Beyond enhanced recovery after surgery (ERAS): Evolving minimally invasive colectomy from multi-day admissions to same-day discharge.

INTRODUCTION: Early discharge is increasingly important in the resource-limited COVID era. Some groups have reported early experiences with same day discharge (SDD) after colectomy. We implemented a routine SDD protocol and report the evolution in our program's outcomes. METHODS: We studied a retrospective cohort of robotic colorectal surgeries from 2016 to 2022. Colectomies were analyzed as a sub-group and stratified by year. RESULTS: The cohort comprised 535 cases, of which 483 were colectomies. Annual case volume increased from 58 to 180 cases (p < 0.001). Operative console time concordantly decreased by 33% (p < 0.001). Average length of stay decreased from five to one days. By 2022, 58% of colectomies were selectively discharged on the same day of surgery. Complication and readmission rates remained constant. CONCLUSIONS: SDD is feasible and safe in selected patients. We illustrate the practical evolution of a surgical practice toward routine SDD, and discuss the factors we found critical to this transition.

Same day discharge following elective, minimally invasive, colorectal surgery : A review of enhanced recovery protocols and early outcomes by the SAGES Colorectal Surgical Committee with recommendations regarding patient selection, remote monitoring, and successful implementation.

BACKGROUND: As enhanced recovery programs (ERPs) have continued to evolve, the length of hospitalization (LOS) following elective minimally invasive colorectal surgery has continued to decline. Further refinements in multimodal perioperative pain management strategies have resulted in reduced opioid consumption. The interest in ambulatory colectomy has dramatically accelerated during the COVID-19 pandemic. Severe restrictions in hospital capacity and fear of COVID transmission forced surgical teams to rethink strategies to further reduce length of inpatient stay. METHODS: Members of the SAGES Colorectal Surgery Committee began reviewing the emergence of SDD protocols and early publications for SDD in 2019. The authors met at regular intervals during 2020-2022 period reviewing SDD protocols, safe patient selection criteria, surrogates for postoperative monitoring, and early outcomes. RESULTS: Early experience with SDD protocols for elective, minimally invasive colorectal surgery suggests that SDD is feasible and safe in well-selected patients and procedures. SDD protocols are associated with reduced opioid use and prescribing. Patient perception and experience with SDD is favourable. For early adopters, SDD has been the natural evolution of well-developed ERPs. Like all ERPs, SDD begins in the office setting, identifying the correct patient and procedure, aligning goals and objectives, and the perioperative education of the patient and their supporting significant others. A thorough discussion with the patient regarding expected activity levels, oral intake, and pain control post operatively lays the foundation for a successful application of SDD programs. These observations may not apply to all patient populations, institutions, practice types, or within the scope of an existing ERP. However, if the underlying principles of SDD can be incorporated into an existing institutional ERP, it may further reduce the incidence of post operative ileus, prolonged LOS, and improve the effectiveness of oral analgesia for postoperative pain management and reduced opioid use and prescribing. CONCLUSIONS: The SAGES Colorectal Surgery Committee has performed a comprehensive review of the early experience with SDD. This manuscript summarizes SDD early results and considerations for safe and stepwise implementation of SDD with a specific focus on ERP evolution, patient selection, remote monitoring, and other relevant considerations based on hospital settings and surgical practices.

[Severe pseudomembranous colitis in patients with previous coronavirus infection]. / Psevdomembranoznyi kolit na fone perenesennoi koronavirusnoi infektsii.

