The role of cytology in patients undergoing pressurized intraperitoneal aerosol chemotherapy (PIPAC) treatment for peritoneal carcinomatosis.

Objectives: Cytology of ascites or peritoneal washing is a routine part of staging of peritoneal metastases (PM). We aim to determine value of cytology in patients undergoing pressurized intraperitoneal aerosol chemotherapy (PIPAC). Methods: Single-center retrospective cohort study included consecutive patients having PIPAC for PM of different primary between January 2015 and January 2020. Results: A total of 75 patients (median 63 years (IQR 51-70), 67 % female) underwent a total of 144 PIPAC. At PIPAC 1 59 % patients had positive and 41 % patients had negative cytology. Patients with negative and positive cytology only differed in terms of symptoms of ascites (16% vs. 39 % respectively, p=0.04), median ascites volume (100 vs. 0 mL, p=0.01) and median PCI (9 vs. 19, p<0.01). Among 20 patients who completed 3 PIPACs (per protocol), cytology changed in one from positive to negative, and in two from negative to positive. Median overall survival was 30.9 months in the per protocol group and 12.9 months in patients having <3 PIPACs (=0.519). Conclusions: Positive cytology under PIPAC treatment is more frequently encountered in patients with higher PCI and symptomatic ascites. Cytoversion was rarely observed and cytology status had no impact on treatment decisions in this cohort.

Early Bleeding After Laparoscopic Roux-en-Y Gastric Bypass: Incidence, Risk Factors, and Management - a 21-Year Experience.

PURPOSE: Morbidity and mortality associated with bariatric surgery are considered low. The aim of this study is to assess the incidence, clinical presentation, risk factors, and management of early postoperative bleeding (POB) after laparoscopic Roux-en-Y gastric by-pass (RYGB). MATERIALS AND METHODS: Retrospective analysis of prospectively collected data of consecutive patients who underwent RYGB in 2 expert bariatric centers between January 1999 and April 2020, with a common bariatric surgeon. RESULTS: A total of 2639 patients underwent RYGB and were included in the study. POB occurred in 72 patients (2.7%). Intraluminal bleeding (ILB) was present in 52 (72%) patients and extra-luminal bleeding (ELB) in 20 (28%) patients. POB took place within the first 3 postoperative days in 79% of patients. The most frequent symptom was tachycardia (63%). Abdominal pain was more regularly seen with ILB, compared to ELB (50% vs. 20%, respectively, p = 0.02). Male sex was an independent risk factor of POB on multivariate analysis (p < 0.01). LOS was significantly longer in patients who developed POB (8.3 vs. 3.8 days, p < 0.01). Management was conservative for most cases (68%). Eighteen patients with ILB (35%) and 5 patients with ELB (25%) required reoperation. One patient died from multiorgan failure after staple-line dehiscence of the excluded stomach (mortality 0.04%). CONCLUSION: The incidence of POB is low, yet it is the most frequent postoperative complication after RYGB. Most POB can be managed conservatively while surgical treatment is required for patients with hemodynamic instability or signs of intestinal obstruction due to an intraluminal clot.

[Obstructed colon cancer: which strategy in 2022?] / Cancer colique en occlusion : quelle prise en charge en 2022 ?

The key priority for obstructed colon cancer (OCC) is urgent resolution of the large bowel obstruction with ideally no compromise of oncological outcomes and low initial and permanent ostomy rates. Proactive management is pivotal to decrease the risk of perforation and septic shock. Staged procedures have an important place to provide optimal treatment and offer similar treatment and outcomes as in the elective setting. The approach is tailored to the patient's condition, the oncological situation and expertise of the available surgical team. This overview concludes by proposing a comprehensive treatment algorithm for individualized treatment of OCC.

