Publications by authors named "Ugo Grossi"

63 Publications

AFCOS: The Development of a Cryptoglandular Anal Fistula Core Outcome Set.

Ann Surg 2022 Jul 11. Epub 2022 Jul 11.

Department of Surgery and Colorectal Surgery, NUTRIM, School of Nutrition and Translational Research in Metabolism, GROW-School for Oncology and Reproduction, Maastricht University Medical Centre+, The Netherlands.

Objective: To develop a cryptoglandular Anal Fistula Core Outcome Set: a minimum set of outcomes that should be measured in all studies of cryptoglandular anal fistula treatment.

Background: Variability in the outcomes that are reported in studies of cryptoglandular anal fistula treatment hampers systematic evidence synthesis to identify the best treatment.

Methods: This study followed guidance from the Core Outcome Measures in Effectiveness Trials initiative and consisted of three stages: (1) generation of candidate outcomes through systematic review of the literature and qualitative patient interviews; (2) prioritization of outcomes by key stakeholders, including patients, surgeons, gastroenterologists, and radiologists in an online Delphi consensus process; and (3) determination of the final Core Outcome Set (COS) in a consensus meeting attended by patients and clinicians.

Results: Sixty-four outcomes were presented in the first Delphi survey round. A total of 191 participants from over 30 countries ranked these outcomes according to their importance in defining treatment success (57.6% surgeons and gastroenterologists, 8.9% radiologists, and 33.5% patients). After two rounds, 53 outcomes were identified as important and discussed in the consensus meeting attended by 10 patients and 12 clinicians. A final 10 outcomes were voted into the COS: clinical fistula healing, radiological healing, recurrence, development of additional fistulas, fistula symptoms, incontinence, psychological impact of treatment, complications and reinterventions, patient satisfaction, and quality of life.

Conclusion: The final COS represents an international, multidisciplinary, patient-centered attempt to establish consistency in fistula research, with a substantial focus on patient priorities for treatment.
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http://dx.doi.org/10.1097/SLA.0000000000005462DOI Listing
July 2022

Anoplasty for anatomical anal stenosis: systematic review of complications and recurrences.

Colorectal Dis 2022 Jul 6. Epub 2022 Jul 6.

II Surgery Unit, Regional Hospital Treviso, AULSS2, Treviso, Italy.

Aim: The optimal surgical treatment for anatomical anal stenosis (AS) remains to be determined. The aim of this study was to determine the rates of complications and recurrence after anoplasty for anatomical AS and, wherever feasible, compare the outcomes for the various techniques.

Method: A PROSPERO-registered systematic review was reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Medline, PubMed, Embase, Cochrane Library of Systematic Review, Scopus and Web of Science were searched for articles published up to May 2021. Studies that assessed the outcomes of anoplasty in adult patients with anatomical AS were selected. The primary outcomes were complications and recurrence. The methodological quality of studies was appraised using the Joanna Briggs Institute critical appraisal tools.

Results: From the total of 2705 unique screened records, 151 were assessed for eligibility. Only 29 studies (two prospective) met the inclusion criteria, reporting data on 556 patients [mean age 53 (18-83) years, 46% female]. Previous history of surgery for haemorrhoidal disease accounted for three quarters of cases. A total of 14 types of anoplasty were found, with the Y-V flap being the most performed technique [27% of cases (n = 149)]. Complications frequently occurred, with a pooled prevalence of 10.2% (95% CI 3.9%-24.1%) after Y-V flap and 11.5% (5.3%-23.0%) after rhomboid/diamond flap. Patients undergoing house flap achieved better results in terms of clinical improvement, satisfaction and quality of life compared with Y-V flap and rhomboid/diamond flap. When considering only studies with at least 12 months of follow-up, the pooled prevalence of recurrence was 4.7% (2.2%-9.8%), with significantly higher rates observed in the prospective versus retrospective series [pooled prevalence 18.9% (11.5%-29.5%) vs. 3.6% (1.7-7.8%), respectively; p < 0.001].

Conclusion: Both complications and recurrence were significantly lower after house flap compared with rhomboid/diamond and Y-V flap. Better designed multicentre studies with longer follow-up are needed to confirm these findings.

Prospero Registration Number: CRD42021239493.
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http://dx.doi.org/10.1111/codi.16248DOI Listing
July 2022

Management and Treatment of External Hemorrhoidal Thrombosis.

Front Surg 2022 3;9:898850. Epub 2022 May 3.

Department of Medicine, Surgery and Neurosciences, Unit of General Surgery and Surgical Oncology, University of Siena, Siena, Italy.

Background: External hemorrhoidal thrombosis (EHT) is a common complication of hemorrhoidal disease. This condition causes extreme pain, likely resulting from internal anal sphincter hypertonicity, which traps the hemorrhoids below the dentate line thus leading to congestion and swelling. The choice of treatment remains controversial and both conservative and surgical options have been proposed in the last decades.

Methods: This mini-review focuses on the most relevant studies found in literature evaluating conservative and surgical management of EHT. Special conditions such as pregnancy and EHT in elderly patients have been considered.

Results: Traditionally, symptoms duration represents the discriminant in the choice between medical and surgical treatment. Several Coloproctological Societies considered conservative treatment as the first-line approach to EHT and a variety of options have been proposed: wait and see, mixture of flavonoids, mix of lidocaine and nifedipine, botulinum toxin injection and topical application of 0.2% glyceryl trinitrate. Meanwhile, different surgical treatments are recommended when EHT fails to respond to conservative management or when symptoms onset falls within the last 48-72 h: drainage with radial incision, conventional excision, excision under local anesthesia and stapled technique.

Conclusion: The management and treatment of EHT is still controversial since no specific guidelines have been published. Both medical and surgical treatment have been proven effective but randomized clinical trials and structured consensus-based guidelines are warranted.
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http://dx.doi.org/10.3389/fsurg.2022.898850DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9110961PMC
May 2022

Anal Fistula Human Amniotic Membrane Endosealing (F-HAME): A Proof of Concept Study.

Front Surg 2022 28;9:869923. Epub 2022 Mar 28.

II Surgery Unit, Regional Hospital Treviso, Treviso, Italy.

