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Bhangu A, Li E; COVIDSurg Collaborative, Fisher A, Manku B.

Aim: This study aimed to describe the change in surgical practice and the impact of SARS-CoV-2 on mortality after surgical resection of colorectal cancer during the initial phases of the SARS-CoV-2 pandemic.

Method: This was an international cohort study of patients undergoing elective colon or rectal cancer resection, without preoperative suspicion of SARS-CoV-2. Centres entered data from their first recorded case of COVID-19 until 19 April 2020. The primary outcome was 30-day mortality. Secondary outcomes included anastomotic leak, postoperative SARS-CoV-2, and a comparison with a pre-pandemic European Society of Coloproctology cohort data.

Results: From 2073 patients in 40 countries, 1.3% (27/2073) had a defunctioning stoma and 3.0% (63/2073) had an end stoma instead of an anastomosis only. 30-day mortality was 1.8% (38/2073), the incidence of postoperative SARS-CoV-2 was 3.8% (78/2073), and the anastomotic leak rate was 4.9% (86/1738). Mortality was lowest in patients without a leak or SARS-CoV2 (14/1601, 0.9%), and highest in patients with both a leak and SARS-CoV-2 (5/13, 38.5%). Mortality was independently associated with an anastomotic leak (adjusted odds ratio 6.01, 95% confidence interval 2.58-14.06), postoperative SARS-CoV-2 (16.90, 7.86-36.38), male sex (2.46, 1.01-5.93), age >70 years (2.87, 1.32-6.20), and advanced cancer stage (3.43, 1.16-10.21). Compared to pre-pandemic data, there were fewer anastomotic leaks (4.9% versus 7.7%), an overall shorter length of stay (6 versus 7 days), but higher mortality (1.7% versus 1.1%).

Conclusion: Surgeons need to further mitigate against both SARS-CoV-2 and anastomotic leak when offering surgery during current and future COVID-19 waves based on patient, operative, and organisational risks.

GlobalSurg Collaborative

BJS Open. 2019 Feb 28;3(3):403-414. doi: 10.1002/bjs5.50138. eCollection 2019 Jun.


Background: End colostomy rates following colorectal resection vary across institutions in high-income settings, being influenced by patient, disease, surgeon and system factors. This study aimed to assess global variation in end colostomy rates after left-sided colorectal resection.

Methods: This study comprised an analysis of GlobalSurg-1 and -2 international, prospective, observational cohort studies (2014, 2016), including consecutive adult patients undergoing elective or emergency left-sided colorectal resection within discrete 2-week windows. Countries were grouped into high-, middle- and low-income tertiles according to the United Nations Human Development Index (HDI). Factors associated with colostomy formation versus primary anastomosis were explored using a multilevel, multivariable logistic regression model.

Results: In total, 1635 patients from 242 hospitals in 57 countries undergoing left-sided colorectal resection were included: 113 (6·9 per cent) from low-HDI, 254 (15·5 per cent) from middle-HDI and 1268 (77·6 per cent) from high-HDI countries. There was a higher proportion of patients with perforated disease (57·5, 40·9 and 35·4 per cent; P < 0·001) and subsequent use of end colostomy (52·2, 24·8 and 18·9 per cent; P < 0·001) in low- compared with middle- and high-HDI settings. The association with colostomy use in low-HDI settings persisted (odds ratio (OR) 3·20, 95 per cent c.i. 1·35 to 7·57; P = 0·008) after risk adjustment for malignant disease (OR 2·34, 1·65 to 3·32; P < 0·001), emergency surgery (OR 4·08, 2·73 to 6·10; P < 0·001), time to operation at least 48 h (OR 1·99, 1·28 to 3·09; P = 0·002) and disease perforation (OR 4·00, 2·81 to 5·69; P < 0·001).

Conclusion: Global differences existed in the proportion of patients receiving end stomas after left-sided colorectal resection based on income, which went beyond case mix alone.

2017 and 2015 European Society of Coloproctology (ESCP) collaborating groups.