OBJECTIVE: To analyze treatment outcomes in patients with severe pseudomembranous colitis and previous coronavirus infection. MATERIAL AND METHODS: We retrospectively analyzed treatment outcomes, clinical, laboratory and histological data in convalescents of COVID-19 who admitted to the department of coloproctology for moderate-to-severe pseudomembranous colitis confirmed by endoscopic examination between 2020 and 2021. RESULTS: There were 13 patients with moderate pseudomembranous colitis and 6 ones with severe pseudomembranous colitis. Mean period after recovery from coronavirus infection was 19 days. Endoscopy revealed whitish-yellow or gray raised plaques on colonic mucosa in all cases. Four patients with signs of peritonitis underwent emergency surgery. Three patients had perforation of caecum; one patient had perforation of sigmoid colon and widespread peritonitis. Two patients underwent urgent surgery for progressive toxic megacolon and ineffective therapy. Subtotal colectomy and ileostomy were performed in all cases. Histological examination revealed necrosis of not only superficial layer of colon mucosa typical for clostridial colitis, but also the entire thickness of mucosa, as well as submucosal and partially muscular layers in some cases. Mucosal crypt atrophy, fibrinoid effusion in muscular layer, diffuse polymorphonuclear cell infiltration and necrosis of muscular and submucosal nerve plexuses, as well as necrosis of vascular walls with deposition of hyaline-like structures characterize microcirculatory ischemic processes in the colon wall. CONCLUSION: Severe pseudomembranous colitis associated with COVID-19 may not be associated with clostridial infection. Further analysis of possible ischemic etiology and pathogenesis of gastrointestinal lesions in COVID-19 is needed for preventive and therapeutic measures.

Ambulatory colectomy: A pilot protocol for same day discharge in minimally invasive colorectal surgery.

BACKGROUND: Since its inception colectomy has routinely been performed in the inpatient setting. The advent of Enhanced Recovery After Surgery (ERAS) protocols has led improved outcomes, including decreased length of stay (LOS). These improvements have introduced the possibility of ambulatory colectomy. However, indications, protocols, and limitations of ambulatory colectomy have not been extensively explored. METHODS: We conducted a retrospective review on ambulatory colectomies performed between February 2019 and August 2021. Patients were candidates for same day discharge (SDD) if they met rigorous preoperative criteria. Following an uncomplicated operation, strict postoperative parameters were required for safe discharge. If the patient underwent SDD following their operation, they were monitored closely via telehealth visits and/or patient communication messages until their one-week postoperative visit. RESULTS: From our review, we identified sixty-nine (n = 69) patients who underwent SDD after colectomy. Of the 69, only one patient was readmitted after discharge (1.4%). All procedures were performed via a robotic-assisted approach (Da Vinci Xi). None of the patients underwent conversion to an open procedure. The most frequently performed procedures included: low anterior resection (LAR) (n = 32, 46.4%) and right hemicolectomy (n = 11, 15.9%). CONCLUSION: Through proper patient education and strictly defined communication between the patient care teams, safe and effective care in the setting of SDD after colectomy can be provided. With recent technological advancements, enhanced mechanisms for patient education throughout all phases, and emerging means of patient-physician communication, via the data included herein the opportunity for same day discharge (SDD) after colectomy is a feasible and safe management plan in the proper patient.

Early versus delayed ileocolic resection for complicated Crohn's disease: is "cooling off" necessary?

BACKGROUND: Ileal Crohn's disease (CD) complicated by intraabdominal abscess, phlegmon, fistula, and/or microperforation is commonly treated with antibiotics, bowel rest, and percutaneous drainage followed by interval ileocolic resection (ICR). This "cool off" strategy is intended to facilitate the safe completion of a one-stage resection using a minimally invasive approach and minimize perioperative complications. There is limited data evaluating the benefits of delayed versus early resection. METHODS: A retrospective review of a prospectively maintained inflammatory bowel disease (IBD) database at a tertiary center was queried from 2013-2020 to identify patients who underwent ICR for complicated ileal CD confirmed on preoperative imaging. ICR cohorts were classified as early (≤ 7 days) vs delayed (> 7 days) based on the interval from diagnostic imaging to surgery. Operative approach and 30-day postoperative morbidity were analyzed. RESULTS: Out of 474 patients who underwent ICR over the 7-year period, 112 patients had complicated ileal CD including 99 patients (88%) with intraabdominal abscess. Early ICR was performed in 52 patients (46%) at a median of 3 days (IQR 2, 5) from diagnostic imaging. Delayed ICR was performed in 60 patients (54%) following a median "cool off" period of 23 days of non-operative treatment (IQR 14, 44), including preoperative percutaneous abscess drainage in 17 patients (28%). A higher proportion of patients with intraabdominal abscess underwent delayed vs early ICR (57% vs 43%, p = 0.19). Overall, there were no significant differences in the rate of laparoscopy (96% vs 90%), conversion to open surgery (12% vs 17%), rates of extended bowel resection (8% vs 13%), additional concurrent procedures (44% vs 52%), or fecal diversion (10% vs 2%) in the early vs delayed ICR groups. The median postoperative length of stay was 5 days in both groups with an overall 25% vs 17% (p = 0.39) 30-day postoperative complication rate and a 6% vs 5% 30-day readmission rate in early vs delayed ICR groups, respectively. Overall median follow-up time was 14.3 months (IQR 1.2, 24.1) with no difference in the rate of subsequent CD-related intestinal resection (4% vs 5%) between the two groups. CONCLUSIONS: In this contemporary series, at a high-volume tertiary referral center, a "cool off" delayed resectional approach was not found to reduce perioperative complications in patients undergoing ICR for complicated ileal Crohn's disease. Laparoscopic ICR can be performed within one week of diagnosis with low rates of conversion and postoperative complications.