The treatment of cryptoglandular anal fistula (AF) is often a challenge for surgeons. Several sphincter-saving procedures have been described as an alternative to fistulotomy, with the common goal of promoting healing and preserve anal continence. The aim of this proof of concept study was to assess the outcomes of human amniotic membrane (HAM) implantation in cryptoglandular transphincteric AF. Two consecutive female were recruited. The primary outcome was clinical healing at 6 months. Secondary outcomes were ultrasonographic healing, complications and reinterventions, AF symptoms, fecal incontinence, psychological impact of treatment, recurrence, development of additional AF, patient satisfaction, and quality of life, as measured using validated questionnaires. Both patients (40 and 54-year-old) previously underwent incision and drainage of anal abscess with concomitant seton placement. HAM implantation was performed as a day case under local anesthesia. No intra- or post-procedural complications occurred. Clinical and radiological healing were not achieved at 6 months. However, the external outlet discharge diminished through time, with sustained improvements in quality of life. Clinical healing occurred at 7 months in both patients. Psychological impact of treatment and patient satisfaction were overall good, with improvements in the PHQ-9, GAD-7, and Short Assessment of Patients Satisfaction. HAM implantation is safe and improves patients' quality of life, progressively leading to clinical healing. Future studies are needed to assess its safety in other etiology of AF.
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http://dx.doi.org/10.3389/fsurg.2022.869923DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8995564PMC
March 2022

Shortcomings of the current classification system for haemorrhoidal disease: Exploring the need for a step forward.

Colorectal Dis 2022 Apr 10. Epub 2022 Apr 10.

Department of Surgery, School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, The Netherlands.

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http://dx.doi.org/10.1111/codi.16144DOI Listing
April 2022

Impact of Hypogammaglobulinemia on the Course of COVID-19 in a Non-Intensive Care Setting: A Single-Center Retrospective Cohort Study.

Front Immunol 2022 10;13:842643. Epub 2022 Mar 10.

Internal Medicine I, Ca' Foncello Hospital, Azienda Unità Locale Socio Sanitaria n. 2 (AULSS2) Marca Trevigiana, Treviso, Italy.

Background: Severity and mortality of COVID-19 largely depends on the ability of the immune system to clear the virus. Among various comorbidities potentially impacting on this process, the weight and the consequences of an antibody deficiency have not yet been clarified.

Methods: We used serum protein electrophoresis to screen for hypogammaglobulinemia in a cohort of consecutive adult patients with COVID-19 pneumonia, hospitalized in non-intensive care setting between December 2020 and January 2021. The disease severity, measured by a validated score and by the need for semi intensive (sICU) or intensive care unit (ICU) admission, and the 30-day mortality was compared between patients presenting hypogammaglobulinemia (HYPO) and without hypogammaglobulinemia (no-HYPO). Demographics, comorbidities, COVID-19 specific treatment during the hospital stay, disease duration, complications and laboratory parameters were also evaluated in both groups.

Results: We enrolled 374 patients, of which 39 represented the HYPO cohort (10.4%). In 10/39 the condition was previously neglected, while in the other 29/39 hematologic malignancies were common (61.5%); 2/39 were on regular immunoglobulin replacement therapy (IgRT). Patients belonging to the HYPO group more frequently developed a severe COVID-19 and more often required sICU/ICU admission than no-HYPO patients. IgRT were administered in 8/39 during hospitalization; none of them died or needed sICU/ICU. Among HYPO cohort, we observed a significantly higher prevalence of neoplastic affections, of active oncologic treatment and bronchiectasis, together with higher prevalence of viral and bacterial superinfections, mechanical ventilation, convalescent plasma and SARS-CoV-2 monoclonal antibodies administration during hospital stay, and longer disease duration. Multivariate logistic regression analysis and Cox proportional hazard regression confirmed the impact of hypogammaglobulinemia on the COVID-19 severity and the probability of sICU/ICU admission. The analysis of the mortality rate in the whole cohort showed no significant difference between HYPO and no-HYPO.

Conclusions: Hypogammaglobulinemia, regardless of its cause, in COVID-19 patients hospitalized in a non-intensive care setting was associated to a more severe disease course and more frequent admission to s-ICU/ICU, particularly in absence of IgRT. Our findings emphasize the add-value of routine serum protein electrophoresis evaluation in patients admitted with COVID-19 to support clinicians in patient care and to consider IgRT initiation during hospitalization.
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http://dx.doi.org/10.3389/fimmu.2022.842643DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8960988PMC
March 2022

Changes in hospital admissions and complications of acute appendicitis during the COVID-19 pandemic: A systematic review and meta-analysis.

Health Sci Rev (Oxf) 2022 Jun 10;3:100021. Epub 2022 Mar 10.

II Surgery Unit, Treviso Regional Hospital, DISCOG, University of Padua, Italy.

Background: Acute appendicitis (AA) is one of the most common emergencies in general surgery worldwide. During the pandemic, a significant decrease in the number of accesses to the emergency department for AA has been recorded in different countries. A systematic review of the current literature sought to determine the impact of Coronavirus Disease 2019 (COVID-19) on hospital admissions and complications of AA.

Method: A systematic search was undertaken to identify repeated cross-sectional studies reporting the management of AA during the COVID-19 pandemic (index period) as compared to the previous year, or at the turn of lockdown (reference period). Data were abstracted on article (country of origin) and patients characteristics (adults, children [i.e. non adults, <18-year-old]), or mixed population) within the two given timeframes, including demographics, number of admissions for AA, number of appendectomies, and complicated appendectomies

Results: Of 201 full-text articles assessed for eligibility, 54 studies from 22 world countries were included. In total, 27 (50%) were conducted on adults, 12 (22%) on children, and 15 (28%) on a mixed patients population. The overall rate ratio of admissions for AA between the two periods was 0.94 (95%CI, 0.75-1.17), with significant differences between studies on adults (0.90 [0.74-1.09]), mixed population (0.50 [0.27-0.90]), and children (1.50 [1.01-2.22]). The overall risk ratio of complicated AA was 1.65 (1.32-2.07), ranging from 1.32 in studies on children, to 2.45 in mixed population.