La principale priorité du cancer du côlon obstructif (CCO) est la levée urgente de l'obstacle colique, sans compromettre les résultats oncologiques tout en réduisant les taux de stomies initiales et permanentes. Une prise en charge proactive est essentielle pour minimiser le risque de perforation et de choc septique. Les procédures par étapes (staged procedures) ont une place primordiale afin de permettre un traitement optimal associé à des résultats proches des conditions de la chirurgie élective. L'approche doit être adaptée à l'état des patients, au stade oncologique, ainsi qu'à l'expertise chirurgicale disponible. Cette synthèse de la littérature se conclut par la proposition d'un algorithme pour le traitement individualisé du CCO.

Selection Criteria for Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC) Treatment in Patients with Peritoneal Metastases.

Background: The standard treatment protocol for PIPAC consists of three procedures. Completion of treatment has been shown to be prognostic of improved survival. The aim of this study was to identify predictors for completion of treatment. Methods: Retrospective multicentric cohort study of patients with peritoneal metastases undergoing PIPAC in three PIPAC expert centers. Per protocol (PP) treatment was defined as patients receiving ≥3 PIPACs and was compared to patients receiving <3. Results: Overall, 183 patients had 517 PIPACs. The main reasons for stopping PIPAC were disease progression in 50% patients, bowel obstruction in 15%, patient's refusal to pursue in 10%, conversion to cytoreductive surgery in 7%, and medical reasons in 8%. Overall, 95 patients (52%) had PP treatment. The PP median OS was 17 vs. 7 months, p = 0.001. PP patients had r ascites (410 ± 100 mL vs. 960 ± 188 mL, p = 0.001), no prior history of bowel obstruction (12% vs. 24%, p = 0.028), and more bimodal treatment (39% vs. 13%, p < 0.001). After multiple regression, bimodal treatment was found as an independent predictive factor for completing PP (OR = 4.202, 95%CI [1.813, 10.630], p < 0.001), along with prior bowel obstruction (OR = 0.389, 95%CI [0.153, 0.920], p = 0.037). Conclusion: The absence of ascites and prior bowel obstruction can help to select patients suitable for PIPAC. Best results seem to be achieved when PIPAC is combined with systemic chemotherapy.

Impact of an Operating Room Nurse Preoperative Dialogue on Anxiety, Satisfaction and Early Postoperative Outcomes in Patients Undergoing Major Visceral Surgery-A Single Center, Open-Label, Randomized Controlled Trial.

Background: Anxiety is common before surgery and known to negatively impact recovery from surgery. The aim of this study was to evaluate the impact of a preoperative nurse dialogue on a patient's anxiety, satisfaction and early postoperative outcomes. Method: This 1:1 randomized controlled trial compared patients undergoing major visceral surgery after a semistructured preoperative nurse dialogue (interventional group: IG) to a control group (CG) without nursing intervention prior to surgery. Anxiety was measured with the autoevaluation scale State-Trait Anxiety Inventory (STAI, Y-form) pre and postoperatively. The European Organization for Research and Treatment of Cancer (EORTC) In-Patsat32 questionnaire was used to assess patient satisfaction at discharge. Further outcomes included postoperative pain (visual analogue scale: VAS 0−10), postoperative nausea and vomiting (PONV), opiate consumption and length of stay (LOS). Results: Over a period of 6 months, 35 participants were randomized to either group with no drop-out or loss to follow-up (total n = 70). The median score of preoperative anxiety was 40 (IQR 33−55) in the IG vs. 61 (IQR 52−68) in the CG (p < 0.001). Postoperative anxiety levels were comparable 34 (IQR 25−46) vs. 32 (IQR 25−44) for IG and CG, respectively (p = 0.579). The IG did not present higher overall satisfaction (90 ± 15 vs. 82.9 ± 16, p = 0.057), and pain at Day 2 was similar (1.3 ± 1.7 vs. 2 ± 1.9, p = 0.077), while opiate consumption, PONV levels and LOS were comparable. Conclusion: A preoperative dialogue with a patient-centered approach helped to reduce preoperative anxiety in patients undergoing major visceral surgery.

[Surgery Sustainability in surgical practice : the "green surgery" concept and its innovations]. / Chirurgie - Pratique chirurgicale et durabilité : le concept de chirurgie verte et ses innovations.

