Incisional Hernia with Loss of Domain as a Consequence of Botulinum Toxin a and the Covid-19 Pandemic

Introduction: Abdominal wall surgery has been one of the major victims of the COVID-19 pandemic, with a large number of patients who have seen their surgery delayed and many are still waiting to be operated on today. On the other hand, botulinum toxin is one of the main protagonists in optimizing abdominal wall surgery, especially important in complex hernia, but we must not forget that it can have adverse effects. Case report: We present the case of a 54-year-old man with a history of obesity, diabetes, hypertension, chronic renal failure and kidney transplant in 2000, who presented a midline incisional hernia as a result of an epigastric hernia operated on in 2006 and subsequently two onlay permanent synthetic mesh in 2010 and 2015. In February 2020 he presented an incisional hernia M2-4W3R3 with a volume of 35%, botox was infiltrated as optimization for surgery and while awaiting placement of a pneumoperitoneum catheter, the surgery was suspended due to the COVID-19 situation. He returns to our clinics in 2022 with a growth of the hernia and a volume of 95%. Weight loss, botulinum toxin and preoperative pneumoperitoneum were indicated. We performed a reconstruction of the abdominal wall with bilateral transversus abdominal release and preperitoneal 45x60cm polyvinylidene fluoride mesh and abdominoplasty. Discussion(s): Botulinum toxin can facilitate abdominal surgery, especially in complex hernias, but we must not forget that blocking the abdominal muscles can have adverse effects. The COVID-19 pandemic has been especially hard on surgical waiting lists, delaying surgeries and aggravating pathologies.

Pseudomembranous colitis in patients with COVID-19 (review)

AIM: to estimate the features of pseudomembranous colitis in patients with COVID-19, diagnostics, conservative treatment and surgery for complications. PATIENTS AND METHODS: a retrospective analysis of 396 patients with pseudomembranous colitis (PMC) in patients with new coronavirus infection was carried out for the period from March 2020 to November 2021. Among them there were 156 (39.3%) males, females - 240 (60.6%), moderate and severe forms of COVID-19 occurred in 97.48%. The diagnosis of PMC was established due to clinical picture, laboratory, instrumental methods (feces on Cl. difficile, colonoscopy, CT, US, laparoscopy). RESULT(S): the PMC rate in COVID-19 was 1.17%. All patients received antibiotics, 2 or 3 antibiotics - 44.6%, glu-cocorticoids were received by all patients. At 82.8%, PMC developed during the peak of COVID-19. To clarify the PMC, CT was performed in 33.8% of patients, colonoscopy - 33.08%, laparoscopy - in 37.1% (to exclude bowel perforation, peritonitis). Conservative treatment was effective in 88.8%, 76 (19.1%) patients had indications for surgery (perforation, peritonitis, toxic megacolon). Most often, with peritonitis without clear intraoperative confir-mation of perforation, laparoscopic lavage of the abdominal cavity was performed (60 patients - 78.9%, mortality - 15.0%), colon resection (n = 6 (7.9%), mortality - 66.6%), ileo-or colostomy (n = 8 (10.5%), mortality - 37.5%), colectomy (n = 2 (2.6%), mortality - 50.0%). The overall postoperative mortality rate was 22.4%, the incidence of surgical complications was 43.4%. In addition, in the postoperative period, pneumonia was in 76.3%, thrombosis and pulmonary embolism in 22.3% of patients. In general, the overall mortality in our patients with PMC was 11.4%, with conservative treatment - 8.8%. CONCLUSION(S): pseudomembranous colitis is a severe, life-threatening complication of COVID-19. In the overwhelm-ing majority of patients, conservative therapy was effective, but almost 1/5 of patients developed indications for surgery, the latter being accompanied by high mortality and a high morbidity rate. Progress in the treatment of PMC, apparently, is associated with early diagnosis, intensive conservative therapy, and in the case of indications for surgery, their implementation before decompensation of the patient's condition and the development of severe intra-abdominal complications and sepsis.Copyright © 2022, Association of Coloproctologists of Russia. All rights reserved.

Adnexal masses surgery in prepubertal and adolescent girls during COVID-19 pandemic

