Basile Pache

Prevalence of measured and reported multimorbidity in a representative sample of the Swiss population

BackgroundLittle is known on the prevalence of multimorbidity (MM) in the general population. We aimed to assess the prevalence of MM using measured or self-reported data in the Swiss population.MethodsCross-sectional, population-based study conducted between 2003 and 2006 in the city of Lausanne, Switzerland, and including 3714 participants (1967 women) aged 35 to 75xa0years. Clinical evaluation was conducted by thoroughly trained nurses or medical assistants and the psychiatric evaluation by psychologists or psychiatrists. For psychiatric conditions, two definitions were used: either based on the participant’s statements, or on psychiatric evaluation. MM was defined as presenting ≥2 morbidities out of a list of 27 (self-reported – definition A, or measured – definition B) or as the Functional Comorbidity Index (FCI) using measured data – definition C.ResultsThe overall prevalence and (95% confidence interval) of MM was 34.8% (33.3%-36.4%), 56.3% (54.6%-57.9%) and 22.7% (21.4%-24.1%) for definitions A, B and C, respectively. Prevalence of MM was higher in women (40.2%, 61.7% and 27.1% for definitions A, B and C, respectively, vs. 28.7%, 50.1% and 17.9% in men, pu2009<u20090.001); Swiss nationals (37.1%, 58.8% and 24.8% for definitions A, B and C, respectively, vs. 31.4%, 52.3% and 19.7% in foreigners, all pu2009<u20090.001); elderly (>65xa0years: 67.0%, 70.0% and 36.7% for definitions A, B and C, respectively, vs. 23.6%, 50.2% and 13.8% for participants <45xa0years, pu2009<u20090.001); participants with lower educational level; former smokers and obese participants. Multivariate analysis confirmed most of these associations: odds ratio (95% Confidence interval) 0.55 (0.47-0.64), 0.61 (0.53-0.71) and 0.51 (0.42-0.61) for men relative to women for definitions A, B and C, respectively; 1.27 (1.09-1.49), 1.29 (1.11-1.49) and 1.41 (1.17-1.71) for Swiss nationals relative to foreigners, for definitions A, B and C, respectively. Conversely, no difference was found for educational level for definitions A and B and abdominally obese participants for all definitions.ConclusionsPrevalence of MM is high in the Lausanne population, and varies according to the definition or the data collection method.

Pressurized IntraPeritoneal Aerosol Chemotherapy – Practical Aspects

INTRODUCTIONnPressurized Intraperitoneal Aerosol Chemotherapy (PIPAC) has been introduced as novel treatment for peritoneal carcinomatosis. Only proper patient selection, stringent safety protocol and careful surgery allow for a secure procedure. We hereby report the essentials for safe implementation.nnnMETHODSnAll consecutive procedures within 20 months after PIPAC implementation were analyzed with regards to practical and surgical aspects. Special emphasis was laid on modifications of technique and safety measures during the implementation process with systematic use of a dedicated checklist. Further, surgical difficulty was documented by use of a visual analogue scale (VAS).nnnRESULTSn127 PIPAC procedures were performed in 58 patients from January 2015 until October 2016. 81% of patients had at least one previous laparotomy. Median operation time was 91xa0min (87-103) for the first 20 cases, 93xa0min (IQR 88-107) for PIPAC21-50, and 103xa0min (IQR 91-121) for the following 77 procedures. Primary and secondary non-access occurred in 3 patients (2%), all of them having prior hyperthermic intraperitoneal chemotherapy (HIPEC). Using open Hasson technique, one single bowel lesion occurred, which was the only intraoperative complication. One 5xa0mm and another 10/12xa0mm trocar were used in 88% of procedures while additional trocars were needed in 12%. No leak of cytostatics was observed and no procedure needed to be stopped. VAS for overall difficulty of the procedure was 3xa0±xa02.4, and 3xa0±xa02.9 and 3xa0±xa02.5, respectively, for abdominal access and intraoperative staging.nnnCONCLUSIONSnWith standardized surgical approach and dedicated safety checklist, PIPAC can be safely introduced in clinical routine with minimal learning curve.