Awareness of climate change grows in the population and people develop eco-responsible habits in their daily and professional life. The health care system is nowadays responsible for 4.6% of global greenhouse gases emissions, and most of them comes from hospital activity. The operating room is one of the greatest contributors of the overall energetic cost and generates a large amount of hospital waste. As an example, all laparoscopic procedures in the US has an energy cost similar to an 80'000 inhabitants city during one year. A better understanding of the environmental impact of surgery is necessary to identify what can be done to limit the ecological impact of surgery without compromising standards of care.

La population est de plus en plus sensibilisée au changement climatique et développe des habitudes écoresponsables dans la vie quotidienne et professionnelle. Le système de santé est aujourd'hui responsable de 4,6 % des émissions de gaz à effet de serre dans les pays développés, dont la plupart proviennent de l'activité hospitalière. Le bloc opératoire est l'un des plus grands contributeurs au coût énergétique global et génère une grande quantité de déchets hospitaliers. À titre d'exemple, aux États-Unis, l'ensemble des laparoscopies a un coût énergétique annuel similaire à celui d'une ville de 80 000 habitants. Une meilleure compréhension de l'impact écologique de la chirurgie est nécessaire pour identifier ce qui peut être fait pour limiter l'impact écologique de la chirurgie sans compromettre les normes de soins.

Challenges Related to Surgical Site Infection Prevention-Results after Standardized Bundle Implementation.

AIM: The aim of this study was to assess the implementation of an intraoperative standardized surgical site infection (SSI) prevention bundle. METHODS: The multimodal, evidence-based care bundle included nine intraoperative items (antibiotic type, timing, and re-dosing; disinfection; induction temperature control > 36.5°; glove change; intra-cavity lavage; wound protection; and closure strategy). The bundle was applied to all consecutive patients undergoing colonic resections. The primary outcome, SSI, was independently assessed by the National Infection Surveillance Committee for up to 30 postoperative days. A historical, institutional pre-implementation control group (2012-2017) with an identical methodology was used for comparison. FINDINGS: In total, 1516 patients were included, of which 1256 (82.8%) were in the control group and 260 (17.2%) were in the post-implementation group. After 2:1 propensity score matching, the groups were similar for all items (p > 0.05). Overall compliance with the care bundle was 77% (IQR 77-88). The lowest compliance rates were observed for temperature control (53% overall), intra-cavity lavage (64% overall), and wound protection and closure (68% and 63% in the SSI group, respectively). Surgical site infections were reported in 58 patients (22.2%) vs. 21.4% in the control group (p = 0.79). Infection rates were comparable throughout the Centers for Disease Control and Prevention (CDC) categories: superficial, 12 patients (4.5%) vs. 4.2%, p = 0.82; deep incisional, 10 patients (3.7%) vs. 5.1%, p = 0.34; organ space, 36 (14%) vs. 12.4%, p = 0.48. After propensity score matching, rates remained comparable throughout all comparisons (all p > 0.05). CONCLUSIONS: The implementation of an intraoperative standardized care bundle had no impact on SSI rates. This may be explained by insufficient compliance with the individual measures.

Current practice and perceptions of safety protocols for the use of intraperitoneal chemotherapy in the operating room: results of the IP-OR international survey.