Conclusion: The pandemic has altered the rate of admissions for AA and appendectomy, with parallel increased incidence of complicated cases in all age groups.
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http://dx.doi.org/10.1016/j.hsr.2022.100021DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8906891PMC
June 2022

Living with cryptoglandular anal fistula: a qualitative investigation of the patient's experience through semi-structured patient interviews.

Qual Life Res 2022 Aug 17;31(8):2505-2518. Epub 2022 Feb 17.

Robin Phillips' Fistula Research Unit, St Mark's Hospital, London, UK.

Purpose: Cryptoglandular anal fistula continues to be a subject of extensive surgical research due to the lack of effective and enduring treatments, some of which incur risks to continence and quality of life. However, the patient experience of disease has seldom been reported. The aims of this study are to understand the impact of living with a fistula and the treatment outcomes that are valued by patients.

Methods: Patients with cryptoglandular anal fistula were recruited using purposive sampling from two tertiary referral centres in the UK and the Netherlands. Patients underwent semi-structured interviews that were audio-recorded and transcribed verbatim. Dutch transcripts were translated into English and underwent independent, thematic analysis using open coding by two study team members to identify common themes and sub-themes.

Results: Twenty interviews were conducted before saturation was reached (11 male, median age 49, Interquartile range 39-55 years). Four broad themes emerged, covering the physical symptoms of fistula, the patient journey towards understanding the condition, life impact, and treatment. Several inter-related sub-themes were found, reflecting the extensive impact and adjustment that the disease entails.

Conclusion: The impact of cryptoglandular anal fistula extends beyond the physical symptoms of pain and discharge, requires significant readjustment, and often negatively impacts psycho-social wellbeing. These aspects of disease should receive greater attention in future assessment of treatment and quality of life.
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http://dx.doi.org/10.1007/s11136-022-03098-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9250474PMC
August 2022

Surgical Management of Hemorrhoidal Disease in Inflammatory Bowel Disease: A Systematic Review with Proportional Meta-Analysis.

J Clin Med 2022 Jan 28;11(3). Epub 2022 Jan 28.

II Surgery Unit, Regional Hospital Treviso, AULSS2, 31100 Treviso, Italy.

Surgical treatment of hemorrhoidal disease (HD) in inflammatory bowel disease (IBD) has been considered to be potentially harmful, but the evidence for this is poor. Therefore, a systematic review of the literature was undertaken to reappraise the safety and effectiveness of surgical treatments in this special circumstance. A MEDLINE, Web of Science, Scopus, and Cochrane Library search was performed to retrieve studies reporting the outcomes of surgical treatment of HD in patients with Crohn's disease (CD) and ulcerative colitis (UC). From a total of 2072 citations, 10 retrospective studies including 222 (range, 2-70) patients were identified. Of these, 119 (54%) had CD and 103 (46%) UC. Mean age was between 41 and 49 years (range 14-77). Most studies lacked information on the interval between surgery and the onset of complications. Operative treatments included open or closed hemorrhoidectomy ( = 156 patients (70%)), rubber band ligation ( = 39 (18%)), excision or incision of thrombosed hemorrhoid ( = 14 (6%)), and doppler-guided hemorrhoidal artery ligation (DG-HAL, = 13 (6%)). In total, 23 patients developed a complication (pooled prevalence, 9%; (95%CI, 3-16%)), with a more than two-fold higher rate in patients with CD compared to UC (11% (5-16%) vs. 5% (0-13%), respectively). Despite the low quality evidence, surgical management of HD in IBD and particularly in CD patients who have failed nonoperative therapy should still be performed with caution and limited to inactive disease. Further studies should determine whether advantages in terms of safety and effectiveness with the use of non-excisional techniques (e.g., DG-HAL) can be obtained in this patient population.
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http://dx.doi.org/10.3390/jcm11030709DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8837177PMC
January 2022

Pulsed Microwave Liver Ablation: An Additional Tool to Treat Hepatocellular Carcinoma.

Cancers (Basel) 2022 Jan 31;14(3). Epub 2022 Jan 31.

4th Surgery Unit, Regional Hospital Treviso, University of Padua, DISCOG, 31100 Padua, Italy.

This study aimed to analyze the outcomes of HCC patients treated with a novel technique-pulsed microwave ablation (MWA)-in terms of safety, local tumor progression (LTP), intrahepatic recurrence (IHR), and overall survival (OS). A total of 126 pulsed microwave procedures have been performed in our center. We included patients with mono- or multifocal HCC (BCLC 0 to D). The LTP at 12 months was 9.9%, with an IHR rate of 27.8% at one year. Survival was 92.0% at 12 months with 29.4% experiencing post-operative complications (28.6% Clavien-Dindo 1-2, 0.8% Clavien-Dindo 3-4). Stratifying patients by BCLC, we achieved BCLC 0, A, B, C, and D survival rates of 100%, 93.2%, 93.3%, 50%, and 100%, respectively, at one year, which was generally superior to or in line with the expected survival rates among patients who are started on standard treatment. The pulsed MWA technique is safe and effective. The technique can be proposed not only in patients with BCLC A staging but also in the highly selected cases of BCLC B, C, and D, confirming the importance of the concept of stage migration. This procedure, especially if performed with a minimally invasive technique (laparoscopic or percutaneous), is repeatable with a short postoperative hospital stay.
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http://dx.doi.org/10.3390/cancers14030748DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8833939PMC
January 2022

First-line steroid treatment for spontaneous intracranial hypotension.

Eur J Neurol 2022 03;29(3):947-949

II Surgery Unit, Regional Hospital Treviso, Treviso, Italy.

Background: Spontaneous intracranial hypotension (SIH) is a syndrome characterized by low cerebrospinal fluid (CSF) pressure and postural headaches, and affects 1 per 20,000 individuals every year.

Case Report: We report an otherwise healthy 38-year-old man admitted to the hospital with orthostatic headache that developed 48 h after a short-haul flight during which he sustained a neck injury due to turbulence. Neurological examination, blood analysis and computed tomography scan performed at the emergency service were normal. Brain and spine magnetic resonance imaging (MRI) showed diffuse pachymeningeal enhancement and contrast medium egress from the subarachnoid space into the epidural space at the level of C2. The patient was treated with bed rest, hydration and 1 mg/kg/day oral prednisone for 5 days, with a gradual withdrawal in the following 7 days. Complete symptomatic relief was observed after 16 days, with resolution of the pathological findings on brain and spinal MRI after 1 month, except for localized pachymeningeal enhancement. Clinical relief was maintained over time until last follow-up visit 9 months later.

