular attention to the long-term outcome related to the disease process requiring LS. From February 1993 to October 2003, LS was attempted in 255 patients (100 males and 155 females with a mean age of 45 ± 19 years) and clinical information was recorded in a prospective database. Indications for splenectomy included idiopathic thrombocytopenic purpura (ITP) (n = 115), HIV-ITP (n = 9), Evans syndrome (n = 6), autoimmune hemolytic anemia (AIHA) (n = 13), hereditary spherocytosis (HS) (n = 19), hematologic malignancy (n = 66), thrombotic thrombocytopenic purpura (n = 1), and others (n = 26). Long-term postoperative follow-up evaluation was obtained through clinical notes, follow-up visits by the referring hematologist, and by phone interviews both with patients and with the referring hematologist. A total of 186 patients (73%) were available for a mean follow-up of 35 months (range, 1–104). Of the ITP patients, 87 (76%) were followed up, with a remission rate of 89% (complete remission in 75%). A similar remission rate was observed in ITP-HIV; in patients available for follow-up (78%), complete remission was achieved in 83%. In Evans, complete remission was achieved in all patients available for follow-up (67%). Clinical response for hemolytic disease ranged between 70% for AIHA and 100% for HS. In the malignant group, the late mortality rate was 22%. The mortality rate in the miscellaneous group was 5%. No cases of splenectomy-related sepsis occurred during follow-up. LS offers advantages for all types of splenic diseases requiring surgery. It provides not only good clinical short-term outcome but also satisfactory long-term hematological results.