OBJECTIVES: To assess the risk perception and the uptake of measures preventing environment-related risks in the operating room (OR) during hyperthermic intraperitoneal chemotherapy (HIPEC) and pressurized intraperitoneal aerosol chemotherapy (PIPAC). METHODS: A multicentric, international survey among OR teams in high-volume HIPEC and PIPAC centers: Surgeons (Surg), Scrub nurses (ScrubN), Anesthesiologists (Anest), Anesthesiology nurses (AnesthN), and OR Cleaning staff (CleanS). Scores extended from 0-10 (maximum). RESULTS: Ten centers in six countries participated in the study (response rate 100%). Two hundred and eleven responses from 68 Surg (32%), 49 ScrubN (23%), 45 Anest (21%), 31 AnesthN (15%), and 18 CleanS (9%) were gathered. Individual uptake of protection measures was 51.4%, similar among professions and between HIPEC and PIPAC. Perceived levels of protection were 7.57 vs. 7.17 for PIPAC and HIPEC, respectively (p<0.05), with Anesth scoring the lowest (6.81). Perceived contamination risk was 4.19 for HIPEC vs. 3.5 for PIPAC (p<0.01). Information level was lower for CleanS and Anesth for HIPEC and PIPAC procedures compared to all other responders (6.48 vs. 4.86, and 6.48 vs. 5.67, p<0.01). Willingness to obtain more information was 86%, the highest among CleanS (94%). CONCLUSIONS: Experience with the current practice of safety protocols was similar during HIPEC and PIPAC. The individual uptake of protection measures was rather low. The safety perception was better for PIPAC, but the perceived level of protection remained relatively low. The willingness to obtain more information was high. Intensified, standardized training of all OR team members involved in HIPEC and PIPAC is meaningful.

Interobserver reliability of the Tile classification system for pelvic fractures among radiologists and surgeons.

OBJECTIVES: To assess the interobserver reliability (IOR) of the Tile classification system, and its potential influence on outcomes, for the interpretation of CT images of pelvic fractures by radiologists and surgeons. METHODS: Retrospective data (1/2008-12/2016) from 238 patients with pelvic fractures were analyzed. Mean patient age was 44 years (SD 20); 66% were male. There were 54 Tile A, 82 Tile B, and 102 Tile C type injuries. The 30-day mortality rate was 15% (36/238). Six observers, three radiologists, and three surgeons with different levels of experience (attending/resident/intern) classified each fracture into one of the 26 second-order subcategories of the Tile classification. Weighted kappa coefficients were used to assess the IORs for the three main categories and nine first-order subcategories. RESULTS: The overall IORs of the Tile system for the main categories and first-order subcategories were moderate (kappa = 0.44) and fair (kappa = 0.31), respectively. IOR was fair to moderate among radiologists, but only fair among surgeons. By level of training, IOR was moderate between attendings and between residents, whereas it was only fair between interns. IOR was moderate to substantial (kappa = 0.56-0.70) between the radiology attending and resident. Association of the Tile fracture type with 30-day mortality was present based on two out of six observer ratings. CONCLUSIONS: The overall IOR of the Tile classification system is only fair to moderate, increases with the level of rater experience and is better among radiologists than surgeons. In the light of these findings, results from studies using this classification system must be interpreted cautiously. KEY POINTS: • The overall interobserver reliability of the Tile pelvic fracture classification is only fair to moderate. • Interobserver reliability increases with observer experience and radiologists have higher kappa coefficients than surgeons. • Interobserver reliability has an impact on the association of the Tile classification system with mortality in two out of six cases.

Consensus statement on safety measures for pressurized intraperitoneal aerosol chemotherapy.

OBJECTIVES: Pressurized intraperitoneal aerosol chemotherapy (PIPAC) is a promising treatment for peritoneal cancer that entails, however, potential risks for the caregivers in the operating room (OR). This study aimed to reach a consensus within the PIPAC community on a comprehensive safety protocol. METHODS: Active PIPAC centers were invited to participate in a two-round Delphi process on 43 predefined items: concise summaries of the existing evidence were presented together with questions formulated using the population, intervention, comparator, and outcome framework. According to the Grading of Recommendations Assessment, Development, and Evaluation, the strength of recommendation was voted by panelists, accepting a consensus threshold of ≥50% of the agreement for any of the four grading options, or ≥70% in either direction. RESULTS: Forty-seven out of 66 invited panelists answered both rounds (response rate 76%). The consensus was reached for 41 out of 43 items (95.3%). Strong and weak recommendations were issued for 30 and 10 items, respectively. A positive consensual recommendation was issued to activate laminar airflow without specific strength, neither strong nor weak. No consensus was reached for systematic glove change for caregivers with a high risk of exposure and filtering facepiece mask class 3 for caregivers with low risk of exposure. CONCLUSIONS: A high degree of consensus was reached for a comprehensive safety protocol for PIPAC, adapted to the risk of exposure for the different caregivers in the OR. This consensus can serve as a basis for education and help reach a high degree of adherence in daily practice.

