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Abstract Background Antibiotic prophylaxis that covers enteric pathogens is essential in preventing surgical site infections (SSIs) after colorectal surgery. Current prophylaxis regimens do not cover extended-spectrum beta-lactamase–producing Enterobacteriaceae (ESBL-PE). We aimed to determine whether the risk of SSI following colorectal surgery is higher in ESBL-PE carriers than in noncarriers. Methods We conducted a prospective cohort study of patients who underwent elective colorectal surgery in 3 hospitals in Israel, Switzerland, and Serbia between 2012 and 2017. We included patients who were aged ≥18 years, were screened for ESBL-PE carriage before surgery, received routine prophylaxis with a cephalosporin plus metronidazole, and did not have an infection at the time of surgery. The exposed group was composed of ESBL-PE–positive patients. The unexposed group was a random sample of ESBL-PE–negative patients. We collected data on patient and surgery characteristics and SSI outcomes. We fit logistic mixed effects models with study site as a random effect. Results A total of 3600 patients were screened for ESBL-PE; 13.8% were carriers SSIs occurred in 55/220 carriers (24.8%) and 49/440 noncarriers (11.1%, P < .001). In multivariable analysis, ESBL-PE carriage more than doubled the risk of SSI (odds ratio [OR], 2.36; 95% confidence interval [CI], 1.50–3.71). Carriers had higher risk of deep SSI (OR, 2.25; 95% CI, 1.27–3.99). SSI caused by ESBL-PE occurred in 7.2% of carriers and 1.6% of noncarriers (OR, 4.23; 95% CI, 1.70–10.56). Conclusions ESBL-PE carriers who receive cephalosporin-based prophylaxis are at increased risk of SSI following colorectal surgery. Standard antibiotic prophylaxis administered before colorectal surgery does not cover extended-spectrum beta-lactamase–producing Enterobacteriaceae (ESBL-PE). We found that ESBL-PE carriers have more than twice the risk of noncarriers of developing surgical site infection following colorectal surgery.

Background Robot-assisted Roux-en-Y gastric bypass (RYGBP) is rapidly evolving as an important surgical approach in the bariatric field. However, the specific learning curve associated with this new approach remains poorly investigated. This study aimed to evaluate the learning curve for robot-assisted RYGBP. Methods A series of 64 consecutive robot-assisted RYGBP procedures were performed between December 2008 and December 2010 by a single surgeon already experienced in advanced laparoscopic procedures but not in bariatric surgery. All data were collected prospectively in a database and reviewed retrospectively. The learning curve was evaluated using the cumulative sum (CUSUM) method. Results Women comprised 76.6% and men 23.4% of this series. These patients had a mean age of 43 years and a mean body mass index (BMI) of 44.5 kg/m 2 . The mean operative time (OT) was 238.1 min (range, 150–400 min). A total of six complications occurred (9.4%). The CUSUM learning curve consisted of two distinct phases: phase 1 (the initial 14 cases; mean OT, 288.9 min) and phase 2 (the subsequent cases; mean OT, 223.6 min), which represented the mastery phase, with a decrease in OT ( P  = 0.0001). The two groups were similar in terms of gender, age, and BMI. The two phases did not differ in terms of complications or hospital stay. Conclusions This series confirms previous study findings concerning the feasibility and the safety of robotic RYGBP even after a limited experience with laparoscopic RYGBP. The data reported in this article suggest that the learning phase for robot-assisted RYGBP can be achieved with 14 cases.

Our objective was to describe the etiologies of acute colitis and to identify patients who require diagnostic endoscopy. Patients with symptoms of gastrointestinal infection and colonic inflammation on CT were prospectively included. Those immunosuppressed, with history of colorectal cancer or inflammatory bowel disease (IBD), were excluded. Microbiological analysis of the feces was performed using PCR assays BD-Max and FilmArray (GI panel,) and fecal cultures. Fecal calprotectin was determined. Patients with negative BD-Max underwent colonoscopy. One hundred and seventy-nine patients were included. BD-Max was positive in 93 patients (52%) and FilmArray in 108 patients (60.3%). Patients with infectious colitis (n = 103, 57.5%) were positive for Campylobacter spp. (n = 57, 55.3%), Escherichia coli spp. (n = 8, 7.8%), Clostridioides difficile (n = 23, 22.3%), Salmonella spp. (n = 9, 8.7%), viruses (n = 7, 6.8%), Shigella spp. (n = 6, 5.8%), Entamoeba histolytica (n = 2, 1.9%) and others (n = 4, 3.9%). Eighty-six patients underwent colonoscopy, which was compatible with ischemic colitis in 18 patients (10.1%) and IBD in 4 patients (2.2%). Fecal calprotectin was elevated in all patients, with a mean concentration of 1922.1 ± 2895.6 μg/g, and was the highest in patients with IBD (8511 ± 9438 μg/g, p  < 0.001). After exclusion of patients with infectious etiology, a fecal calprotectin > 625 μg/g allowed identifying patients with IBD with an area under ROC curve of 85.1%. To conclude, computed tomography-proven colitis was of infectious etiology in 57.5% of patients. The main pathogens identified were Campylobacter spp. (55.3%), Clostridioides difficile (22.3%) and Salmonella spp. (8.7%). Ischemic colitis (10.1%) and IBD (2.2%) were seldom represented. No colorectal cancer was found.