Conclusion: Successful conservative treatment barely exceeds one quarter of cases of SIH. The clinical benefits of steroids may result from several mechanisms of action, for example, improving brain oedema and inflammation, determining fluid retention, and facilitating reabsorption of the CSF from extradural space. Notwithstanding that epidural blood patch remains the most successful treatment for SIH, future studies should explore the effectiveness of steroids as first-line therapy in addition to the most commonly suggested measures of bed rest and hydration.
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http://dx.doi.org/10.1111/ene.15195DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9303736PMC
March 2022

Comparison between Dexamethasone and Methylprednisolone Therapy in Patients with COVID-19 Pneumonia Admitted to Non-Intensive Medical Units.

J Clin Med 2021 Dec 12;10(24). Epub 2021 Dec 12.

Medicine 1 Unit, Department of Medicine, Ca' Foncello University Hospital, 31100 Treviso, Italy.

(1) Background: Data on different steroid compounds for the treatment of hospitalized COVID-19 (coronavirus disease 2019) patients are still limited. The aim of this study was to compare COVID-19 patients admitted to non-intensive units and treated with methylprednisolone or dexamethasone. (2) Methods: This was a single-center retrospective study that included consecutive patients with COVID-19 hospitalized in medical wards during the second wave of the pandemic. Thirty-day mortality and the need for intensive or semi-intensive care were the main clinical outcomes analyzed in patients receiving methylprednisolone (60 mg/day) compared with dexamethasone (6 mg/day). Secondary outcomes included complication rates, length of hospital stay, and time to viral clearance. (3) Results: Two-hundred-forty-six patients were included in the analysis, 110 treated with dexamethasone and 136 with methylprednisolone. No statistically significant differences were found between the two groups of patients regarding 30-day mortality (OR 1.35, CI95% 0.71-2.56, = 0.351) and the need for intensive or semi-intensive care (OR 1.94, CI95% 0.81-4.66, = 0.136). The complication rates, length of hospital stay, and time to viral clearance did not significantly differ between the two groups. (4) Conclusions: In patients hospitalized for COVID-19 in non-intensive units, the choice of different steroid compounds, such as dexamethasone or methylprednisolone, did not affect the main clinical outcomes.
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http://dx.doi.org/10.3390/jcm10245812DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8703463PMC
December 2021

What paradigm shifts occurred in the management of acute diverticulitis during the COVID-19 pandemic? A scoping review.

World J Clin Cases 2021 Aug;9(23):6759-6767

Department of General Surgery, University of Insubria, University Hospital of Varese, Varese 21100, Italy.

Background: Acute colonic diverticulitis (ACD) is common in Western countries, with its prevalence increasing throughout the world. As a result of the coronavirus disease 2019 (COVID-19), elective surgery and in-patients' visits have been cancelled or postponed worldwide.

Aim: To systematically explore the impact of the pandemic in the management of ACD.

Methods: MEDLINE, Embase, Scopus, MedxRiv, and the Cochrane Library databases were searched to 22 December 2020. Studies which reported on the management of patients with ACD during the COVID-19 pandemic were eligible. For cross sectional studies, outcomes of interest included the number of hospital admission for ACD, as well as key features of disease severity (complicated or not) across two time periods (pre- and during lockdown).

Results: A total of 69 papers were inspected, and 21 were eligible for inclusion. Ten papers were cross sectional studies from seven world countries; six were case reports; three were qualitative studies, and two review articles. A 56% overall decrease in admissions for ACD was observed during lockdown, peaking 67% in the largest series. A 4%-8% decrease in the rate of uncomplicated diverticulitis was also noted during the lockdown phase. An initial non-operative management was recommended for complicated diverticulitis, and encouraged to an out-of-hospital regimen. Despite initial concerns on the use of laparoscopy for Hinchey 3 and 4 patients to avoid aerosolized contamination, societal bodies have progressively mitigated their initial recommendations as actual risks are yet to be ascertained.

Conclusion: During the COVID-19 pandemic, fewer patients presented and were diagnosed with ACD. Such decline may have likely affected the spectrum of uncomplicated disease. Established outpatient management and follow up for selected cases may unburden healthcare resources in time of crisis.
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http://dx.doi.org/10.12998/wjcc.v9.i23.6759DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8362525PMC
August 2021

Gender distribution in the editorial boards of surgical journals: A snapshot from Western Europe.

Surgery 2021 10 6;170(4):1292. Epub 2021 Aug 6.

II Surgery Unit, Treviso Regional Hospital, DISCOG, University of Padua, Padua, Italy.

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http://dx.doi.org/10.1016/j.surg.2021.07.006DOI Listing
October 2021

E-consensus on telemedicine in colorectal surgery: a RAND/UCLA-modified study.

Updates Surg 2022 Feb 26;74(1):163-170. Epub 2021 Jul 26.

IV Surgery Unit, Treviso Regional Hospital, DISCOG, University of Padua, Padua, Italy.

Coronavirus disease 2019 (COVID-19) is revolutionizing healthcare delivery. The aim of the study was to reach consensus among experts on the possible applications of telemedicine in colorectal surgery. A group of 48 clinical practice recommendations (CPRs) was developed by a clinical guidance group based on coalescence of evidence and expert opinion. The Telemedicine in Colorectal Surgery Italian Working Group included 54 colorectal surgeons affiliated to the Italian Society of Colo-Rectal Surgery (SICCR) who were involved in the evaluation of the appropriateness of each CPR, based on published RAND/UCLA methodology, in two rounds. Stakeholders' median age was 44.5 (IQR 36-60) years, and 44 (81%) were males. Agreement was obtained on the applicability of telemonitoring and telemedicine for multidisciplinary pre-operative evaluation. The panel voted against the use of telemedicine for a first consultation. 15/48 statements deemed uncertain on round 1 and were re-elaborated and assessed by 51/54 (94%) panelists on round 2. Consensus was achieved in all but one statement concerning the cost of a teleconsultation. There was strong agreement on the usefulness of teleconsultation during follow-up of patients with diverticular disease after an in-person visit. This e-consensus provides the boundaries of telemedicine in colorectal surgery in Italy. Standardization of infrastructures and costs remains to be better elucidated.
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http://dx.doi.org/10.1007/s13304-021-01139-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8312353PMC
February 2022

Target Therapies for NASH/NAFLD: From the Molecular Aspect to the Pharmacological and Surgical Alternatives.