Impact of the COVID-19 pandemic on the management of colorectal cancer in Denmark.

INTRODUCTION: The COVID-19 pandemic has had a global impact on cancer care but the extent to which this has affected the management of colorectal cancer (CRC) in different countries is unknown. CRC management in Denmark was thought to have been relatively less impacted than in other nations during the first wave of the pandemic. The aim of this study was to determine the pandemic's impact on CRC in Denmark. METHODS: The Danish national cancer registry identified patients with newly diagnosed with CRC from 1 March 2020 to 1 August 2020 (pandemic interval) and corresponding dates in 2019 (prepandemic interval). Data regarding clinicopathological demographics and perioperative outcomes were retrieved and compared between the two cohorts. RESULTS: Total CRC diagnoses (201 versus 359 per month, P = 0.008) and screening diagnoses (38 versus 80 per month, P = 0.016) were both lower in the pandemic interval. The proportions of patients presenting acutely and the stage at presentation were, however, unaffected. For those patients having surgery, both colonic and rectal cancer operations fell to about half the prepandemic levels: colon (187 (i.q.r. 183-188) to 96 (i.q.r. 94-112) per month, P = 0.032) and rectal cancers (63 (i.q.r. 59-75) to 32 (i.q.r. 28-42) per month, P = 0.008). No difference was seen in surgical practice or postoperative 30-day mortality rate (colon 2.2 versus 2.2 per cent, P = 0.983; rectal 1.0 versus 2.9 per cent, P = 0.118) between the cohorts. Treatment during the pandemic interval was not independently associated with death at 30 or 90 days. CONCLUSION: The initial wave of the COVID-19 pandemic reduced the number of new diagnoses made and number of operations but had limited impact on technique or outcomes of CRC care in Denmark.

A Novel Predictive Model for Anastomotic Leakage in Colorectal Cancer Using Auto-artificial Intelligence.

AIM: Anastomotic leakage (AL) in left-sided colorectal cancer is a serious complication, with an incidence rate of 6-18%. We developed a novel predictive model for AL in colorectal surgery with double-stapling technique (DST) anastomosis using auto-artificial intelligence (AI). PATIENTS AND METHODS: A total of 256 patients who underwent curative surgery for left-sided colorectal cancer between 2017 and 2021 were included. In addition to conventional clinicopathological factors, we included the type of circular stapler using DST, conventional double-row circular stapler (DCS) or EEA™ circular stapler with Tri-Staple™ technology, 28 mm Medium/Thick (Covidien, New Haven, CT, USA) which had triple-row circular stapler (TCS) as a covariate. Auto-AI software Prediction One (Sony Network Communications Inc.) was used to predict AL with 5-fold cross validation. Predictive accuracy was assessed using the area under the receiver operating characteristic curve. Prediction One also evaluated the 'importance of variables' (IOV) using a method based on permutation feature importance. RESULTS: The area under the curve of the AI model was 0.766. The type of circular stapler used was the most influential factor contributing to AL (IOV=0.551). CONCLUSION: This auto-AI predictive model demonstrated an improvement in accuracy compared to the conventional model. It was suggested that use of a TCS may contribute to a reduction in the AL rate.

Ileorectal anastomosis in patients with Crohn's disease. Postoperative complications and functional outcome-a systematic review.