Study Objective: Global burden on healthcare system by COVID-19 patients had a significant impact on non-COVID diseases treatment.1-3 This study compares the characteristics of adnexal masses surgery in girls and adolescents during the 2020 and 2021 COVID-19 pandemic with the homologous non-COVID-19 period in 2018 and 2019. Design(s): A retrospective observational study using medical records of girls under 19 years of age with surgery of adnexal masses. Patients with neonatal cysts and patients with differences of sex development were excluded from the study. Setting(s): Mother and Child Health Care Institute of Serbia 'Dr Vukan Cupic' (Belgrade, Serbia). The study was approved by the Clinical Research Committee of the Institution. Participant(s): Patients (N=130) who had surgery for adnexal masses, of whom 49 with ovarian torsion. Interventions and Main Outcome Measure(s): Patients were diagnosed in the Institute, but also in other health institutions that referred them for final treatment to the Institute. Surgery was usually performed by gynecologists, and sometimes by pediatric surgeons as urgent abdominal operations. Open or minimally invasive approaches were used, depending on the medical indications, surgeon's experience, and the circumstances related to the organization of work in the COVID-19 period. Results and Discussion: All data of the main outcome measures are shown in Table 1. In the COVID-19 period, the time from the onset of symptoms to diagnosis is statistically significantly longer than in the non-COVID-19 period (t=2,151;p=0,034). In the COVID-19 period, there were statistically significantly fewer adnexal masses surgery than in non-COVID-19 period (chi2=8,892;p=0,003). There was also decrease in number of surgically treated patients with twisted adnexal masses, but without statistical significance. Ovarian preservations in benign adnexal processes were statistically more frequent in the non-COVID-19 period (chi2=6,575;p=0,01). There was increase in percentage of adnexectomies in the COVID-19 period. During the COVID-19 period, the number of laparoscopic procedures decreased significantly, which could be associated with the technical issues and deficit in medical staff during that period (chi2=50,915;p < 0,001). Conclusion(s): Advice on reducing non-necessary visits to the doctor given to patients during the COVID-19 pandemic led to a decrease in number of surgical procedures for adnexal masses in girls and adolescents. This also caused prolonged time to diagnosis, but did not affect the interval from the symptoms onset to operation. Reduction of number of laparoscopic procedures and ovarian preservation in benign adnexal diseases indicates a decline in the quality of health care during COVID-19 pandemic. [Formula presented]Copyright © 2023

Changing characteristics of emergency surgery during COVID-19 pandemic: a retrospective cohort study.

BACKGROUND: In other countries, researchers have noticed diverse variations in the features of patients undergoing emergency surgery during the COVID-19 pandemic. In Mexico, there is not information about this issue. METHODS: Workers of the Mexican Government, who required emergency surgeries were studied by the general surgery service of a General Hospital administered by the Institute of Social Security and Services for State Workers Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado (ISSSTE), through the periods from March-August 2019 (non-exposed) and March-August 2020 (exposed). The analysis included: demographic data, laboratory information, post-operative diagnoses, symptoms' length, days of emergency stay, and post-operative stay. RESULTS: One hundred and ninety-three emergency surgeries were analyzed; 106 in 2019 and 87 in 2020 (a decrease of 18%). Throughout the pandemic, the number of days between the symptoms' onset and surgery was greater: 2019, 7.6 ± 4.6 days; 2020, 14 ± 6.7 days (p < 0.0001). In addition, cases of acute appendicitis decreased (2019-60.3%; 2020-42.5%), and those of acute calculous cholecystitis increased (2019-12.2%; 2020-24.1%). CONCLUSION: Through the COVID-19 pandemic, there were notable changes in the characteristics of Mexican Government's workers who warranted emergency surgery.

ANTECEDENTES: En otros países, han notado diversos cambios en las características de los pacientes sometidos a cirugía de emergencia durante la pandemia de COVID-19. En México no existe información sobre este tema. MÉTODO: Estudiamos a los trabajadores del gobierno mexicano que requirieron tratamiento quirúrgico de emergencia por el servicio de cirugía general de un Hospital General del Instituto de Seguridad y Servicios Sociales para los Trabajadores del Estado (ISSSTE), durante los periodos de marzo-agosto de 2019 (no expuestos) y marzo-agosto de 2020 (expuestos). El análisis incluyó: datos demográficos, datos de laboratorio, diagnósticos postoperatorios, duración de los síntomas, días de estancia en emergencias y estadía postoperatoria. RESULTADOS: Se analizaron 193 cirugías de emergencia; 106 en 2019 y 87 en 2020 (una disminución del 18%). En la pandemia, el número de días entre el inicio de los síntomas y la cirugía fue mayor: 2019, 7.6 ± 4.6 días; 2020, 14 ± 6.7 días (p < 0.0001). Además, disminuyeron los casos de apendicitis aguda (2019-60,3%; 2020-42,5%) y aumentaron los de colecistitis litiásica aguda (2019-12,2%; 2020-24,1%). CONCLUSIÓN: Durante la pandemia de COVID-19, hubo cambios notables en las características de los trabajadores del gobierno mexicano que ameritaron cirugías de emergencia.