J Pers Med 2021 Jun 2;11(6). Epub 2021 Jun 2.

4th Surgery Unit, Regional Hospital Treviso, DISCOG, University of Padua, 31100 Padua, Italy.

Non-alcoholic fatty liver disease represents an increasing cause of chronic hepatic disease in recent years. This condition usually arises in patients with multiple comorbidities, the so-called metabolic syndrome. The therapeutic options are multiple, ranging from lifestyle modifications, pharmacological options, to liver transplantation in selected cases. The choice of the most beneficial one and their interactions can be challenging. It is mandatory to stratify the patients according to the severity of their disease to tailor the available treatments. In our contribution, we review the most recent pharmacological target therapies, the role of bariatric surgery, and the impact of liver transplantation on the NAFLD outcome.
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http://dx.doi.org/10.3390/jpm11060499DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8229090PMC
June 2021

The impact of COVID-19 pandemic on a tertiary referral proctology center: no one should be left behind.

Minerva Surg 2022 Feb 23;77(1):30-34. Epub 2021 Jun 23.

Section of Proctology, USL Toscana Centro, Prato, Italy.

Background: Coronavirus disease 2019 (COVID-19) has disrupted healthcare delivery. We aimed to describe a novel strategy to mitigate the impact of COVID-19 pandemic on a tertiary referral proctology center during the first wave of infection in Italy.

Methods: All patients booked appointments at the Proctology Unit between March 9 and May 4, 2020 were identified. Patients booked for a first visit underwent a structured remote consultation. Patients with perianal or sacrococcygeal abscesses, major anorectal bleeding, incoercible anal pain and red flags for malignancy were labelled as "non-deferrable." A flowchart was designed to comply with adequate assistance of proctologic patients. Demographics, clinical data and outcomes of in-office procedures were collected.

Results: On a total of 548 booked visits, 198 (36.1%) were cancelled before remote consultation. Of the remaining 350, 112 (32.0%) attended a follow-up visit. Among 238 (68.0%) patients undergoing remote consultation, 88 (25.1%) were deemed "deferrable" and 148 (42.3%) "non-deferrable." Two (0.6%) were hospitalized for COVID-19 while waiting for an outpatient visit. Twenty-five of 88 (28.4%) deferrable patients cancelled their appointment as felt no longer necessary. A total of 45 of 148 (30.4%) non deferrable patients (mean age, 46 years; 31% females) underwent in-office procedures, most often related to anal abscess and/or fistula (48.9%). Final diagnosis of malignancy occurred in four cases. A 55% increase in the number of in-office procedures was noted compared to the previous year. None of the attending patients nor staff members resulted COVID-19 positive during the study period.

Conclusions: Despite the uncertainties accompanying the use of remote consultations in proctology, the results of this study may inform the development of strategies for restructuring activities in response to future emergencies of this magnitude.
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http://dx.doi.org/10.23736/S2724-5691.21.08897-3DOI Listing
February 2022

Unusual splenic cystic mass in a 60-year-old male.

ANZ J Surg 2022 01 16;92(1-2):291-292. Epub 2021 Jun 16.

Second Surgery Unit, Regional Hospital Treviso, DISCOG, University of Padua, Padua, Italy.

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http://dx.doi.org/10.1111/ans.17025DOI Listing
January 2022

Mixed adenoneuroendocrine carcinoma (MANEC) of the lower gastrointestinal tract: A systematic review with Bayesian hierarchical survival analysis.

Eur J Surg Oncol 2021 11 14;47(11):2893-2899. Epub 2021 May 14.

4th Surgery Unit, Regional Hospital Treviso, DISCOG, University of Padua, Italy.

Background: Mixed adeno-neuroendocrine carcinomas (MANEC) are a subgroup of mixed neuroendocrine non-neuroendocrine neoplasms (MiNEN) described as mixed neoplasms containing dual neuroendocrine and non-neuroendocrine components. The aim of this study was to appraise the prevalence of MANEC in the lower gastrointestinal (GI) tract and provide reliable estimates of survival.

Method: A systematic review was undertaken in accordance with PRISMA guidelines using PubMed, Embase, Cochrane Library of Systematic Review, Web of Science, and Scopus databases, and a Bayesian hierarchical survival pooled analysis was performed.

Results: Of 182 unique records identified, 71 studies reporting on 752 patients met the inclusion criteria. Mean age was 64.2 ± 13.6, with a male-to-female ratio of 1.25. Overall, 60.3% of MANEC were located in the appendix, 29.3% in the colon, and 10.4% in the anorectum. More than a quarter (29%) of patients had stage IV disease at diagnosis, with higher prevalence in appendiceal than colonic and anorectal primaries. More than 80% had a high-grade (G3) endocrine component. Of the 152 patients followed up for a median of 20 months (interquartile range limits, 16.5-32), median overall survival was 12.3 months (95% credible interval [95%CrI], 11.3-13.7), with a 1.12 [95%CrI, 0.67-1.83] age-adjusted hazard ratio between metastatic and non-metastatic MANEC. Stage IV disease at diagnosis was more prognostically unfavorable in cases of colonic compared to anorectal origin.

Conclusion: MANEC is a clinically aggressive pathological entity. The results of this study provide new insights for the understanding of tumor location within the lower GI tract and its prognosis in terms of overall survival.
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http://dx.doi.org/10.1016/j.ejso.2021.05.021DOI Listing
November 2021

Systematic Characterization of Defecographic Abnormalities in a Consecutive Series of 827 Patients With Chronic Constipation.

Dis Colon Rectum 2021 11;64(11):1385-1397

Centre for Neuroscience, Surgery and Trauma, and GI Physiology Unit, Barts and the London School of Medicine & Dentistry, Queen Mary University London, London, United Kingdom.