AIM: The objective of this systematic review was to investigate the outcomes of ileorectal anastomosis (IRA) in Crohn's disease and to clarify whether there are any time-related trends in outcome measures. The primary outcomes are risk of anastomotic leakage, death, clinical recurrence and subsequent diverting or permanent stoma and/or proctectomy. Secondary end-points are quality of life and functional outcome. METHODS: Systematic searches were conducted using the Cochrane Library, Embase and MEDLINE. The complete search strategy is uploaded online at http://www.crd.york.ac.uk/prospero/. Human studies in English with over five subjects were included and no limit was set regarding the date of publication. All relevant studies were screened by two reviewers. The web-based software platform www.covidence.org was used for primary screening of the title, abstract, full-text review and data extraction. RESULTS: The search identified 2231 unique articles. After the screening process, 37 remained. Key results were an overall anastomotic leak rate of 6.4%; cumulative rates of clinical recurrence of 43% and 67% at 5 and 10 years, respectively; an overall rate of proctectomy of 18.9%; and subsequent ileostomy required in 18.8%. Only one study presented useful data on quality of life. Recurrence rates remained stable over time. A small decline in the anastomotic leak rate was found. CONCLUSIONS: Only minor improvements in the outcomes of IRA in patients with Crohn´s disease have occurred during the past 50 years regarding anastomotic leakage and recurrence, except for a slight increase in the rate of a functioning IRA. These results call for implementation guidelines in patient selection for IRA and postoperative medical treatment and follow-up.

Laparoscopic colorectal resections during the COVID-19 pandemic - business as usual?

INTRODUCTION: To analyse the outcomes of major colorectal resections performed during the COVID-19 pandemic, to assess safety and explore all precautionary measures. METHOD: All patients who underwent major elective colorectal resections at St Helens and Knowsley Teaching Hospital NHS Trust between 24th March 2020 (the date that the Royal Colleges of Surgery produced their guidelines re operating during the pandemic) and 17th April 2020 were analysed from a prospectively maintained database. The primary outcome was 7-day mortality and secondary outcomes were the development of a positive COVID-19 test consequent to hospital stay and the overall complication rate. RESULTS: In this 24 day time frame 27 patients (17 males) underwent elective colorectal resections at St Helens and Knowsley NHS Trust. The median age was 69 (41-84) years and median ASA was 2 (1-3). The median Body Mass Index was 30 (21-40.7). Twenty-five patients underwent surgery for cancer and two patients had urgent resections for low-grade sepsis secondary to diverticular colovesical fistulae. 24 patients underwent laparoscopic colorectal resections and 3 patients underwent planned open surgery. 7-day mortality was 0%, and no patients/staff contracted COVID-19 during the post-operative period. The overall complication rate was 14.8%. At a median follow-up of 29 (17-44) days via telephone, there have been no reported COVID-19 related symptoms in any of these patients. CONCLUSION: Our experience demonstrated that it was possible to undertake laparoscopic colorectal resections despite the COVID-19 pandemic posing a major threat to humanity, providing that adequate and stringent precautions are undertaken.

Results of surgical treatment of uncomplicated colon cancer: case series with follow-up / Resultados del tratamiento quirúrgico del cáncer de colon no complicado: serie de casos con seguimiento

SUMMARY: The standard treatment of colonic cancer (CC) continues to be the radical resection of the intestinal segment compromised with free margins, associated or not with adjuvant therapies. The aim of this study was to determine postoperative morbidity (POM) and 5-year overall survival (OS) in patients with uncomplicated colon cancer surgically treated. Retrospective case series of patients with uncomplicated CC undergoing colectomy and lymphadenectomy, consecutively, at Clínica Red Salud Mayor Temuco, between 2007 and 2019. The outcomes variable were POM and 5-years OS. Other variables of interest were surgical time, number of resected lymph nodes, hospital stay and recurrence. Descriptive statistics was used (measures of central tendency and dispersion), and OS analysis was applying Kaplan Meier curves. In this study, 52 patients (53.8 % men) were intervened, with a median age of 68 years. The most frequent localization and stages were right colon (42.3 %); IIIA and IIIB respectively (78.9 %). Median surgical time, number of resected lymph nodes and hospital stay were 98 min, 34 and 4.5 days respectively. POM was 17.3 % (9 cases). With a median follow- up of 58 months, a recurrence of 19.2 % was verified, and the 5-year OS for stages IIA, IIIA, IIIB and IVA was 83.3 %, 73.6 %, 68.2 % and 40.0 % respectively. The results, in terms of POM, mortality and 5-year OS, were similar to national and international series.