Comparison of Partial Hepatectomy and Transarterial Chemoembolization in Intermediate-Stage Hepatocellular Carcinoma: A Systematic Review and Meta-Analysis.

INTRODUCTION: According to the Barcelona Clinic Liver Cancer (BCLC) algorithm, transarterial chemoembolization (TACE) is recommended in patients with hepatocellular carcinoma (HCC) of intermediate stage (BCLC-B), whereas partial hepatectomy (PH) is restricted to early stage A. Expanding the indication for PH to intermediate stage remains debated. OBJECTIVE: This meta-analysis aimed to analyze short- and long-term outcomes of PH compared to TACE in patients with intermediate-stage HCC. METHODS: A meta-analysis was conducted according to PRISMA guidelines. Trials comparing PH with TACE in patients with intermediate-stage HCC were selected. Only patients of BCLC-B stage were included in the analyses. Primary endpoint was overall survival (OS) and secondary endpoint was 90-day postprocedural mortality. Random-effects models were used to analyze time ratios (TRs). RESULTS: Seven eligible trials were analyzed, including 1,730 BCLC-B patients undergoing PH (n = 750) or TACE (n = 980). Comparison of OS between PH and TACE determined a pooled TR of 1.91 (95% CI 1.24-2.94; p < 0.001). Survival rates at 1-, 3-, and 5-year were 85, 60, and 42% after PH, compared to 73, 60, and 20% after TACE (p < 0.001). There was no difference in postprocedural mortality between PH and TACE with rates of 3.7 and 3.4%, respectively (TR 0.95; 95% CI 0.17-5.50; p = 0.879). CONCLUSIONS: In patients with intermediate HCC, PH was associated with increased long-term survival compared to TACE, with comparable postprocedural mortality. These results suggest considering PH as treatment option in intermediate HCC and highlight the urgent need to refine the selection of patients with BCLC-B stage who may benefit from PH.

[Update in surgical oncology]. / Chirurgie viscérale.

The main novelties in 2019 are about colorectal surgery and oncologic surgery. Acute diverticulitis and mechanical bowel obstruction are frequently diagnosed in primary care medicine. In 2019, EAES (European Association for Endoscopic Surgery) and SAGES (Society of American Gastrointestinal and Endoscopic Surgeons) published their recommendations for the management of diverticulitis. Recent data, along with our current practice favor ambulatory treatment without antibiotics for mild diverticulitis. For mechanical bowel obstruction, multicentric studies have demonstrated the increasing role of imaging in predicting the need for surgery and reducing operative delays. The role of minimally invasive techniques in this clinical condition is also emphasized. In addition, the latest published results about neoadjuvant treatment of colon and rectal cancer are reviewed.

Les principales nouveautés 2019 concernent la chirurgie colorectale en général et la chirurgie oncologique. La diverticulite aiguë et l'iléus mécanique sont fréquemment rencontrés en médecine de premier recours. En 2019, les sociétés EAES (European Association for Endoscopic Surgery) et SAGES (Society of American Gastrointestinal and Endoscopic Surgeons) ont édité leurs recommandations pour la prise en charge de la diverticulite. Au CHUV, un algorithme pour la prise en charge de la diverticulite simple est établi en partenariat avec le service des urgences, mettant l'accent sur les traitements ambulatoires et sans antibiotiques pour la plupart des cas. Des études multicentriques ont également permis de démontrer le rôle croissant de l'imagerie dans la prise en charge de l'iléus mécanique, du timing opératoire et des approches mini-invasives. Nous reviendrons aussi sur les principaux résultats publiés en 2019 concernant le traitement néo-adjuvant du cancer colique et rectal.

[Functional disorders in digestive surgery : an update]. / Chirurgie viscérale : quoi de neuf sur le plan fonctionnel ?