Background: Barium defecography can assess structural and functional abnormalities in patients with chronic constipation.

Objective: The purpose of this study was to determine the prevalence of individual and overlapping defecographic findings in this setting.

Design: This was a cross-sectional study.

Settings: The study was conducted at a university hospital tertiary GI physiology department.

Patients: Consecutive examinations of 827 consecutive patients presenting over a 30-month period with well-defined symptom severity (≥12 points on the Cleveland Clinic Constipation score) were included. Systematic evaluation of images with results stratified by sex is described.

Main Outcome Measures: Six individual functional or anatomic (intussusception, rectocele, enterocele, megarectum, excessive dynamic perineal descent) defecographic observations were defined a priori, thus permitting 26 possible combinations of findings (ie, 63 abnormal types + 1 normal).

Results: Patients with constipation (mean symptom score = 19) were predominantly female (88%), with median age of 49 years (range, 17-98 y) . All 6 individual radiologic findings were identified with a total of 43 combinations found in the cohort; the 14 most prevalent of these accounted for >85% of patients. Only 136 patients (16.4%) had a normal defecography (34.3% males vs 13.9% females; p < 0.0001). Overall, 612 patients (74.0%) had structural (n = 508 (61.4%)) or functional (n=104 (12.6%)) abnormalities in isolation, with 79 (9.6%) others exhibiting combinations of both. Functional abnormalities in isolation were more common in males compared with females (22.5% vs11.2%; p = 0.025) as opposed to structural abnormalities (57.8% vs 85.7%; p < 0.0001). Expulsion time was longer in females compared with males (110 s (60-120 s) vs 90 s (60-120 s); p = 0.049).

Limitations: The study was limited by its lack of multiorgan opacification.

Conclusions: These results provide a contemporary atlas of defecographic findings in constipation. Several individual structural and functional features have been systematically classified, with overlap greater than previously acknowledged and profound differences among sexes that carry implications for tailoring management. See Video Abstract at http://links.lww.com/DCR/B552.

Caracterizacin Sistemtica De Anomalas Defecogrficas En Una Serie Consecutiva De Pacientes Con Estreimiento Crnico: ANTECEDENTES:La defecografía con bario puede evaluar anomalías estructurales y funcionales en pacientes con estreñimiento crónico.OBJETIVO:Determinar la prevalencia de hallazgos defecográficos individuales y superpuestos en este entorno.DISEÑO:Transversal.ENTORNO CLINICO:Hospital Universitario de tercer nivel, departamento de fisiología gastrointestinal.PACIENTES:Exploraciones consecutivas de 827 pacientes consecutivos que se presentaron durante un período de 30 meses con una gravedad de los síntomas bien definida (≥12 puntos en la escala de estreñimiento de la Cleveland Clinic): evaluación sistemática de imágenes con resultados estratificados por sexo.PRINCIPALES MEDIDAS DE VALORACION:Se definieron a priori seis observaciones defecográficas individuales, funcionales o anatómicas (intususcepción, rectocele, enterocele, megarecto, descenso perineal dinámico excesivo), lo que permitió 26 combinaciones posibles de hallazgos (es decir, 63 tipos anormales + 1 normal).RESULTADOS:Los pacientes con estreñimiento (puntuación media de síntomas, 19) eran predominantemente mujeres (88%) con una edad mediana de 49 (17-98) años. Se identificaron 6 hallazgos radiológicos individuales con un total de 43 combinaciones encontradas en la cohorte; los 14 más predominantes de éstos representaron >85% de los pacientes.Solo 136 (16,4%) pacientes tuvieron una defecografía normal (34,3% hombres vs. 13,9% mujeres; P < 0,0001). En general, 612 (74,0%) pacientes tenían anomalías estructurales (n = 508 [61,4%]) o funcionales (n = 104 [12,6%]) de forma aislada, y otros 79 (9,6%) presentaban combinaciones de ambas. Las anomalías funcionales aisladas fueron más comunes en los hombres en comparación con las mujeres (22,5% vs. 11,2%, P = 0,025) en comparación con las anomalías estructurales (57,8 vs. 85,7%, P < 0,0001). El tiempo de expulsión fue mayor en las mujeres en comparación con los hombres (110 [60-120] vs. 90 [60-120] segundos; P = 0,049).LIMITACIONES:Falta de opacificación multiorgánica.CONCLUSIONES:Estos resultados proporcionan un atlas contemporáneo de hallazgos defecográficos en estreñimiento. Varias características individuales, estructurales y funcionales; se han clasificado sistemáticamente, con una superposición mayor que la reconocida anteriormente y con grandes diferencias entre los sexos que tienen implicaciones para adaptar su tratamiento. Consulte Video Resumen en http://links.lww.com/DCR/B552.
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http://dx.doi.org/10.1097/DCR.0000000000001923DOI Listing
November 2021

Long-Term Outcomes of Sectorial Longitudinal Augmented Prolapsectomy for Asymmetric Muco-hemorrhoidal Prolapse: An Observational Study of 433 Consecutive Patients.

Surg Innov 2022 Feb 8;29(1):27-34. Epub 2021 Apr 8.

Division of General, Mini-invasive and Obesity Surgery, University of Study of Campania "Luigi Vanvitelli", Naples, Italy.

Purpose: Hemorrhoidal disease (HD) is a widespread condition severely influencing patients' quality of life. Recently, the large diffusion of stapled hemorrhoidopexy has revealed a new unexpected pathological entity: the asymmetric mucosal prolapse. We aimed to assess the outcomes of the sectorial longitudinal augmented prolapsectomy (SLAP), a technique dedicated to asymmetric prolapse, in terms of HD symptoms, prolapse recurrence, and rectal stenosis.

Methods: Patients affected by III-IV-degree symptomatic HD with asymmetric mucosal prolapse undergone SLAP of 1 or 2 hemorrhoidal columns (SLAP1 or SLAP2) were retrospectively assessed. The severity of hemorrhoid symptoms and fecal continence status were evaluated before and after surgery. Mean outcome was evaluation of medium-long-term outcomes as the occurrence of recurrence and anal or rectal stenosis. Secondary outcome was the evaluation of postoperative bleeding, reoperation rate, length of hospitalization, fecal urgency, and time to return to work.