RESUMEN: El tratamiento estándar del cáncer de colon (CC), continua siendo la resección radical del segmento intestinal comprometido con márgenes libres (al menos 5 cm por encima y debajo del tumor), pudiendo asociarse o no a terapias complementarias. El objetivo de este estudio fue determinar morbilidad postoperatoria (MPO) y supervivencia actuarial global (SVAG) a 5 años en pacientes resecados por CC no complicado. Serie de casos con seguimiento, de pacientes con CC no complicado, sometidos a colectomía subtotal y linfadenectomía, de forma consecutiva, en Clínica Red Salud Mayor Temuco, entre 2007 y 2019. Las variables resultado fueron MPO y SV actuarial global (SVAG) a 5 años. Otras variables de interés fueron: tiempo quirúrgico, número de linfonodos resecados, estancia hospitalaria y recurrencia. Se utilizó estadística descriptiva, con medidas de tendencia central y dispersión; y análisis de SV con curvas de Kaplan Meier. Se intervinieron 52 pacientes (53,8 % hombres), con una mediana de edad de 68 años. La localización y estadios más frecuentes fueron colon derecho (42,3 %); IIIA y IIIB respectivamente (78,9 %). La resecabilidad de la serie fue 100 %. La medianas del tiempo quirúrgico, del número de linfonodos resecados y de estancia hospitalaria; fueron de 98 min, 34 y 4.5 días respectivamente. La MPO fue 17,3 % (9 casos). Con una mediana de seguimiento de 58 meses, se verificó una recurrencia de 19,2 %; y una SVAG a 5 años para los estadios IIA, IIIA, IIIB y IVA; de 83,3 %; 73,6 %; 68,2 % y 40,0 % respectivamente. Los resultados obtenidos, en términos de MPO, mortalidad y SVAG a 5 años, fueron similares a series de nacionales e internacionales.

Colon ischemia in patients with severe COVID-19: a single-center retrospective cohort study of 20 patients.

PURPOSE: Thromboembolic complications due to COVID-19 are common in patients requiring critical care and are associated with high morbidity and mortality rates. The aim of this study was to evaluate clinical manifestations and postoperative outcomes after colectomy for COVID-19-associated colonic ischemia in the first versus the second wave of the pandemic. METHODS: A retrospective cohort study of patients with severe COVID-19 at our institution between 1 March 2020 and 31 January 2021 was performed. All patients with severe COVID-19, requiring critical care and surgical treatment of colonic ischemia, were included. The main outcomes were surgical complications and mortality rate. RESULTS: A total of 190 patients were included of whom 20 (10.5%) patients underwent surgery for colon ischemia. Preoperatively, D-dimer was elevated, especially in the first wave (median 15.24 (interquartile range 6.00-32.00) vs. 2.09 (1.42-4.28) mg/L, p = 0.025). Twelve (60%) patients underwent a (sub)total colectomy, 7 (35%) a right hemicolectomy, and one patient (5%) an ileocecal resection. Grade 3b complications occurred in one of 5 patients (20%) in the first and in 9 of 15 patients (60%) in the second wave. The overall in-hospital mortality was similar in both waves (40% vs. 47%), with death occurring after a median stay of 21 days. CONCLUSION: In this cohort study of patients with severe COVID-19 and colonic ischemia, clinical presentation and laboratory findings varied. However, the majority of patients required (sub)total colectomy. Despite a lower threshold to surgery in the second wave, mortality remained high.

Subtotal colectomy for refractory ulcerative colitis with COVID-19 infection; a first case report in Japan.

We report a 60-year-old male who was transferred to our hospital for the operation because of refractory ulcerative colitis (UC). He was diagnosed to be infected with COVID-19 for SARS-CoV-2 PCR test positive at the time of transfer. We determined emergency operation because his general condition was poor such as malnutrition and ADL decline due to exacerbation of UC and air embolization by central venous catheter removal. He underwent subtotal colectomy with a sigmoid mucous fistula and ileostomy. He was well postoperatively. This is a first case report in Japan who underwent an operation for UC with COVID-19 infection.