Surgical management of oncologic situations in visceral surgery is increasing. Overall survival and related quality of life are improved, due to enhanced perioperative care, improvement in strategies like surgical technique and oncological therapy. Functional disorders, whether or not related to oncologic disease, are not to be forgotten. Often underestimated, and causing significant distress, they deserve our best care. In the present review, the recent progresses on three particular topics are summarized : sacral neuromodulation for fecal incontinence, low anterior resection syndrome and achalasia.

Les interventions de chirurgie viscérale pour indications oncologiques sont en augmentation. Avec l'amélioration des traitements et des stratégies chirurgicales et oncologiques, la survie et la qualité de vie des patients sont en progression constante. Les aspects fonctionnels en chirurgie viscérale, qu'ils découlent ou non d'une pathologie oncologique préalable, sont souvent sous-estimés et invalidants, et méritent toute notre attention. Nous vous proposons, pour ce début d'année 2019, une combinaison de trois mini-revues sur le sujet : la neuromodulation sacrée lors d'incontinence fécale, le syndrome de résection antérieure basse et l'achalasie.

[Screening for anal cancer : is it the same as for cervical cancer ?] / Dépistage du cancer anal : doit-on faire de même que pour le cancer du col utérin ?

Anal dysplasia is usually caused by HPV infection and can lead to squamous anal cancer. The purpose of this article is to describe the classification of these precursor lesions but above all to identify the groups of patients at risk and to clarify the screening and follow-up that must be initiated.

Les lésions de dysplasie anale sont des lésions de l'épithélium du canal anal secondaires à une infection persistante par un Papilloma Virus Humain (HPV). Certaines de ces lésions vont progresser vers le carcinome épidermoïde du canal anal. Le but de cet article est de décrire la classification de ces lésions précurseurs mais surtout de déterminer les groupes de patients à risque et de clarifier le dépistage et le suivi qui doivent être instaurés.

[Update in Surgical Oncology]. / Chirurgie viscérale.

In 2017, data from large multicentre randomized controlled trials assessed the safety of minimally invasive techniques for liver or esophagus resection with similar oncologic outcome compared to open approach. Patients also benefit from progress in medical oncology in particular with the development of new targeted therapies, offering surgery to patients with initially non-resectable disease. The increase in complete tumor response after neoadjuvant treatment allows more conservative approaches, like organ preserving surgery for rectal cancer. The constant improvement in perioperative care and enhanced recovery programs (Enhanced Recovery After Surgery - ERAS) reduce both length of hospital stay and costs, decrease the risk of postoperative complications, and offer better quality of life to the patients.

En 2017, des études multicentriques randomisées ont permis de préciser le rôle prépondérant des techniques mini-invasives pour la chirurgie de l'œsophage ou du foie avec des résultats oncologiques similaires à la chirurgie ouverte. Les patients bénéficient également de progrès en oncologie médicale suite au développement de l'immunothérapie permettant ainsi de proposer la chirurgie à des patients jugés initialement non résécables. L'amélioration de la réponse au traitement néoadjuvant permet d'appliquer des approches plus conservatrices, comme la préservation du rectum après radiochimiothérapie. Les avancées dans la gestion périopératoire du patient (Enhanced Recovery After Surgery - ERAS), rendent les durées d'hospitalisation plus courtes avec une réduction des coûts, diminuent le risque de survenue de complications et assurent une meilleure qualité de vie au patient.

[Current surgical treatment for hepatocellular carcinoma : critical appraisal of current guidelines]. / Traitement chirurgical du carcinome hépatocellulaire : les recommandations actuelles sont-elles trop restrictives ?

Hepatocellular carcinoma (HCC) management has evolved in the last decades. Current available treatments include interventional radiology like radiofrequency ablation, transarterial chemoembolization or Yttrium 90 radioembolization. Surgery, when possible, has been proven to be the most effective treatment in reducing the risk of long-term local recurrence. American and European societies (AASLD, EASL, respectively) guidelines for the management of HCC endorse The Barcelona Clinic Liver Cancer (BCLC) treatment allocation system. One drawback of the BCLC system is its restrictiveness regarding surgical indications. This present article aims in reviewing the indications of surgical resection for HCC.