Results: We enrolled 433 patients (277 SLAP1 and 156 SLAP2). Hemorrhoidal symptoms recurrence was reported in 9 patients undergone SLAP1 and 4 patients undergone SLAP2, while prolapse recurrence occurred, respectively, in 4 and 2 patients. No major intraoperative complications occurred. An emergency reintervention for postoperative bleeding occurred in 13 cases undergone SLAP1 and in 5 patients treated with SLAP2. Fecal incontinence occurred in 8 and 4 cases of patients treated with SLAP1 and SLAP2.

Conclusions: The combination of a simple hemorrhoidectomy to a mucosal rectal prolapsectomy should be part of every coloproctologist background. Promising and satisfying results can be achieved using SLAP for HD associated with asymmetric prolapse.
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http://dx.doi.org/10.1177/15533506211007292DOI Listing
February 2022

Which Is the Best Treatment in Recurrent Thymoma? A Systematic Review and Meta-Analysis.

Cancers (Basel) 2021 Mar 29;13(7). Epub 2021 Mar 29.

Università Cattolica del Sacro Cuore, 00168 Rome, Italy.

Background: Optimal recurrent thymoma management remains arguable because of limited patient numbers, and relatively late and variable recurrence patterns. Given the absence of high-quality evidence and relatively small study cohorts, we performed a quantitative meta-analysis to determine the outcome of surgical and non-surgical approaches assessing the five-year overall survival (5y overall survival (OS)) in patients with recurrent thymoma.

Methods: We performed a comprehensive literature search and analysis according to PRISMA guidelines of studies published from 1 January 1980 until 18 June 2020 from PubMed/MEDLINE, EMBASE, and Scopus. We included studies with the cohorts' superior to 30 patients describing recurrent thymoma treatment, comparing surgical and non-surgical approaches reporting survival data.

Results: Literature search revealed 3017 articles. Nine studies met all inclusion criteria and were selected for the meta-analysis. The recurrences were local/regional in 73-98% of cases and multiple in 49-72%. After treatment, 5y OS ranged from 48-77% and 10y OS from 37-51%. The quantitative meta-analysis showed a better outcome comparing surgical vs other treatments. Two studies showed statistically significant risk differences in the 5y OS favoring complete resection. After pooling results of seven studies using the random model, the combined 5y OS risk difference was 0.39, with lower and upper limits of 0.16 and 0.62, respectively ( = 0.001), and a moderate heterogeneity among studies ( = 0.098, I2 = 43.9%). Definitive conclusions could not be drawn regarding the prognostic impact of myasthenia gravis, histology, and patterns of relapse reported in literature.

Conclusions: Surgical treatment after thymoma recurrence is associated with a significant better 5y OS; therefore, surgical resection should be preferred in all technically feasible cases.
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http://dx.doi.org/10.3390/cancers13071559DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8036834PMC
March 2021

E-consensus on telemedicine in proctology: A RAND/UCLA-modified study.

Surgery 2021 08 22;170(2):405-411. Epub 2021 Mar 22.

Colorectal Surgical Unit, Department of Surgery, Infermi Hospital, Biella, Italy.

Background: Coronavirus disease 2019 is revolutionizing healthcare delivery. The aim of this study was to reach a consensus among experts as to the possible applications of telemedicine in the proctologic field.

Methods: A group of 55 clinical practice recommendations was developed by a clinical guidance group based on coalescence of evidence and expert opinion. The Telemedicine in Proctology Italian Working Group included 47 Italian Society of Colorectal Surgery nominated experts evaluating the appropriateness of each clinical practice recommendations based on published RAND/UCLA methodology in 2 rounds.

Results: Stakeholder median age was 53 years (interquartile range limits 40-60), and 38 (81%) were men. Nine (19%) panelists reported no experience with telemedicine before the pandemic. Agreement was obtained on a minimum of 3 to 5 years of practice in the proctologic field before starting teleconsultations, which should be regularly paid, with advice and prescriptions incorporated into a formal report sent to the patient by e-mail along with a receipt. Of the panelists, 35 of 47 (74%) agreed that teleconsultation carries the risk of misdiagnosis of cancer, thus recommending an in-person assessment before scheduling any surgery. Fifteen additional clinical practice recommendations were re-elaborated in the second round and assessed by 44 of 47 (93.6%) panelists. The application of telemedicine for the diagnosis of common proctologic conditions (eg, hemorrhoidal disease, anal abscess and fistula, anal condylomas, and anal fissure) and functional pelvic floor disorders was generally considered inappropriate. Teleconsultation was instead deemed appropriate for the diagnosis and management of pilonidal disease.

Conclusion: This e-consensus revealed the boundaries of telemedicine in Italy. Standardization of infrastructures, logistics, and legality remain to be better elucidated.
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http://dx.doi.org/10.1016/j.surg.2021.01.049DOI Listing
August 2021

Mixed adenoneuroendocrine carcinoma of the caecum presenting as extensive ileocolonic intussusception.

ANZ J Surg 2021 10 24;91(10):E646-E647. Epub 2021 Feb 24.

4th Surgery Unit, Regional Hospital Treviso, DISCOG, The University of Padua, Padua, Italy.

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http://dx.doi.org/10.1111/ans.16687DOI Listing
October 2021

Chronic constipation in adults: Contemporary perspectives and clinical challenges. 2: Conservative, behavioural, medical and surgical treatment.

Neurogastroenterol Motil 2021 07 1;33(7):e14070. Epub 2021 Feb 1.

National Bowel Research Centre and GI Physiology Unit, Centre for Neuroscience, Surgery & Trauma, Blizard Institute, Barts and the London School of Medicine & Dentistry, Queen Mary University of London, London, UK.

Background: Chronic constipation is a prevalent disorder that affects quality of life of patients and consumes resources in healthcare systems worldwide. In clinical practice, it is still considered a challenge as clinicians frequently are unsure as to which treatments to use and when. Over a decade ago, a Neurogastroenterology and Motility journal supplement devoted to the investigation and management of constipation was published (Neurogastroenterol Motil 2009;21(Suppl 2):1). In October 2018, the 3rd London Masterclass, entitled "Contemporary management of constipation" was held. The faculty members of this symposium were invited to write two reviews to present a collective synthesis of talks presented and discussions held during this meeting. The first review addresses epidemiology, diagnosis, clinical associations, pathophysiology, and investigation.

