Goodbye Hartmann trial: a prospective, international, multicenter, observational study on the current use of a surgical procedure developed a century ago.

BACKGROUND: Literature suggests colonic resection and primary anastomosis (RPA) instead of Hartmann's procedure (HP) for the treatment of left-sided colonic emergencies. We aim to evaluate the surgical options globally used to treat patients with acute left-sided colonic emergencies and the factors that leading to the choice of treatment, comparing HP and RPA. METHODS: This is a prospective, international, multicenter, observational study registered on ClinicalTrials.gov. A total 1215 patients with left-sided colonic emergencies who required surgery were included from 204 centers during the period of March 1, 2020, to May 31, 2020. with a 1-year follow-up. RESULTS: 564 patients (43.1%) were females. The mean age was 65.9 ± 15.6 years. HP was performed in 697 (57.3%) patients and RPA in 384 (31.6%) cases. Complicated acute diverticulitis was the most common cause of left-sided colonic emergencies (40.2%), followed by colorectal malignancy (36.6%). Severe complications (Clavien-Dindo ≥ 3b) were higher in the HP group (P < 0.001). 30-day mortality was higher in HP patients (13.7%), especially in case of bowel perforation and diffused peritonitis. 1-year follow-up showed no differences on ostomy reversal rate between HP and RPA. (P = 0.127). A backward likelihood logistic regression model showed that RPA was preferred in younger patients, having low ASA score (≤ 3), in case of large bowel obstruction, absence of colonic ischemia, longer time from admission to surgery, operating early at the day working hours, by a surgeon who performed more than 50 colorectal resections. CONCLUSIONS: After 100 years since the first Hartmann's procedure, HP remains the most common treatment for left-sided colorectal emergencies. Treatment's choice depends on patient characteristics, the time of surgery and the experience of the surgeon. RPA should be considered as the gold standard for surgery, with HP being an exception.

The Challenge of Pneumatosis Intestinalis: A Contemporary Systematic Review.

PURPOSE: Pneumatosis intestinalis is a radiological finding with incompletely understood pathogenesis. To date, there are no protocols to guide surgical intervention. METHODS: A systematic review of literature, according to PRISMA criteria, was performed. Medline and PubMed were consulted to identify articles reporting on the items "emergency surgery, pneumatosis coli, and pneumatosis intestinalis" from January 2010 up to March 2022. This study has not been registered in relevant databases. RESULTS: A total of 1673 patients were included. The average age was 67.1 ± 17.6 years. The etiology was unknown in 802 (47.9%) patients. Hemodynamic instability (246/1673-14.7% of the patients) was associated with bowel ischemia, necrosis, or perforation (p = 0.019). Conservative management was performed in 824 (49.2%) patients. Surgery was performed 619 (36.9%) times, especially in unstable patients with bowel ischemia signs, lactate levels greater than 2 mmol/L, and PVG (p = 0.0026). In 155 cases, surgery was performed without pathological findings. CONCLUSIONS: Many variables should be considered in the approach to patients with pneumatosis intestinalis. The challenge facing the surgeons is in truly identifying those who really would benefit and need surgical intervention. The watch and wait policy as a first step seems reasonable, reserving surgery only for patients who are unstable or with high suspicion of bowel ischemia, necrosis, or perforation.

Conservative management of complicated colonic diverticulitis: long-term results.

BACKGROUND: The management of recurrent diverticulitis after initial non-operative treatment remains controversial. Recurrences after medical treatment have been described up to 36% but only 3 to 5% develop complicated disease. AIM: To investigate the effectiveness of conservative treatment during a prolonged follow-up after first episode of complicated diverticulitis. METHODS: This retrospective single-center study describes the conservative management and outcomes of 207 with complicated acute colonic diverticulitis treated at Parma University Hospital from 1 January 2012 until 31 December 2019. The follow-up was performed until December 2020. Diverticulitis severity was staged according to WSES CT driven classification for acute diverticulitis. RESULTS: We enrolled 207 patients (118 males, 89 females). The mean age was 59 ± 14.5 years. CT scan of the abdomen was always performed. Almost all patients were treated with bowel rest and antibiotics (98.5%). Percutaneous drainage of abscessed diverticulitis was performed 12 times (5.7%). Average follow-up was 48 ± 28.8 months. 79 patients had new episodes of diverticulitis (38.1%) and 23 patients had high severity new episodes (11.1%). 11 patients underwent surgery (7.7%). Lower CT-Stages showed a higher recurrence rate (P = 0.002). Grade III diverticulitis showed a lower recurrence rate (P = 0.007). Patients with chronic NSAID use showed a higher incidence of high severity new episodes (P = 0.039). No recurrence rate differences were noted among patients with or without home therapy (P > 0.05). CONCLUSIONS: Non-operative treatment is an effective and safe option in selected patients with complicated diverticulitis. The recurrence's severity is generally lower than the previous episodes and this can justify the conservative management.

Effects of Bariatric Surgery on COVID-19: a Multicentric Study from a High Incidence Area.