 2018 Sep;20 Suppl 6:69-89. doi: 10.1111/codi.14371.



Laparoscopy has now been implemented as a standard of care for elective colonic resection around the world. During the adoption period, studies showed that conversion may be detrimental to patients, with poorer outcomes than both laparoscopic completed or planned open surgery. The primary aim of this study was to determine whether laparoscopic conversion was associated with a higher major complication rate than planned open surgery in contemporary, international practice.


Combined analysis of the European Society of Coloproctology 2017 and 2015 audits. Patients were included if they underwent elective resection of a colonic segment from the caecum to the rectosigmoid junction with primary anastomosis. The primary outcome measure was the 30-day major complication rate, defined as Clavien-Dindo grade III-V.


Of 3980 patients, 64% (2561/3980) underwent laparoscopic surgery and a laparoscopic conversion rate of 14% (359/2561). The major complication rate was highest after open surgery (laparoscopic 7.4%, converted 9.7%, open 11.6%, P < 0.001). After case mix adjustment in a multilevel model, only planned open (and not laparoscopic converted) surgery was associated with increased major complications in comparison to laparoscopic surgery (OR 1.64, 1.27-2.11, P < 0.001).


Appropriate laparoscopic conversion should not be considered a treatment failure in modern practice. Conversion does not appear to place patients at increased risk of complications vs planned open surgery, supporting broadening of selection criteria for attempted laparoscopy in elective colonic resection.

PMID: 30255643 / DOI: 10.1111/codi.14371

2017 European Society of Coloproctology (ESCP) collaborating group.

 2018 Sep;20 Suppl 6:15-32. doi: 10.1111/codi.14362.



The optimal bowel preparation strategy to minimise the risk of anastomotic leak is yet to be determined. This study aimed to determine whether oral antibiotics combined with mechanical bowel preparation (MBP+Abx) was associated with a reduced risk of anastomotic leak when compared to mechanical bowel preparation alone (MBP) or no bowel preparation (NBP).


A pre-planned analysis of the European Society of Coloproctology (ESCP) 2017 Left Sided Colorectal Resection audit was performed. Patients undergoing elective left sided colonic or rectal resection with primary anastomosis between 1 January 2017 and 15 March 2017 by any operative approach were included. The primary outcome measure was anastomotic leak.


Of 3676 patients across 343 centres in 47 countries, 618 (16.8%) received MBP+ABx, 1945 MBP (52.9%) and 1099 patients NBP (29.9%). Patients undergoing MBP+ABx had the lowest overall rate of anastomotic leak (6.1%, 9.2%, 8.7% respectively) in unadjusted analysis. After case-mix adjustment using a mixed-effects multivariable regression model, MBP+Abx was associated with a lower risk of anastomotic leak (OR 0.52, 0.30-0.92, P = 0.02) but MBP was not (OR 0.92, 0.63-1.36, P = 0.69) compared to NBP.


This non-randomised study adds ‘real-world’, contemporaneous, and prospective evidence of the beneficial effects of combined mechanical bowel preparation and oral antibiotics in the prevention of anastomotic leak following left sided colorectal resection across diverse settings. We have also demonstrated limited uptake of this strategy in current international colorectal practice.

PMID: 30255646 / DOI: 10.1111/codi.14362

2017 European Society of Coloproctology (ESCP) collaborating group.

 2018 Sep;20 Suppl 6:47-57. doi: 10.1111/codi.14373.



Some evidence suggests that primary anastomosis following left sided colorectal resection in the emergency setting may be safe in selected patients, and confer favourable outcomes to permanent enterostomy. The aim of this study was to compare the major postoperative complication rate in patients undergoing end stoma vs primary anastomosis following emergency left sided colorectal resection.


A pre-planned analysis of the European Society of Coloproctology 2017 audit. Adult patients (> 16 years) who underwent emergency (unplanned, within 24 h of hospital admission) left sided colonic or rectal resection were included. The primary endpoint was the 30-day major complication rate (Clavien-Dindo grade 3 to 5).