Thromboprophylaxis in gynaecology: a review of current evidence

Key content: Thromboembolism is a major cause of preventable morbidity and mortality. Hospital acquired thrombosis (HAT) accounts for 50-60% of all thromboembolic events. As well as effects on patient safety, there are considerable cost implications to both prophylaxis and treatment. While guidance exists on thromboprophylaxis for patients in obstetrics and those undergoing general surgery, there is a paucity of guidance relating to gynaecological practice. Increasing prevalence of risk factors and multimorbidity is paralleled by higher risk of thromboembolic events. Gynaecological surgery presents some unique risk factors for thrombosis. Learning objectives: To understand the basic pathophysiology of thrombosis in relation to risk factors particularly relevant to gynaecology and pelvic surgery. To know the current evidence in key areas relevant to gynaecological practice: early pregnancy;day case surgery;minimally invasive gynaecological surgery;open and complex benign gynaecology and gynaecological oncology. To be aware of proposed guidance on risk assessment and prophylaxis in thrombosis as relevant to the gynaecologist based on current evidence. Ethical issues: Problems with thromboprophylaxis in high-risk patients include noncompliance and refusing animal products/injections. Clinicians may be reluctant to institute thromboprophylaxis, most times because of the possible risks of bleeding. Copyright © 2022 Royal College of Obstetricians and Gynaecologists.

Candida nivariensis infection in South East Asia: Series of case reports from Selayang Hospital, Malaysia and South East Asia Region

Introduction: Candida nivariensis, first described from Spain in 2005 is an emerging fungal pathogen. Malaysia has cap-tured a total of 11 cases since its first reported here in 2014. Indonesia, Thailand, and Vietnam are among South East Asia countries that reported its occurrence too. Objective(s): The occurrence and characteristics of Candida nivariensis in South East Asia are studied. We would like to highlight two cases from Selayang Hospital, Malaysia that occurred during pandemic COVID-19 in 2020 and 2022. Case Description: In July 2020, a 60-year-old lady underlying poorly controlled diabetes mellitus, CKD stage V approach-ing ESRD, congestivecardiac failure, hypertension, and dyslipidemiawas diagnosed as complicated MSSAbacteremia secondary to right gluteal carbuncle.Appropriate antibiotics were commenced.Aggressive source control including incision and drainage, cauterization of right gluteal carbuncle, and multiple wound debridement for the infected gluteal wound was performed. She underwent a trephine sigmoid loop colostomy.Tracheostomy was done following prolong ventilation.Anidulafungin as empir-ical fungal coverage was commenced in ICU as she further deteriorated. Candida nivariensis was isolated later from her blood culture. In February 2022, a 74-year-old man underlying Diabetes mellitus, chronic kidney disease, hypertension, ischemic heart disease with two vessels disease stented, post-Whipple's procedure due to necrotizing pancreatitis in 2014 complicated with chronic abdominal pain with hyperalgesia admitted to the ward for acute right lacunar infarct with failed swallowing test and neurogenic bladder.His general condition deteriorated with worsening of biochemical and septic parameters.His blood culture grew C. nivariensis following which anidulafungin was started. No distant seeding and no signs of endophthalmitis. He then required mechanical ventilatory support complicated with multiorgan failure, leading to ICU admission. Method(s): For both cases, yeast isolates were subcultured on Sabouraud dextrose agar and CHROMagar. Matrix-assisted laser desorption ionization time of flight mass spectrometry (MALDI-T OF MS) with molecular testing was performed for confirmation of isolates.Phylogenetic tree among isolates from Malaysia was analyzed.Antifungal susceptibility test (AFST) to study the minimum inhibitory concentration (MIC) among treatment options was performed using the e-test method. Result(s): Wide use of MALDI-T OF MS with molecular testing increased the detection rate of the species. Isolation sites in Malaysia and South East Asia region include blood culture, peritoneal fluid, high vaginal swab, and oropharyngeal swab. Risk factors namely immunocompromised status, indwelling vascular catheter, abdominal surgeries, renal failure or on dialy-sis support, polymicrobial usage, and prolonged stay in ICU. AFST established susceptibility towards fluconazole, high MIC to itraconazole and low MIC against amphotericin B, anidulafungin and voriconazole for both patients who unfortunately succumbed to their illness. Conclusion(s): Diagnosing C. nivariensis is challenging due to its closely related phylogenetic with C. glabrata, and C. bracarensis, thus molecular testing is vital. Inadequate antifungal coverage or delay of treatment could be detrimental to pa-tient's outcome. Continuous epidemiological surveillance is crucial to address this potential invasive fungal pathogen and to observe emerging of drug resistance.

Sutureless versus purse string with complete sac dissection in laparoscopic inguinal hernia repair in children: a randomized clinical trial

Introduction: Pediatric inguinal hernia is a common surgical condition with a cumulative incidence of 4.2%. Minimal invasive surgery is playing a growing role in the treatment of this condition. We compared the outcomes of laparoscopic sutureless herniotomy and purse string with sac dissection repair with regards to complications and operative time. Method(s): One hundred fifty-two patients were operated on in two centers with two different techniques: sac dissection and purse-string suture, and sutureless repair. Operative time and recurrence were the main outcomes for comparison. Result(s): Sutureless repair has a shorter operative time (29 +/- 10 min) compared to purse string repair (38 +/- 13 min). The recurrence rate showed no statistical significance difference. However, the recurrence rate of sutureless repair was three times higher than that of purse string repair, and all recurrences were in large defects of 10-15 mm. Conclusion(s): Sutureless repair is safe for defects up to 10 mm with excellent operative time. However, it had an unfavorable outcome in larger defects. Copyright © 2022, The Author(s), under exclusive licence to Springer Nature Singapore Pte Ltd.