La prise en charge du carcinome hépatocellulaire (CHC) s'est beaucoup développée au cours des deux dernières décennies. L'éventail des traitements disponibles inclut les techniques de radiologie interventionnelle telles que la radiofréquence, la chimio-embolisation intra-artérielle, et plus récemment, la radio-embolisation à l'Yttrium 90. La chirurgie, lorsqu'elle est possible, reste le traitement le plus efficace prouvé pour réduire le risque de récidive à long terme. Les recommandations actuelles suivies par les sociétés savantes européennes (EASL) et américaines (AASLD) pour la prise en charge des CHC se basent sur l'algorithme de la Barcelona Clinic Liver Cancer (BCLC) qui est très restrictif au regard de la place du traitement chirurgical. Le but de cet article est de revoir les indications au traitement chirurgical du CHC.

Lower gastrointestinal bleeding-Computed Tomographic Angiography, Colonoscopy or both?

BACKGROUND: Lower endoscopy (LE) is the standard diagnostic modality for lower gastrointestinal bleeding (LGIB). Conversely, computed tomographic angiography (CTA) offers an immediate non-invasive diagnosis visualizing the entire gastrointestinal tract. The aim of this study was to compare these 2 modalities with regards to diagnostic value and bleeding control. METHODS: Tertiary center retrospective analysis of consecutive patients admitted for LGIB between 2006 and 2012. Comparison of patients with LE vs. CTA as first exam, respectively, with emphasis on diagnostic accuracy and bleeding control. RESULTS: Final analysis included 183 patients; 122 (66.7%) had LE first, while 32 (17.5%) had CTA; 29 (15.8%) had neither of both exams. Median time to CTA was shorter compared to LE (3 (IQR = 8.2) vs. 22 (IQR = 36.9) hours, P < 0.001). Active bleeding was identified in 31% with CTA vs. 15% with LE (P = 0.031); a non-actively bleeding source was found by CTA and LE in 22 vs. 31%, respectively (P = 0.305). Bleeding control required endoscopy in 19%, surgery in 14% and embolization in 1.6%, while 66% were treated conservatively. Post-interventional bleeding was mostly controlled by endoscopic therapy (57%). 80% of patients with active bleeding on CTA required surgery. CONCLUSIONS: Post-interventional LGIB was effectively addressed by LE. For other causes of LGIB, CTA was efficient, and more available than colonoscopy. Treatment was conservative for most patients. In case of active bleeding, CTA could localize the bleeding source and predict the need for surgery.

Prospective Evaluation of Discharge Trends after Colorectal Surgery within an Enhanced Recovery after Surgery Pathway.

INTRODUCTION: Enhanced recovery after surgery (ERAS) pathways proved to reduce complications, length of hospital stay and costs after colorectal surgery. Standardized discharge criteria have been established that are fulfilled after complete medical recovery is achieved. This study aimed to assess the timing of complete medical recovery in relation to the timing of actual discharge, and to assess reasons for prolonged hospital stay within an ERAS pathway. METHODS: One hundred fourteen consecutive patients undergoing elective colorectal surgery within an ERAS pathway were included in this prospective analysis. Fulfillment of discharge criteria was assessed daily and reasons for prolonged hospital stay were documented. RESULTS: Thirty percent of patients went home on the day that all discharge criteria were met. Overall, patients were discharged at a median of 2 days (interquartile range 1-3) after fulfillment of discharge criteria. Reasons for delayed discharge were (1) organizational in 20%; (2) patient or surgeon unwilling in 29%; and (3) because the patient was deemed to be discharged too soon distance from the operation in 51%. CONCLUSION: In this observational study, only 30% of patients were discharged on the day all recovery criteria were met. The main reason for continued hospitalization was surgeon- or patient-related reluctance or 'precaution'; thus, better and more of general information seems to be necessary.