Candida albicans mycotic aneurysm of aortic arch following laparoscopic right hemicolectomy for colon cancer.

An 81-year-old man was referred to the colorectal surgeons for an elective laparoscopic right hemicolectomy for a caecal adenocarcinoma (T2N0M0). The operation was uneventful; however, 12 days postoperatively the patient developed symptoms of sepsis of unknown origin. After extensive investigations and work up, Candida albicans was grown as the causative organism with the site of infection being a new saccular mycotic aneurysm arising from the distal, posterior aspect of the aortic arch. The mycotic aneurysm was not initially considered as a differential diagnosis, and this case highlights the importance of consideration of mycotic aneurysm as a differential diagnosis in postsurgical septic patients.

Oral neomycin and bacitracin are effective in preventing surgical site infections in elective colorectal surgery: a multicentre, randomized, parallel, single-blinded trial (COLORAL-1).

Several regimens of oral and intravenous antibiotics (OIVA) have been proposed with contradicting results, and the role of mechanical bowel preparation (MBP) is still controversial. This study aims to assess the effectiveness of oral antibiotic prophylaxis in preventing Surgical Site Infections (SSI) in elective colorectal surgery. In a multicentre trial, we randomized patients undergoing elective colorectal resection surgery, comparing the effectiveness of OIVA versus intravenous antibiotics (IVA) regimens to prevent SSI as the primary outcome (NCT04438655). In addition to intravenous Amoxicillin/Clavulanic, patients in the OIVA group received Oral Neomycin and Bacitracin 24 h before surgery. MBP was administered according to local habits which were not changed for the study. The trial was terminated during the COVID-19 pandemic, as many centers failed to participate as well as the pandemic changed the rules for engaging patients. Two-hundred and four patients were enrolled (100 in the OIVA and 104 in the IVA group); 3 SSIs (3.4%) were registered in the OIVA and 14 (14.4%) in the IVA group (p = 0.010). No difference was observed in terms of anastomotic leak. Multivariable analysis indicated that OIVA reduced the rate of SSI (OR 0.21 / 95% CI 0.06-0.78 / p = 0.019), while BMI is a risk factor of SSI (OR 1.15 / 95% CI 1.01-1.30 p = 0.039). Subgroup analysis indicated that 0/22 patients who underwent OIVA/MBP + vs 13/77 IVA/MBP- experienced an SSI (p = 0.037). The early termination of the study prevents any conclusion regarding the interpretation of the data. Nonetheless, Oral Neomycin/Bacitracin and intravenous beta-lactam/beta-lactamases inhibitors seem to reduce SSI after colorectal resections, although not affecting the anastomotic leak in this trial. The role of MBP requires more investigation.

Elective laparoscopic colectomy in a patient 3 weeks after coronavirus disease 2019 infection: a case report.

BACKGROUND: According to previous reports, surgery is not recommended until at least 4 weeks after the symptoms of coronavirus disease 2019 resolve. However, strong evidence has not been established regarding the optimal timing and preoperative examination for elective laparoscopic colectomy for colorectal cancer in individuals with a previous coronavirus disease 2019 infection. CASE PRESENTATION: A 63-year-old Asian man underwent elective laparoscopic colectomy for sigmoid colon cancer 3 weeks after asymptomatic coronavirus disease 2019. The postoperative course was good, and none of the surgical staff was infected with coronavirus disease 2019. CONCLUSION: In this patient infected with coronavirus disease 2019 within 4 weeks of surgery, preoperative venous ultrasound of the lower extremities and a chest computed tomography scan were useful examinations for ensuring a safe surgical procedure for the patient and the staff. Surgery within 4 weeks may be possible with careful selection of cases based on thorough preoperative examination. This report may contribute to the development of a consensus on performing safe elective colectomy for colon cancer in persons previously infected with coronavirus disease 2019.

The impact of the novel coronavirus pandemic on gastrointestinal operative volume in the United States.