Paediatric inflammatory multisystem syndrome presenting as acute appendicitis: A case report and literature review

Aims: Paediatric inflammatory multisystem syndrome-temporally associated with SARS-CoV-2 (PIMS-TS) is a novel hyperinflammatory condition that most commonly presents with an acute abdomen. Here we present a case of PIMS-TS mimicking appendicitis and a review of The literature with a proposed protocol for managing abdominal pain in patients with recent SARS-CoV-2 infection. Result(s): An 8-year old girl presented with suspected appendicitis. She underwent a day case open appendicectomy with normal appendix confirmed on histology. Unfortunately, she re-presented The following day with persistently high fever and was investigated for post-appendicectomy complication. She was started on intravenous antibiotics. MRI of abdomen and pelvis showed no collection but evidence of lymphadenopathy. on post-operative day four she was transferred to The tertiary centre PICU for specialist management of suspected severe PIMS-TS. Common abdominal radiological findings in PIMS-TS include ascites, bowel wall thickening and mesenteric inflammation. In addition, CRp and ferritin have been found to be significantly higher in PIMS-TS. White cells may be raised with neutrophilia and lymphopaenia. In addition, highly deranged inflammatory markers in The context of a normal abdominal imaging are more consistent with PIMS-TS than appendicitis. We propose anyone with these findings is considered as having PIMS-TS and requires urgent imaging including combined senior surgical and paediatrician review. Conclusion(s): PIMS-TS may present mimicking acute appendicitis and given The severe cardiac compromise that can develop in patients with PIMS-TS is it important to avoid unnecessary General anaesthetic and abdominal Surgery where possible. Our proposed protocol could help reduce unnecessary abdominal Surgery in these patients.

Impact of COVID-19 Pandemic Lockdown on the Prognosis, Morbidity, and Mortality of Patients Undergoing Elective and Emergency Abdominal Surgery: A Retrospective Cohort Study in a Tertiary Center, Saudi Arabia.

The SARS-CoV-2 pandemic's main concerns are limiting the spread of infectious diseases and upgrading the delivery of health services, infrastructure, and therapeutic provision. The goal of this retrospective cohort study was to evaluate the emergency experience and delay of elective abdominal surgical intervention at King Abdul-Aziz University Hospital from October 2019 to October 2020, with a focus on post-operative morbidity and mortality before and during the COVID-19 pandemic. This study compares two groups of patients with emergent and elective abdominal surgical procedures between two different periods; the population was divided into two groups: the control group, which included 403 surgical patients, and the lockdown group, which included 253 surgical patients. During the lockdown, surgical activity was reduced by 37.2% (p = 0.014), and patients were more likely to require reoperations and blood transfusions during or after surgery (p= 0.002, 0.021, and 0.018, respectively). During the lockdown period, the average length of stay increased from 3.43 to 5.83 days (p = 0.002), and the patients who developed complications (53.9%) were more than those in the control period (46.1%) (p = 0.001). Our tertiary teaching hospital observed a significant decline in the overall number of surgeries performed during the COVID-19 pandemic and lockdown period. During the lockdown, abdominal surgery was performed only on four patients; they were positive for COVID-19. Three of them underwent exploratory laparotomy; two of the three developed shock post-operative; one patient had colon cancer (ASA score 3), one had colon disease (ASA score 2), and two had perforated bowels (ASA scores 2 and 4, respectively). Two out of four deaths occurred after surgery. Our results showed the impact of the COVID-19 lockdown on surgical care as both 30-day mortality and total morbidity have risen considerably.

Patient Specific Augmented Reality in Extended Robotic Esophagus Resection for Type Ii Gastroesophageal Junction Adenocarcinoma

For several procedures augmented reality (AR) allowed surgeons to work by the realtime visual feedback of the surgery field during lockdown by the COVID-19 pandemic. Integrating AR into medical practice could play a key role for the improvement of the learning curve and lower the costs. Also renovate the educational model with one consensus regarding the financing of medical specialist degree. A global surgical model has not yet been achieved for type II adenocarcinoma of the gastro-esophageal junction (GEJ), while its incidence increases worldwide. Controversies exist about the type of resection. Minimally invasive surgery provides magnified anatomy that enables to perform dissection at the appropriate planes. This technique has made possible the standardization of surgery by 'concentric-structured model' for cancers arising in the middle part of esophagus. A patient specific model for GEJ will be conducted using the data of surgeries applied to the real anatomy with AR. The validity will be investigated, conforming the images. Dutch single-center cohort study have demonstrated that after gastrectomy a positive margin was more common. While, esophagus resection provided a more complete lymph node dissection. The CARDIA trial has shown that one of the strongest independent prognostic factors is the presence of metastatic lymph nodes. Importantly, patients with positive upper mediastinal lymph nodes had a poorer prognosis. Related to this, German group have shown feasibility and superiority of a fully robotic surgery allowing a highly controlled lymph node dissection. Also, Korean study reported favorable outcomes of full four-arm robotic compared to robotic surgery combined with open abdominal surgery. The increasing incidence of GEJ cancers, the different approaches and emerging new minimal invasive and robotic approach need a comprehensive anatomy concept of the type II GEJ. By having a global concept of surgical anatomy, surgery procedures can be performed consistently and standardized worldwide.