Minimally invasive surgery and enhanced recovery after surgery: The ideal combination?

Enhanced recovery after surgery (ERAS) and minimally invasive surgery are both in the limelight due to their potential positive effects on surgical outcome. Large randomized trials and meta‐analyses validated the use of both, laparoscopy and ERAS protocol, as individual measures. A synergistic effect of both entities might contribute to even better outcomes. This review hence assessed the literature upon up‐to‐date studies combining both methods.

Influence of Enhanced Recovery Pathway on Surgical Site Infection after Colonic Surgery

Background The present study aimed to evaluate a potential effect of ERAS on surgical site infections (SSI). Methods Colonic surgical patients operated between May 2011 and September 2015 constituted the cohort for this retrospective analysis. Over 100 items related to demographics, surgical details, compliance, and outcome were retrieved from a prospectively maintained database. SSI were traced by an independent National surveillance program. Risk factors for SSI were identified by univariate and multinomial logistic regression. Results Fifty-four out of 397 patients (14%) developed SSI. Independent risk factors for SSI were emergency surgery (OR 1.56; 95% CI 1.09–1.78, p = 0.026), previous abdominal surgery (OR 1.7; 95% CI 1.32–1.87, p = 0.004), smoking (OR 1.71; 95% CI 1.22–1.89, p = 0.014), and oral bowel preparation (OR 1.86; 95% CI 1.34–1.97, p = 0.013), while minimally invasive surgery (OR 0.3; 95% CI 0.16–0.56, p < 0.001) protected against SSI. Compliance to ERAS items of >70% was not retained as a protective factor for SSI after multivariate analysis (OR 0.94; 95% CI 0.46–1.92, p = 0.86). Conclusions Smoking, open and emergency surgery, and bowel preparation were risk factors for SSI. ERAS pathway had no independent impact while minimally invasive approach did. This study was registered under ResearchRegistry.com (UIN researchregistry2614).

Preoperative Nutritional Conditioning of Crohn’s Patients—Systematic Review of Current Evidence and Practice

Crohn’s disease is an incurable and frequently progressive entity with major impact on affected patients. Up to half of patients require surgery in the first 10 years after diagnosis and over 75% of operated patients require at least one further surgery within lifetime. In order to minimize surgical risk, modifiable risk factors such as nutritional status need to be optimized. This systematic review on preoperative nutritional support in adult Crohn’s patients between 1997 and 2017 aimed to provide an overview on target populations, screening modalities, routes of administration, and expected benefits. Pertinent study characteristics (prospective vs. retrospective, sample size, control group, limitations) were defined a priori. Twenty-nine studies were retained, of which 14 original studies (9 retrospective, 4 prospective, and 1 randomized controlled trial) and 15 reviews. Study heterogeneity was high regarding nutritional regimens and outcome, and meta-analysis could not be performed. Most studies were conducted without matched control group and thus provide modest level of evidence. Consistently, malnutrition was found to be a major risk factor for postoperative complications, and both enteral and parenteral routes were efficient in decreasing postoperative morbidity. Current guidelines for nutrition in general surgery apply also to Crohn’s patients. The route of administration should be chosen according to disease presentation and patients’ condition. Further studies are needed to strengthen the evidence.

Impact of Teaching on Surgical Site Infection after Colonic Surgery.