Background Partial splenectomy (PS) is a spleen-preserving technique that is applied as a result of trauma, focal lesions or hematological conditions. Despite the improvement of laparoscopic techniques within the past several decades, minimally invasive PS has remained a marginal technique that has not been well evaluated. Our objective was to provide an update on the indications and the feasibility of this procedure. Methods The MEDLINE database (PubMed) was searched, and all relevant articles that involved a true minimally invasive PS (i.e., segmental or lobar devascularization of the spleen with parenchymal transection) were included. The search was conducted until the 31st of March 2014. Demographic data, operative indications, estimated blood losses, operative times, conversion rates and complications were extracted from the included articles and were summarized for discussion. Results Out of the 195 publications that were retrieved, 33 were included, which were mainly case reports and case series that represented a total of 187 patients. There were 37 men, 33 women and 117 patients of unknown gender. The mean age of the patients was ranged from 6 to 58 years. The mean total operative time was between 70 and 216 min for conventional laparoscopy and between 108 and 120 min for the robotic approach. For most studies, the mean estimated blood loss was minimal. The complication rate was 5.36 % for conventional laparoscopy and 5.56 % for the robotic approach. Conclusion The outcomes of minimally invasive PS were favorable and comparable to those of the open technique according to the literature. This procedure may constitute an attractive alternative to the open technique for selected cases. Moreover, a robotic approach might be an interesting technical option, but additional research is needed before any definitive conclusions can be drawn.

Background Reshaping the tumor microenvironment by novel immunotherapies represents a key strategy to improve cancer treatment. Nevertheless, responsiveness to these treatments is often correlated with the extent of T cell infiltration at the tumor site. Remarkably, microsatellite stable rectal cancer is characterized by poor T cell infiltration and, therefore, does not respond to immune checkpoint blockade. To date, the only available curative option for these patients relies on extensive surgery. With the aim to broaden the application of promising immunotherapies, it is necessary to develop alternative approaches to promote T cell infiltration into the tumor microenvironment of these tumors. In this regard, recent evidence shows that radiotherapy has profound immunostimulatory effects, hinting at the possibility of combining it with immunotherapy. The combination of long-course chemoradiotherapy and immune checkpoint inhibition was recently shown to be safe and yielded promising results in rectal cancer, however short-course radiotherapy and immune checkpoint inhibition have never been tested in these tumors. Methods Our clinical trial investigates the clinical and biological impact of combining pembrolizumab with short-course radiotherapy in the neo-adjuvant treatment of localized rectal cancer. This phase II non-randomized study will recruit 25 patients who will receive short-course preoperative radiotherapy (5 Gy × 5 days) and four injections of pembrolizumab starting on the same day and on weeks 4, 7 and 10. Radical surgery will be performed three weeks after the last pembrolizumab injection. Our clinical trial includes an extensive translational research program involving the transcriptomic and proteomic analysis of tumor and blood samples throughout the course of the treatment. Discussion Our study is the first clinical trial to combine short-course radiotherapy and immune checkpoint inhibition in rectal cancer, which could potentially result in a major breakthrough in the treatment of this cancer. Additionally, the translational research program will offer insights into immunological changes within the tumor and blood and their correlation with patient outcome. Taken together, our work will help optimizing future treatment combinations and, possibly, better selecting patients. Trial registration This study was registered with www.clinicaltrial.gov : NCT04109755 . Registration date: June, 2020.

BackgroundThe purpose of this analysis is to compare the robotic EndoWrist Stapling System (EWSS) 45 mm (Intuitive Surgical Inc. Sunnyvale, CA, USA) and the ECHELON FLEX™ ENDOPATH® Staplers (EFES) 60 mm (Ethicon, Cincinnati, OH, USA) for gastric pouch formation during robotic gastric bypass surgery.MethodsPatients who underwent robotic gastric bypass surgery with stapling using EWSS were matched with patients who underwent the same procedure with the EFES. Demographic, intra- and postoperative, and cost data were collected and analyzed.ResultsA total of 49 patients were identified who had undergone robotic gastric bypass surgery using EWSS. They were matched with 49 patients who underwent the equivalent procedure using EFES. With similar demographic parameters, corrected operating room time without cholecystectomy took longer for the patients that underwent surgery with EWSS (+22 min, p = 0.1042). Stapler clamping was unsuccessful in 19.0% of all recorded attempts with EWSS. Two intra-operative complications unrelated to stapling and one complication due to stapling were observed in the EWSS cohort, while none was observed for the EFES group. Significantly, more recharges were needed with EWSS to complete the gastric pouch (4.9 vs. 4.1, p = 0.0048) and overall stapling costs for the procedure were significantly higher (2212.2 vs. 1787.4 USD, p = 0.0001).ConclusionGastric pouch formation using EWSS during robotic gastric bypass surgery is feasible. Due to the shorter length of EWSS compared to EFES, more stapling recharges are required to complete gastric pouch formation and the stapling costs for gastric bypass surgery are higher. Further systematic research should be conducted to precisely determine the value of the robotic EWSS for gastric bypass surgery.