Mesenteric Ischemia in Patients with Coronavirus 2019: A Scoping Review.

Background: Coronavirus 2019 (COVID-19) is a systemic disease associated with severe gastrointestinal complications including life-threatening mesenteric ischemia. We sought to review and summarize the currently available literature on the presentation, management, and outcomes of mesenteric ischemia in patients with COVID-19. Patients and Methods: The PubMed database was searched to identify studies published between January 2020 and January 2021 that reported one or more adult (≥18 years) patients with COVID-19 who developed mesenteric ischemia during hospitalization. The demographic characteristics, clinical and imaging findings, management, and outcomes of patients from each study were extracted and summarized. Results: A total of 35 articles reporting on 61 patients with COVID-19 with mesenteric ischemia met the eligibility and were included in our study. The mean age was 60 (±15.9) years, and 53% of patients were male. Imaging findings of these patients included mesenteric arterial or venous thromboembolism, followed by signs of mesenteric ischemia. Sixty-seven percent of patients were taken to the operating room for an exploratory laparotomy and bowel resection and 21% were managed conservatively. The terminal ileum was the most commonly involved area of necrosis (26%). The mortality rate of patients with COVID-19 with mesenteric ischemia was 33%, and the most common cause of death was multiorgan failure or refractory septic shock. Twenty-seven percent of patients managed operatively died during the post-operative period. Conclusions: Mesenteric ischemia in patients with COVID-19 is a devastating complication associated with a high rate of morbidity and mortality. Further efforts should focus on developing strategies for early recognition and management.

COVID-19 WITH ACUTE COLONIC PSEUDO-OBSTRUCTION

CASE: A 83-year-old male with a history of non-insulin dependent diabetes mellitus, and coronary artery disease presented with four days of worsening myalgias, subjective fevers, and abdominal distention. He had no history of abdominal surgery, sick contacts or medication changes. He had a temperature of 99.2°F, a heart rate of 80 beats per minute, a respiratory rate of 18 breaths per minute, a blood pressure of 105/80 mmHg, and an oxygen saturation of 96% on room air. On examination, the abdomen was distended but without tenderness or guarding. Abdomen Computed Tomography (CT) scan revealed pancolonic severe gaseous dilatation with no transition point. COVID 19 polymerase chain reaction was noted to be positive, along with an elevated D-dimer of 2.58, ESR of 60 mm/h and CRP 40 mg/l;otherwise the laboratory workup including a respiratory and gastrointestinal panel, blood and sputum culture were negative. Following multidisciplinary and shared decisionmaking, a rectal tube was placed and the patient was given neostigmine with resolution of symptoms and subsequent radiographic demonstration of improvement in the colonic distention within 48 hours. Unfortunately, the patient suffered a cardiac arrest on day 5 of his hospitalization and per the family's request, aggressive treatment was aborted in favor of comfort measures. IMPACT/DISCUSSION: While COVID-19 is primarily an airborne infection, widespread expression of its receptor, Angiotensin Converting Enzyme type 2 (ACE2), throughout the gastrointestinal (GI) tract causes GI tract-related clinical symptoms in the absence of respiratory symptoms, leading to a delay in COVID-19 infection diagnosis. While anorexia (50.2%) and diarrhea (49.5%) are the most common gastrointestinal symptoms of COVID 19, our patient presented with abdominal discomfort (2%). Acute colonic pseudo-obstruction or Ogilvie syndrome is a functional disorder characterized by profound dilatation of the colon without a true mechanical obstruction. An association between certain viral infections (Herpes) and intestinal pseudo-obstruction has been demonstrated previously. The mechanism of such a development is hypothesized to be due to the viral invasion of the myenteric plexus. Similarly, COVID-19 has demonstrated neurotropic potential leading to the development of Ogilvie syndrome. Treatment modalities available for the treatment include bowel rest, nasogastric and rectal tube placement, electrolyte correction, neostigmine and possible endoscopic/surgical intervention with a preferably good prognosis. CONCLUSION: 1. The full range of effects of the COVID 19 virus are yet to be discovered. Loss of parasympathetic spinal control of bowel motility may be one possible manifestation of this disease. 2. Gastrointestinal sequelae of COVID 19 respond well to conservative management and should warrant a low threshold for the investigation and implementation of such treatment.