OBJECTIVEnThe present study aimed to evaluate whether teaching had an influence on surgical site infections (SSI) after colonic surgery.nnnDESIGNnColonic surgeries between January 2014 and December 2016 were retrospectively reviewed. Demographics, surgical details, and SSI rates were compared between teaching procedures vs. experts. Risk factors for SSI were identified by multinominal logistic regression.nnnSETTINGnSSI were prospectively assessed by an independent National Surveillance Program (www.swissnoso.ch) at Lausanne University Hospital CHUV, a tertiary academic institution.nnnPARTICIPANTSnIncluded in the present analysis were patients documented in a prospective institutional enhanced recovery after surgery (ERAS) database and who were prospectively monitored by the independent National Infection Surveillance Committee between January 1, 2014 and December 31, 2016.nnnRESULTSnIn all, 315 patients constituted the study cohort. Demographic and surgical items were comparable between teaching (n = 161) vs. expert operations (n = 135) except for higher occurrence of wound contamination class III-IV (13 vs. 19%, p = 0.046) in patients operated by experts. Overall, 61 patients (19%) developed SSI, namely 25 patients (16%) in the teaching group and 32 patients (24%) in the expert group (p = 0.077). Contamination class III-IV (OR = 3.2; 95% CI: 1.4-7.5, p = 0.005) and open surgery (OR = 3.4; 95% CI: 1.8-6.7, p < 0.001) were independent risk factors for SSI, while teaching had no significant impact (OR = 0.6; 95% CI: 0.3-1.2, p = 0.153).nnnCONCLUSIONSnSurgical teaching was feasible and safe after colonic surgery in the present cohort and had no impact on SSI rate.

Inflammatory Response and Toxicity After Pressurized IntraPeritoneal Aerosol Chemotherapy

Background: Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC) is a novel mode of intraperitoneal (IP) drug delivery claiming high IP tissue concentrations with low systemic uptake. The aim was to study inflammatory response and systemic toxicity after PIPAC. Methods: Retrospective monocentric analysis of a consecutive cohort of PIPAC patients between January 2015 and April 2016. Detailed hematological and biochemical analysis was performed the day before surgery and once daily until discharge. Comparative statistics were performed using Mann-Whitney U test and Wilcoxon signed ranked test. Results: Fourty-two consecutive patients underwent a total of 91 PIPAC procedures. Twenty patients received oxaliplatin and 22 cisplatin+doxorubicin (37 vs. 54 procedures). Creatinine, AST and ALT were not significantly altered after PIPAC (p=0.095, p= p=0.153 and p=0.351) and not different between oxaliplatin and cisplatin+doxorubicin regimens (p=0.371, p=0.251 and p=0.288). C-reactive protein (CRP) and procalcitonin (PCT) increased on post-operative day (POD) 2: ∆max 29±5 mg/L (p<0.001) and ∆max 0.05±0.01 μg/L (p=0.005), respectively. Leucocytes increased at POD 1: ∆max 2.2±0.3 G/L (p<0.001). Albumin decreased at POD 2: ∆max -6.0±0.5 g/L (p<0.001). CRP increase correlated positively with Peritoneal Cancer Index (tumor load) (ρ =0.521, p<0.001). Conclusion: PIPAC was followed by a modest and transitory inflammatory response that was commensurate to the disease extent. No hematological, renal or hepatic toxicity was observed even after repetitive administration.

Respiratory Complications After Colorectal Surgery: Avoidable or Fate?

BackgroundThe prevention of post-operative pulmonary complications (PPC) is targeted by several enhanced recovery (ERAS) items including early mobilisation, prevention of fluid overload and omission of routine nasogastric tubes. The aim of the present study was to assess the impact of ERAS on PPC.MethodsThis was a retrospective analysis of an institutional database including consecutive colorectal ERAS procedures from May 2011 until May 2017. Multiple logistic regressions were performed to identify risk factors for PPC among demographic, surgical characteristics and items related to the ERAS protocol.ResultsIn total, 1298 patients were included; among them 120 (9.2%) had one or more PPC. Multivariable analysis retained minimally invasive surgery [odds ratio (OR) 0.26; 95% confidence interval (CI) 0.15–0.46] and compliance to the ERAS protocol ofu2009≥u200970% (OR 0.53; CI 0.30–0.94) as protective factors. Emergency surgery (OR 2.70; CI 1.20–6.01), blood loss ofu2009≥u2009200xa0mL (OR 2.06; CI 1.20–3.53) and ASA score ofu2009≥u20093 (OR 2.00; CI 1.12–3.57) were independent risk factors. Median length of hospital stay was significantly longer in patients who experienced respiratory complications (21 [4–183] vs. 6 [1–95] days, pu2009≤u20090.001).ConclusionsMinimally invasive surgery and high compliance with the ERAS protocol can help to prevent PPC.