INTRODUCTION: The favorable effects of bariatric surgery (BS) on overall pulmonary function and obesity-related comorbidities could influence SARS-CoV-2 clinical expression. This has been investigated comparing COVID-19 incidence and clinical course between a cohort of patients submitted to BS and a cohort of candidates for BS during the spring outbreak in Italy. MATERIALS AND METHODS: From April to August 2020, 594 patients from 6 major bariatric centers in Emilia-Romagna were administered an 87-item telephonic questionnaire. Demographics, COVID-19 incidence, suggestive symptoms, and clinical outcome parameters of operated patients and candidates to BS were compared. The incidence of symptomatic COVID-19 was assessed including the clinical definition of probable case, according to World Health Organization criteria. RESULTS: Three hundred fifty-three operated patients (Op) and 169 candidates for BS (C) were finally included in the statistical analysis. While COVID-19 incidence confirmed by laboratory tests was similar in the two groups (5.7% vs 5.9%), lower incidence of most of COVID-19-related symptoms, such as anosmia (p: 0.046), dysgeusia (p: 0.049), fever with rapid onset (p: 0.046) were recorded among Op patients, resulting in a lower rate of probable cases (14.4% vs 23.7%; p: 0.009). Hospitalization was more frequent in C patients (2.4% vs 0.3%, p: 0.02). One death in each group was reported (0.3% vs 0.6%). Previous pneumonia and malignancies resulted to be associated with symptomatic COVID-19 at univariate and multivariate analysis. CONCLUSION: Patients submitted to BS seem to develop less severe SARS-CoV-2 infection than subjects suffering from obesity.

Conservative Management of Complicated Colonic Diverticulitis in Early and Late Elderly.

Background and Objectives: The management of complicated diverticulitis in the elderly can be a challenge and initial non-operative treatment remains controversial. In this study, we investigate the effectiveness of conservative treatment in elderly people after the first episode of complicated diverticulitis. Materials and Methods: This retrospective single-centre study describes 71 cases of elderly patients with complicated acute colonic diverticulitis treated with conservative management at Parma University Hospital from 1 January 2012 to 31 December 2019. Diverticulitis severity was staged according to WSES CT driven classification for acute diverticulitis. Patients was divided into two groups: early (65-74 yo) and late elderly (>75 yo). Results: We enrolled 71 elderly patients conservatively treated for complicated acute colonic diverticulitis, 25 males and 46 females. The mean age was 74.78 ± 6.8 years (range 65-92). Localized abdominal pain and fever were the most common symptoms reported in 34 cases (47.88%). Average white cells count was 10.04 ± 5.05 × 109/L in the early elderly group and 11.24 ± 7.89 in the late elderly group. CRP was elevated in 29 (78.3%) cases in early elderly and in 23 late elderly patients (67.6%). A CT scan of the abdomen was performed in every case (100%). Almost all patients were treated with bowel rest and antibiotics (95.7%). Average length of stay was 7.74 ± 7.1 days (range 1-48). Thirty-day hospital readmission and mortality were not reported. Average follow-up was 52.32 ± 31.8 months. During follow-up, home therapy was prescribed in 48 cases (67.6%). New episodes of acute diverticulitis were reported in 20 patients (28.1%), elevated WBC and chronic NSAID therapy were related to a higher risk of recurrence in early elderly patients (p < 0.05). Stage IIb-III with elevated WBC during first episode, had a higher recurrence rate compared to the other CT-stage (p = 0.006). Conclusions: The management of ACD in the elderly can be a challenge. Conservative treatment is safe and effective in older patients, avoiding unnecessary surgery that can lead to unexpected complications due to co-morbidities.

Peripheral neuropathies after bariatric surgery. Preliminary results from a single-centre prospective study in Northern Italy.

INTRODUCTION: Bariatric surgery (BS) has gained popularity in order to treat morbid obesity. However, post-operative (PO) neurologic complications have become increasingly recognized. Our aim was to examine incidence, clinical presentation, and outcomes of neurologic disorders secondary to BS. METHODS: Patients who underwent BS between the years 2012 and 2015 at Parma University were included in this survey, and assessed before (T0) and 1 year after surgery (T1). Baseline characteristics and medical comorbidities, type of surgery, and PO complications were retrieved. Patients with a previous history of peripheral neuropathic disease were excluded from the analysis. If a patient presented with a new onset neurologic symptom including extremity numbness, paresthesia, muscle weakness, the status was considered "positive" for PO-neuropathy. RESULTS: Overall, we retrieved data from 61 patients (n=30 Roux-en-Y Gastric bypasses, n=31 Gastric banding; 81.0% females). Of them, 7 (11.4%) developed some signs of PO-neuropathy, that eventually disappeared at T+24 months. The most common manifestations were paresthesia (n=6) and muscle weakness (n=4), similarly distributed in Gastric Bypass (n=4) and Gastric Banding (n=3) groups. Although patients affected by PO-neuropathy exhibited higher SF-36 score at T0 (p=0.018), no significant differences were found regarding BMI (T0, T1), percentual weight loss, serological data (i.e. vitamin B1, B2, B6, B12: in all cases p>0.05). CONCLUSION: PO-BS neuropathy is usually associated with lower levels of vitamin B1, B2, B12. However, no differences in PO-BMI, excess weight loss, and metabolic data levels were found. Larger data and more extended follow-up are required to validate our results.

Laparoscopic gastric bypass with remnant gastrectomy in a super-super obese patient with gastric metaplasia: a surgical hazard?

The endoscopic inaccessibility of the gastric remnant after Roux-en-Y gastric bypass (RYGBP) for morbid obesity represents an important issue for patients with familiar history of gastric cancer (GC) or affected by premalignant lesions, such as intestinal metaplasia. If a different bariatric procedure is contraindicated, RYGBP with remnant gastrectomy represents a reasonable alternative, significantly reducing the risk of GC but potentially increasing postoperative morbidity. For this reason, only few cases have been reported in the recent Literature and none regarding a super-super obese patient. We present the case of a 55-year-old super-super obese man with a family history of GC and antral gastritis with extensive intestinal metaplasia at preoperative upper endoscopy, who underwent laparoscopic RYGBP with remnant gastrectomy.