COVID-19 pandemic and clinicopathologic characteristics of colorectal cancer in Korea: A multicenter, retrospective study

Background: The coronavirus disease 2019 (COVID-19) pandemic has affected not only the control and management of infectious diseases, but also those of other diseases by deteriorating the general healthcare systems worldwide. In accordance with the suggestion by the WHO for postponement of non-urgent procedures, diagnosis and treatment strategies for the patients with malignancy have been changed. The aim of this study was to investigate the impact of COVID-19 pandemic on primary colorectal cancer (CRC) from multi-institutions in Korea. Methods: Medical records of consecutive patients with CRC between March 2019 and February 2021 in six university hospitals were reviewed. Recurrent diseases, admission for management of complications or enterostomy repair, and other pathologies than adenocarcinoma were excluded. Baseline characteristics and perioperative outcomes were compared after a cohort was divided into the two groups: before and after around March 2020, when the COVID-19 test has been mandatory for all admitted patients in most institutions. Treatment characteristics and pathologic outcomes were also compared between the two groups. Results: A total of 3895 patients with CRC admitted during the study period. After 454 patients were excluded, 1820 and 1621 patients were assigned to the pre-pandemic and pandemic groups. The proportion of patients who could not receive curative or palliative surgery for stage IV diseases was not different (88 vs. 91, P>0.999), and 3262 patients underwent surgery for primary CRC. Among them, the pandemic group showed more previous abdominal surgery (21.2% vs. 15.4%, P<0.001), higher preoperative CEA level (46.7 vs. 16.0 ng/mL, P=0.021), and less stent insertion for obstructive lesion (33% vs. 46.4%, P=0.043). There was no difference in sex, age, the ASA grade, and tumor location between the groups. Perioperative outcomes including operation time, operation method, operation type, and postoperative complication rates were not different, whereas more stoma formation was performed in the pandemic group (15.3% vs. 12.4%, P=0.024). Pathologic outcomes including TNM stage, tumor diameter, harvested lymph nodes, and lymphovascular invasion were not different. However, the pandemic group showed higher tendency of lymph node metastasis (44% vs. 40.6%, P=0.070) and more adjuvant chemotherapy (26.4% vs. 20.1%, P<0.001). Conclusions: Although a few factors indicated more advanced CRC, clinical features and perioperative outcomes of the patients in COVID-19 pandemic seemed not to be aggravated in Korea. The national healthcare system which was not shut down in the pandemic, and relatively small number of COVID-19 prevalence might influence these results, although patients' access and medical checkup seemed to decrease slightly. The cause and effect of decreased medical access would be clarified by long-term follow up data.

Robotic Abdominal Surgery and COVID-19: A Systematic Review of Published Literature and Peer-Reviewed Guidelines during the SARS-CoV-2 Pandemic.

Background: Significant concern emerged at the beginning of the SARS-CoV-2 pandemic regarding the safety and practicality of robotic-assisted surgery (RAS). We aimed to review reported surgical practice and peer-reviewed published review recommendations and guidelines relating to RAS during the pandemic. Methods: A systematic review was performed in keeping with PRISMA guidelines. This study was registered on Open Science Framework. Databases were searched using the following search terms: 'robotic surgery', 'robotics', 'COVID-19', and 'SARS-CoV-2'. Firstly, articles describing any outcome from or reference to robotic surgery during the COVID-19/SARS-CoV-2 pandemic were considered for inclusion. Guidelines or review articles that outlined recommendations were included if published in a peer-reviewed journal and incorporating direct reference to RAS practice during the pandemic. The ROBINS-I (Risk of Bias in Non-Randomised Studies of Intervention) tool was used to assess the quality of surgical practice articles and guidelines and recommendation publications were assessed using the AGREE-II reporting tool. Publication trends, median time from submission to acceptance were reported along with clinical outcomes and practice recommendations. Results: Twenty-nine articles were included: 15 reporting RAS practice and 14 comprising peer-reviewed guidelines or review recommendations related to RAS during the pandemic, with multiple specialities (i.e., urology, colorectal, digestive surgery, and general minimally invasive surgery) covered. Included articles were published April 2020-December 2021, and the median interval from first submission to acceptance was 92 days. All surgical practice studies scored 'low' or 'moderate' risk of bias on the ROBINS-I assessment. All guidelines and recommendations scored 'moderately well' on the AGREE-II assessment; however, all underperformed in the domain of public and patient involvement. Overall, there were no increases in perioperative complication rates or mortalities in patients who underwent RAS compared to that expected in non-COVID practice. RAS was deemed safe, with recommendations for mitigation of risk of viral transmission. Conclusions: Continuation of RAS was feasible and safe during the SARS-CoV-2 pandemic where resources permitted. Post-pandemic reflections upon published robotic data and publication patterns allows us to better prepare for future events and to enhance urgent guideline design processes.