From 591 patients, 455 (77%) received an end stoma, 103 a primary anastomosis (17%) and 33 primary anastomosis with defunctioning stoma (6%). In multivariable models, anastomosis was associated with a similar major complication rate to end stoma (adjusted odds ratio for end stoma 1.52, 95%CI 0.83-2.79, P = 0.173). Although a defunctioning stoma was not associated with reduced anastomotic leak (12% defunctioned [4/33] vs 13% not defunctioned [13/97], adjusted odds ratio 2.19, 95%CI 0.43-11.02, P = 0.343), it was associated with less severe complications (75% [3/4] with defunctioning stoma, 86.7% anastomosis only [13/15]), a lower mortality rate (0% [0/4] vs 20% [3/15]), and fewer reoperations (50% [2/4] vs 73% [11/15]) when a leak did occur.


Primary anastomosis in selected patients appears safe after left sided emergency colorectal resection. A defunctioning stoma might mitigate against risk of subsequent complications.

PMID: 30255647 / DOI: 10.1111/codi.14373

Awab A(1), El Mansoury D, Benkabbou A, Elmoussaoui R, Elhijri A, Alilou M, Azzouzi A.

Author information:

(1)Surgery Intensive Care Unit, Ibn Sina Teaching Hospital, Rabat, Morocco.

DOI: 10.1111/j.1463-1318.2011.02654.x

PMID: 21689335  [Indexed for MEDLINE]

Colorectal Dis. 2012 Feb;14(2):e76. doi: 10.1111/j.1463-1318.2011.02654.x.

Honoré C(1), Goéré D, Souadka A, Dumont F, Elias D.

Author information:

(1)Department of Surgical Oncology, Institut Gustave Roussy, Cancer Center, Villejuif, France.

Comment in Eur J Surg Oncol. 2016 Jun;42(6):836-40.

BACKGROUND: In colorectal cancer, complete cytoreductive surgery associated with  hyperthermic intraperitoneal chemotherapy achieves encouraging results in early peritoneal carcinomatosis (PC), but this early detection can only be accurately accomplished during a systematic second-look surgery. This costly and invasive approach can only be proposed to selected patients. The objective of this study was to identify risk factors predictive of developing PC after curative surgery for colorectal cancer.

METHODS: After a systematic review of the literature published between 1940 and 2011, all clinical studies reporting the incidence of PC after curative surgery for colorectal cancer were searched for factors associated with the primary tumor that were likely to influence the incidence of recurrent PC.

RESULTS: Sixteen clinical studies were considered informative, all nonrandomized, three prospective and 13 retrospective, including 4-395 patients. Overall, the methodological quality of the reported studies was low. Data were available for the following factors: synchronous PC, synchronous ovarian metastases, perforated primary tumor, serosal and/or adjacent organ invasion, histological subtype, and  positive peritoneal cytology with reported incidences of recurrent PC between 8 and 75%. No study was found that mentioned an impact of lymph node invasion, tumor location, laparoscopy, occlusive tumors, or bleeding tumor on recurrent PC.

CONCLUSIONS: Evidence regarding the incidence of recurrent PC after curative surgery for colorectal cancer is poor. Emerging data indicate three situations that could result in a real higher risk of recurrent PC: synchronous PC, synchronous isolated ovarian metastases, and a perforated primary tumor.

DOI: 10.1245/s10434-012-2473-5

PMID: 23090572  [Indexed for MEDLINE]

Ann Surg Oncol. 2013 Jan;20(1):183-92. doi: 10.1245/s10434-012-2473-5. Epub 2012 Oct 23.

Majbar MA(1), Naya MS, Elalaoui M, Raiss M, Sabbah F, Hrora A, Ahallat M.


Author information:

(1)Clinique Chirurgicale C, Ibn Sina University Hospital, Rabat, Morocco,


DOI: 10.1007/s00384-014-1991-y

PMID: 25129524  [Indexed for MEDLINE]


Int J Colorectal Dis. 2015 Mar;30(3):425-6. doi: 10.1007/s00384-014-1991-y. Epub  2014 Aug 17.

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