Timing, diagnosis and treatment of surgical site infections after colonic surgery – Prospective surveillance of 1263 patients

BACKGROUNDnSurgical site infections (SSIs) are the most frequent complication after colorectal surgery and have a major impact on length of stay and costs.nnnAIMnTo analyse the incidence, timing, and treatment of SSIs within 30 days after colonic surgery.nnnMETHODSnThis was a quality improvement project through retrospective analysis of consecutive colonic surgeries between February 2012 and October 2017 at Lausanne University Hospital (CHUV). SSIs were prospectively assessed by an independent national surveillance programme (www.swissnoso.ch) up to 30 postoperative days. Treatment strategies including drainage of infection (direct wound opening or percutaneous) and surgical management were reviewed.nnnFINDINGSnThe study cohort included 1263 patients with 532 procedures (42%) performed as emergencies. SSIs were observed in 271 patients (21%), occurring at median postoperative day (POD) 9 (interquartile range (IQR): 4-16). Specifically, 53 (4%) were superficial incisional, 65 (5%) deep incisional, and 153 (12%) organ space infections (anastomotic insufficiency included). Superficial incisional SSI occurred at a median of POD 10.5 (IQR: 7-15), deep incisional at a median of POD 10 (8-15) and organ space at a median of POD 8 (5-11). Diagnosis was performed post discharge in 64 cases (24%). Whereas 47% of organ space infections were detected by POD 7, this rate was only 26% for superficial and deep incisional infections (Pxa0= 0.003). Surgical management was necessary in 133 cases (49%), and the remaining cases were managed by drainage without general anaesthesia (138 cases, 51%).nnnCONCLUSIONnOrgan space infections occurred early in the postoperative course, whereas incisional infections were mostly detected post discharge over the entire 30-day observation period, emphasizing the importance of proper follow-up using a systematic, complete and independent surveillance programme.

Feasibility of early postoperative mobilisation after colorectal surgery: a retrospective cohort study

BACKGROUNDnEnhanced Recovery After Surgery (ERAS) guidelines advocate early postoperative mobilisation to counteract catabolic changes due to immobilisation and maintain muscle strength. The present study aimed to assess compliance to postoperative mobilisation according to ERAS recommendations.nnnMATERIALS AND METHODSnThis is a retrospective cohort study on consecutive colorectal surgical procedures treated within an established ERAS protocol within a single center between May 2011 and May 2017. Demographics, surgical details, ERAS related items and surgical outcome were prospectively assessed in a dedicated database and compared between ambulant patients (at least 6u202fh out of bed at postoperative day (POD) 1) vs. patients not meeting the target (delayed mobilisation). Risk factors for decreased postoperative mobilisation were identified through multivariable logistic regression.nnnRESULTSn1170 patients were retained. 676 patients (58%) did not mobilise as recommended by ERAS protocol at POD1. Emergency operation (Odds Ratio (OR) 0.40; 95% Confidence Interval (CI) 0.18-0.91, pu202f=u202f0.028), ageu202f>u202f70 years (OR 0.69; 95% CI 0.47-1.00, pu202f=u202f0.050) and intraoperative total fluidsu202f>u202f2000u202fmL (OR 0.59; 95% CI 0.37-0.93, pu202f=u202f0.025) were independent risk factors for delayed mobilisation. Patients with delayed mobilisation had significantly more overall (Clavien grade IV) (55% vs. 29%, p=<0.001), major (Clavien grade IIIb-V) (16% vs. 7%, p=<0.001) and respiratory (12% vs. 4%, p=<0.001) complications, as well as longer length of stay (12u202f±u202f14 vs. 6±7days, p=<0.001).nnnCONCLUSIONSnMore than half of patients did not mobilise as recommended by ERAS guidelines. Emergency surgery, advanced age and fluid overload were independent risk factors for delayed mobilisation, which was associated with increased postoperative complications.