Familial mediterranean fever (FMF) in Apulia: rare, or actually not? A 14 year experience as Internist

Familial Mediterranean fever (FMF) is a hereditary autoinflammatory disorder characterized by recurrent attacks of fever and serosal inflammation. The clinical features consist of especially abdominal pain, chest pain and arthralgias, plus erysipelas-like manifestations. According to the available literature, most patients with FMF experience their first attack in early childhood, before the ages of 10 and 20 years in 65 and 90% of cases, respectively. Rarely, the initial attack can occur in individuals older than 50 years of age. We report our experience with FMF during the last 14 yrs [1], following case #1 aged 36 yrs. [2]. In the regions of Apulia and Basilicata, we could identify several family clusters due to historical and geographical roots. In the initial series of 60 cases, the five most frequent MEFV variants were E148Q/R761H (41.9%, compound heterozygosity), K695R (10.2%, heterozygosity), E148Q (8.2%, heterozygosity), E148Q/R761H/A744S (6.1% compound heterozygosity), and P369S (6.1%, heterozygosity). Notably, the mean disease onset was 22 yrs and the diagnostic delay was 15 yrs. The severity of symptoms was generally mild/intermediate but about 30% of this initial series had undergone unnecessary abdominal surgery. Females were significantly older than males (median 40 vs. 30 yrs., respectively, P = 0.03). Symptoms including fever were largely responsive to the average dose of colchicine 1 mg/day ad libitum. Only one case required canakinumab for resistance/intolerance to colchicine. We did not observe severe cases of secondary amyloidosis and kidney damage. Later, we extended our observations and concluded that the combination of available expert information with sensitive predictor tools could result in a more accurate interpretation of clinical consequences of MEFV gene variants, and a better genetic counselling and patient management, with respect to symptom severity as well [3, 4]. We recently reported the rare case of a very late onset of FMF symptoms in a patient aged 86 [5]. Further studies in FMF have focused the attention on environmental factors including intestinal microbiota [6], COVID-19 pandemic [7], blood-based test for diagnosis and functional subtyping of FMF by the ex vivo colchicine assay [8], and histopathological characteristics of synovitis in FMF [9]. Following these seminal observations, we conclude that the Apulia region represents a new endemic area for FMF, a puzzling inherited autoinflammatory disorder. Clinical presentation of FMF can be misleading and requires a complete and early workup to recognize the disease and avoid unjustified surgery. Colchicine remains the gold standard therapy to prevent FMF attacks and fatal long-term complications [10, 11].

Clinical expression of symptomatic Familiar Mediterranean Fever (FMF) in Lebanese patients: a real-life survey study

Background: Familial Mediterranean fever (FMF) is an autosomal recessive autoinflammatory disease characterized by recurrent fever and serositis attacks. We aimed to explore clinical aspects of FMF including knowledge, diagnosis, symptoms, and medication in a Lebanese cohort enrolled by ad-hoc questionnaire. Methods: During November 2021-March 2022 we conducted an online survey by a google form questionnaire (33 items) advertised across Lebanese communities, hospitals, internists, and specialists. Patients and children's parents voluntarily provided information about FMF knowledge, diagnosis, presence, and severity of symptoms before and after medication. Since COVID-19 and FMF may share some common symptoms due to activation of the inflammasome pathway, we further investigated this aspect in the FMF cohort with symptomatic COVID-19. Results: A total of 123 FMF patients participated in this survey (75 females, age range 1-67 years;10 subjects from Armenia, Persia, and Turkey). The most frequent MEFV variants were M694V, M694I, E148Q, V726A, R202Q, and A744S. Before the diagnosis 70% of the subjects had no knowledge about FMF. The diagnosis was late in 40% of subjects (at age ≥20 years). A misdiagnosis occurred in 21% of subjects and was associated with unnecessary procedures such as heavy antibiotic prescription, appendectomy, and abdominal surgery. Prior to the diagnosis and targeted FMF therapy, subjects described typical febrile periodical attacks of systemic serositis with a frequency of more than attack once per month (48%) with intensity ranging from moderate to severe (95%). Following therapy with colchicine, 65% of the subjects reported mild symptoms. In addition, 60% of subjects had COVID-19 infection which was symptomatic in 80% of the cases. Concerning COVID-19, 63% of symptomatic COVID-19 subjects reported that FMF symptoms were higher compared to COVID-19, 23% reported that COVID-19 symptoms were higher than FMF symptoms, and 14% reported no difference between the two diseases. Additionally, 12% reported consequences of FMF-COVID- 19 combined symptoms, mainly joint pain due to persisting arthralgias. Conclusion: In Lebanon, an endemic region for FMF with a mixture of the ethnic communities from the Mediterranean area, FMF diagnosis can be missed, delayed, or initially erroneously classified. Nevertheless, the diagnostic ability is improving over time. This is the first study in Lebanon to clarify aspects of FMF knowledge, diagnosis, and symptoms as well as evaluation of COVID-19 and FMF interplay. The complex interaction and consequences between COVID-19 infection and the genetic autoinflammatory FMF is being further investigated.