Purpose: The present is the second of these reviews, providing contemporary perspectives and clinical challenges regarding behavioral, conservative, medical, and surgical treatments for patients presenting with constipation. It includes a management algorithm to guide clinical practice.
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http://dx.doi.org/10.1111/nmo.14070DOI Listing
July 2021

Laparoscopic appendectomy as an index procedure for surgical trainees: clinical outcomes and learning curve.

Updates Surg 2021 Feb 4;73(1):187-195. Epub 2021 Jan 4.

Emergency Surgery Department, St. Orsola University Hospital, Bologna, Italy.

Surgical training is essential to maintain safety standards in healthcare. The aim of this study is to evaluate learning curves and short-term postoperative outcomes of laparoscopic appendectomy (LA) performed by trainees (TRN) and attendings (ATT). The present study included the medical records of patients with acute appendicitis who underwent a fully LA in our department between January 2013 and December 2018. Cases were divided into trainees (TRN and ATT groups based on the experience of the operating surgeon. The primary outcome measures were 30-day morbidity and mortality. Preoperative patients' clinical characteristics, intraoperative findings, operative times, and postoperative hospitalization were compared. Operative times were used to extrapolate learning curves and evaluate the effects of changes in faculty using CUSUM charts. A propensity score matching analysis was performed to reduce differences between cohorts regarding both preoperative characteristics and intraoperative findings. A total of 1173 patients undergoing LA for acute appendicitis were included, of whom 521 (45%) in the TRN group and 652 (55%) in the ATT group. No significant differences were found between the two groups in terms of complication rates, operative times and length of hospital stay. However, CUSUM chart analysis showed decreased operating times in the TRN group. Operative times improved more quickly for advanced cases. The results of this study indicate that LA can be performed by trainees without detrimental effects on clinical outcomes, procedural safety, and operative times. However, the learning curve is longer than previously acknowledged.
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http://dx.doi.org/10.1007/s13304-020-00950-zDOI Listing
February 2021

DElayed COloRectal cancer care during COVID-19 Pandemic (DECOR-19): Global perspective from an international survey.

Surgery 2021 04 17;169(4):796-807. Epub 2020 Nov 17.

Digestive Disease Institute, Department of Colorectal Surgery, Cleveland Clinic Florida, Fort Lauderdale, FL.

Background: The widespread nature of coronavirus disease 2019 (COVID-19) has been unprecedented. We sought to analyze its global impact with a survey on colorectal cancer care during the pandemic.

Methods: The impact of coronavirus disease 2019 on preoperative assessment, elective surgery, and postoperative management of colorectal cancer patients was explored by a 35-item survey, which was distributed worldwide to members of surgical societies with an interest in colorectal cancer care. Respondents were divided into 2 comparator groups: (1) "delay" group: colorectal cancer care affected by the pandemic and (2) "no delay" group: unaltered colorectal cancer practice.

Results: A total of 1,051 respondents from 84 countries completed the survey. No substantial differences in demographics were found between the delay (745, 70.9%) and no delay (306, 29.1%) groups. Suspension of multidisciplinary team meetings, staff members quarantined or relocated to coronavirus disease 2019 units, units fully dedicated to coronavirus disease 2019 care, and personal protective equipment not readily available were factors significantly associated to delays in endoscopy, radiology, surgery, histopathology, and prolonged chemoradiation therapy-to-surgery intervals. In the delay group, 48.9% of respondents reported a change in the initial surgical plan, and 26.3% reported a shift from elective to urgent operations. Recovery of colorectal cancer care was associated with the status of the outbreak. Practicing in coronavirus disease-free units, no change in operative slots and staff members not relocated to coronavirus disease 2019 units were statistically associated with unaltered colorectal cancer care in the no delay group, while the geographic distribution was not.

Conclusion: Global changes in diagnostic and therapeutic colorectal cancer practices were evident. Changes were associated with differences in health care delivery systems, hospital's preparedness, resource availability, and local coronavirus disease 2019 prevalence rather than geographic factors. Strategic planning is required to optimize colorectal cancer care.
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http://dx.doi.org/10.1016/j.surg.2020.11.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7670903PMC
April 2021

Short-Term Outcomes of Polycarbophil and Lysate Gel after Open Hemorrhoidectomy: A Prospective Cohort Study.

J Clin Med 2020 Dec 10;9(12). Epub 2020 Dec 10.

Department of Health Sciences, University of Catanzaro, Viale Europa, 88100 Catanzaro, Italy.

Background: Pain is the most common complication after open excisional hemorrhoidectomy (OEH). We assessed the effectiveness of polycarbophil and lysate gel (EmorsanGel) on pain control after OEH.

Research Design And Methods: Fifty consecutive patients undergoing OEH were included. All patients received stool softeners and oral analgesia in the post-operative period. EmorsanGel was also used topically by the last 25 patients (EmorsanGel group (EG)) until Post-Operative Day 20 (POD 20). The primary outcome was the effectiveness of EmorsanGel on pain relief using an 11-point visual analogue scale (VAS). Morbidity, wound healing (WH), and time to work were documented at POD 1, POD 10, POD 20, and POD 40.

Results: Of the 50 patients enrolled, twenty-eight (56%) were males; median age, 49 (range, 28-73) years. The VAS score decreased over time in all patients, with significantly lower scores at POD 20 in the EG (1.44 (SD, 1.16) vs. 2.12 (0.93) in the control group (CG); = 0.045). All patients in the EG achieved complete WH at last follow-up, compared to only 17 (68%) in the CG ( = 0.004). The likelihood of WH was 66% higher in the EG (OR, 1.66 [95%CI, 0.80-3.44; = 0.172).

Conclusions: EmorsanGel is safe and effective at reducing pain after EOH, promoting earlier WH compared to standard care treatment.
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http://dx.doi.org/10.3390/jcm9123996DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7763882PMC
December 2020
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