BACKGROUND: In March 2020, the Surgeon General recommended limiting elective procedures to prepare for the COVID-19 surge. We hypothesize a consequence of COVID-19 is reduced operative volume across the country. We aim to examine changes in volume of common gastrointestinal operations during COVID-19, including elective, urgent/emergent, and cancer operations. We also evaluate if hospitals with more COVID-19 admissions were most impacted. METHODS: The Vizient database was used to determine monthly operative volume from November 2019 to June 2020 for elective operations (hiatal hernia repairs, bariatric surgery), urgent operations (cholecystectomies, appendectomies, inguinal hernia repairs), and cancer operations (colectomies, gastrectomies, esophagectomies). COVID-19 admissions per hospital were also determined. November 2019-January 2020 was defined as "pre-COVID." The monthly reduction in volume from pre-COVID was calculated for each operation. The top quartile (25%) of hospitals with the most COVID admissions were also evaluated separately from hospitals with fewer COVID cases. Data were analyzed using analysis of variance. RESULTS: Data from 559 hospitals were analyzed. The volumes of all operations evaluated were significantly reduced during the pandemic except gastrectomies and esophagectomies for cancer. The greatest reduction in all operations was in April. In April, the volume of bariatric surgery reduced by 98% (P < 0.001), hiatal hernia repairs by 96% (P < 0.001), urgent cholecystectomies by 42% (P < 0.001), urgent inguinal hernia repairs by 40% (P < 0.001), urgent appendectomies by 24% (P < 0.001), and colectomies for cancer by 39% (P < 0.001). Hospitals with the most COVID-19 admissions had greater reductions in all operations than hospitals with fewer COVID cases. CONCLUSIONS: The coronavirus pandemic led to a significant reduction in volume of all gastrointestinal operations evaluated except gastrectomies and esophagectomies. While elective, non-cancer operations were most affected, urgent and some cancer operations also declined significantly. As COVID-19 continues to surge, Americans may suffer continued limited access to surgical care and a significant operative backlog may be forthcoming.

Unusual case of cholecystocolonic fistula secondary to megabowel.

Cholecystocolonic fistula with associated idiopathic megabowel (megacolon and megarectum) is a rare presentation as acute large bowel obstruction. Frequently presenting with chronic constipation, acute bowel obstruction is rarely encountered in the presence of concomitant cholecystocolonic fistula. This presents diagnostic and management difficulties with no consensus on appropriate surgical approach. This case highlights the outcomes following emergency total colectomy and subtotal cholecystectomy as a single-stage procedure for a 68-year-old man presenting with cholecystocolonic fistula secondary to idiopathic megabowel as acute large bowel obstruction.

Minimal invasive surgery for left colectomy adapted to the COVID-19 pandemic: laparoscopic intracorporeal resection and anastomosis, a 'don't touch the bowel' technique.

AIM: The COVID-19 pandemic has forced surgeons to adapt their standard procedures. The modifications introduced are designed to favour minimally invasive surgery. The positive results obtained with intracorporeal resection and anastomosis in the right colon and rectum prompt us to adapt these procedures to the left colon. We describe a 'don't touch the bowel' technique and outline the benefits to patients of the use of less surgically aggressive techniques and also to surgeons in terms of the lower emission of aerosols that might transmit the COVID-19 infection. METHODS: This was an observational study of intracorporeal resection and anastomosis in left colectomy. We describe the technical details of intracorporeal resection, end-to-end stapled anastomosis and extraction of the specimen through mini-laparotomy in the ideal location. RESULTS: We present preliminary results of 17 patients with left-sided colonic pathologies, 15 neoplasia and two diverticular disease, who underwent four left hemicolectomies, six sigmoidectomies and seven high anterior resections. Median operating time was 186 min (range 120-280). No patient required conversion to extracorporeal laparoscopy or open surgery. Median hospital stay was 4.7 days (range 3-12 days). There was one case of anastomotic leak managed with conservative treatment. CONCLUSION: Intracorporeal resection and end-to-end anastomosis with the possibility of extraction of the specimen by a mini-laparotomy in the ideal location may present benefits and also adapts well to the conditions imposed by the COVID-19 pandemic. Future comparative studies are needed to demonstrate these benefits with respect to extracorporeal anastomosis.