COMBINED ENDOSCOPIC ROBOTIC SURGERY FOR COMPLEX COLON POLYPS: A RETROSPECTIVE STUDY

Purpose/Background: Combined endoscopic robotic surgery (CERS) is a novel surgical technique that modifies traditional endoscopic laparoscopic surgery with robotic assistance to aid in removal of complex colonic polyps. Hypothesis/Aim: This study aimed to evaluate the safety and outcomes of combined endoscopic robotic surgery. Methods/Interventions: A retrospective review of a prospective database was conducted. Patients underwent CERS by a single colorectal surgeon from March 2018 to October 2021. Polyps were initially found by a referring gastroenterologist and deemed unresectable by traditional endoscopy. Complex polyps were identified in the colon endoscopically while the da Vinci Xi robot was utilized to aid in polyp resection. Once complete, the resection site was over-sewn with absorbable Lembert sutures under endoscopic supervision. Based on pathology, patients were instructed to undergo repeat colonoscopy 3 to 12 months from their operative date. Results/Outcome(s): Combined endoscopic and robotic surgery was successfully completed in 85 of 93 (91%) cases. Patients were converted to other procedures due to discovery of a smaller polyp than anticipated, concern for malignancy, involvement of the ileocecal valve, inability to lift the polyp, or involvement of the appendiceal stump. Among the 85 participants seeing CERS to completion, average age was 66 years (SD=10), body mass index was 29 (SD=6), and history of abdominal surgeries was 1 (SD=1). Median operative time and polyp size were 73 mins (range 31-184 mins) and 40 mm (range 5-180 mm), respectively. Most common polyp locations were cecum, ascending, and transverse colon (29%, 29%, 24%). Pathology mainly demonstrated tubular adenoma (76%). To date, 40 patients underwent follow-up colonoscopy, with an average follow-up time of 7 months (range 3-22 months). Of those, one patient (2.5%) had resection site polyp recurrence. Limitations: Limitations for our study include lack of randomization and follow-up rate to assess for recurrence. The low compliance rate may be due to patient reluctance to get a colonoscopy or procedure cancelations/ difficulty scheduling due to changing COVID-19 regulations. Conclusions/Discussion: Most recent literature reports median operative times for combined endoscopic laparoscopic surgery (CELS) as 85 mins (range 50-225 mins) and 135 mins (range 120-170 mins). Resection site polyp recurrence for traditional endoscopic mucosal resection and CELS ranges from 13.1% and 3.3-10%, respectively. Our findings suggest that CERS is associated with decreased operating time and resection site polyp recurrence. Overall, CERS is a practical technique that enhances current methods for the resection of complex colonic polyps.

The Feasibility and Benefits of Preoperative Whey Protein-Infused Carbohydrate Loading in Elderly with Hip Fractures Undergoing Surgery: A Pilot Study

Introduction: Preoperative carbohydrate loading in Enhanced Recovery After Surgery (ERAS) is an independent predictor of postoperative outcomes. By reducing the impact of surgical stress response, fasting-induced insulin resistance is modulated. As a clear fluid, consuming whey protein-infused carbohydrate is safe up to 2 hours preoperatively. Widely practiced in abdominal surgeries, its implementation in hip fracture surgeries is yet to be recognized. Methods: We aim to identify the feasibility of preoperative carbohydrate loading in hip fracture surgery and assess its clinical effects. A randomized controlled, open labelled trial in patients ≥ 65 years old without diabetes mellitus, has hip fracture was conducted in University Malaya Medical Centre between November 2020 and May 2021. Intervention: Carbohydrate loading (Resource-Nestle®) with 100g on the day before surgery and 50g up to 2 hours preoperatively versus standard preoperative fasting. Results: Thirty ASA 1-3 patients (carbohydrate loading and control, n = 15 each), mean age 79 years (SD±8.5), mean body mass index 23.8 (SD±3.5kg/m2) were recruited. Analysis for feasibility of carbohydrate loading (n = 15) demonstrated attrition rate of 20%, n = 3 (one participant completed the drinks but operation was postponed and two patients were not served the third drink by ward staff). Otherwise, patients were 100% compliant with no adverse events reported. 26 randomized participants were analyzed for secondary outcomes (intervention n = 12, control n = 14). There was no significant difference among groups in the postoperative nausea and vomiting, pain score, fatigue level and muscle strength assessed at 24-48 hours postoperatively. Conclusion: COVID-19 pandemic had interrupted recruitment resulting in a small number of participants. Nevertheless, this study demonstrated that implementation of preoperative carbohydrate loading is feasible for hip fracture surgeries without complications but requires careful coordination among surgical, anaesthetic and nursing teams. An adequately powered randomized controlled study is needed to examine the full benefits of preoperative carbohydrate loading in this group of patients.