Robotic surgery has emerged as a new technology over the last decade and has brought with it new challenges, particularly in terms of teaching and training. To overcome these challenges, robotic courses, virtual simulation, and dual consoles have been successfully introduced. In fact, there are several simulators currently on the market that have proven to be a valid option for training, especially for the novice trainee. Robotic courses have also found success around the world, allowing participants to implement robotic programs at their institution, typically with the help of a proctor. More recently, the dual console has enabled two surgeons to be operating at the same time. Having one experienced surgeon and one trainee each at his or her own console has made it an obvious choice for training. Although these methods have been successfully introduced, the data remain relatively scarce concerning their role in training. The aim of this article was to review the various methods and tools involved in the training of surgeons in robotic surgery.

Background Colon surgery has been shown to modulate the intestinal microbiota. Our objective was to characterize these changes using state-of-the-art next generation sequencing techniques. Methods We performed a single-centre prospective observational cohort study to evaluate the changes in the gut microbiota, i.e., taxon distribution, before and after elective oncologic colon surgery in adult patients with different antimicrobial prophylaxis regimens (standard prophylaxis with cefuroxime/metronidazole versus carbapenems for extended-spectrum beta-lactamase-producing Enterobacterales [ESBL-E] carriers). We obtained rectal samples on the day of surgery, intraoperative luminal samples, and rectal or stoma samples 3 days after surgery. We performed metataxonomic analysis based on sequencing of the bacterial 16S rRNA gene marker. Similarities and differences between bacterial communities were assessed using Bray–Curtis similarity, visualised using principal coordinates analysis and statistically tested by PERMANOVA. Comparison of taxa relative abundance was performed using ANCOM. Results We included 27 patients between March 27, 2019 and September 17, 2019. The median age was 63.6 years (IQR 56.4–76.3) and 44% were females. Most (81%) patients received standard perioperative prophylaxis as they were not ESBL carriers. There was no significant association between ESBL carriage and differences in gut microbiome. We observed large and significant increases in the genus Enterococcus between the preoperative/intraoperative samples and the postoperative sample, mainly driven by Enterococcus faecalis . There were significant differences in the postoperative microbiome between patients who received standard prophylaxis and carbapenems, specifically in the family Erysipelotrichaceae . Conclusion This hypothesis-generating study showed rapid changes in the rectal microbiota following colon cancer surgery.

Background Surgical wound infection contributes to prolonged recovery time after pilonidal sinus excision. As a standard procedure after surgery, we recommend our patients to perform water irrigations in the intergluteal cleft 4 to 6 times a day during the post-operative period. Our hypothesis is that this should reduce healing time and complication rates. The aim of this study was to measure the importance of sacro coccygeal hygiene in the management of pilonidal sinus disease. Methods We retrospectively collected data after surgical management of pilonidal sinus (sinusectomy procedures) in our division over a 10-year period. Patients were divided into three groups according to their local hygiene during postoperative follow-up and scored one (G1: good hygiene) to three (G3: poor hygiene). Primary outcome was complication rates. Secondary endpoints were, healing time, follow-up, time off work, and recurrence rate. Results In G1 (N = 112), complication rate was 3.6%. In G2 (N = 109), it was 5.5%, whereas in G3 (N = 71), it reached 7.03%. However, there were no statistically significant differences between hygiene groups regarding complication rates in both univariate and multivariable analysis. Regarding secondary outcomes, there were significant differences between hygiene groups concerning median follow-up (p = 0.0001) and median time off work (p = 0.0127). Conclusion Good hygiene of wound is essential for optimal, rapid healing without complications. The importance of this report is to show that thanks to our hygiene follow-up strategy with frequent perineal irrigations and regular follow-up checks, patients with at a first glance “unclean local conditions”, reached similar complications, median healing time and recurrences rates to patients with medium and good wound hygiene level.

Anal sphincter incontinence is a chronic disease, which dramatically impairs quality of life and induces high costs for the society. Surgery, considered as the best curative option, shows a disappointing success rate. Stem/progenitor cell therapy is pledging, for anal sphincter incontinence, a substitute to surgery with higher efficacy. However, the published literature is disparate. Our aim was to perform a review on the development of cell therapy for anal sphincter incontinence with critical analyses of its pitfalls. Animal models for anal sphincter incontinence were varied and tried to reproduce distinct clinical situations (acute injury or healed injury with or without surgical reconstruction) but were limited by anatomical considerations. Cell preparations used for treatment, originated, in order of frequency, from skeletal muscle, bone marrow or fat tissue. The characterization of these preparations was often incomplete and stemness not always addressed. Despite a lack of understanding of sphincter healing processes and the exact mechanism of action of cell preparations, this treatment was evaluated in 83 incontinent patients, reporting encouraging results. However, further development is necessary to establish the correct indications, to determine the most-suited cell type, to standardize the cell preparation method and to validate the route and number of cell delivery.