Paola Nardi - Academia.edu (original) (raw)

Papers by Paola Nardi

Research paper thumbnail of The multi-societal European consensus on the terminology, diagnosis and management of patients with synchronous colorectal cancer and liver metastases: an E-AHPBA consensus in partnership with ESSO, ESCP, ESGAR, and CIRSE

Research paper thumbnail of Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

British Journal of Surgery

Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The a... more Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains...

Research paper thumbnail of The MIS-COVID-AGICT Study: Trend of Minimally Invasive Surgery for Gastrointestinal Cancer Treatment During the First Waves of the COVID-19 Pandemic in Italy. Subgroup Analysis from the COVID-AGICT Study: COVID-19 and Advanced Gastrointestinal Cancer Surgical Treatment

Journal of Laparoendoscopic & Advanced Surgical Techniques

Research paper thumbnail of Emergency surgical treatment of colonic acute diverticulitis: a multicenter observational study on behalf of the Italian society of colorectal surgery (SICCR) Lombardy committee

Updates in Surgery

Colonic diverticulitis can be treated conservatively, but some cases require surgery. Patients ca... more Colonic diverticulitis can be treated conservatively, but some cases require surgery. Patients can undergo Hartmann's procedure (H) or resection with primary anastomosis (RA), with or without diverting stoma. This multicenter observational retrospective study aims to evaluate the adherence to current guidelines by assessing the rate of RA and H in Lombardy, Italy, and to analyze differences in patients' features. This study included data collected from nine surgical units performing emergency surgery in Lombardy, in 2019 and 2021. Data for each year were retrospectively collected through a survey among Italian Society of Colorectal Surgery (SICCR) Lombardy members. Additional data were about: Hinchey's classification, laparoscopic (VLS) or converted procedures, procedures with more than two operators, procedures in which the first operator was older than 40 years, night or weekend procedures, older-than-80 patients, COVID-19 positivity (just 2021). The total number of operations performed was 254, 115 RA and 130 H (45.3% and 51.2%, diff. 12%, p = 0.73), and 9 (3.5%) other procedures. RAs were more frequent for Hinchey 1 and 2 patients, whereas Hs were more frequent for Hinchey 3 and 4. RAs without ileostomy were significantly less than Hs (66 vs. 130, p = 0.04). Laparoscopy was more used for RA compared to H (57 vs. 21, p = 0.03), whereas no difference was found between RA and H with respect to conversion rate, the presence of more than two operators in the team, the presence of a first operator older than 40 years, night or weekend operations, and for older-than-80 patients. This study confirms the adherence to current guidelines for the treatment of acute colonic diverticulitis in Lombardy, Italy. It can be considered as a preliminary survey with interesting results that may open the way to a further prospective observational study to clarify some aspects in the management of this disease.

Research paper thumbnail of Elective surgery system strengthening: development, measurement, and validation of the surgical preparedness index across 1632 hospitals in 119 countries

The Lancet

Background The 2015 Lancet Commission on global surgery identified surgery and anaesthesia as ind... more Background The 2015 Lancet Commission on global surgery identified surgery and anaesthesia as indispensable parts of holistic health-care systems. However, COVID-19 exposed the fragility of planned surgical services around the world, which have also been neglected in pandemic recovery planning. This study aimed to develop and validate a novel index to support local elective surgical system strengthening and address growing backlogs. Methods First, we performed an international consultation through a four-stage consensus process to develop a multidomain index for hospital-level assessment (surgical preparedness index; SPI). Second, we measured surgical preparedness across a global network of hospitals in high-income countries (HICs), middle-income countries (MICs), and low-income countries (LICs) to explore the distribution of the SPI at national, subnational, and hospital levels. Finally, using COVID-19 as an example of an external system shock, we compared hospitals' SPI to their planned surgical volume ratio (SVR; ie, operations for which the decision for surgery was made before hospital admission), calculated as the ratio of the observed surgical volume over a 1-month assessment period between June 6 and Aug 5, 2021, against the expected surgical volume based on hospital administrative data from the same period in 2019 (ie, a pre-pandemic baseline). A linear mixed-effects regression model was used to determine the effect of increasing SPI score. Findings In the first phase, from a longlist of 103 candidate indicators, 23 were prioritised as core indicators of elective surgical system preparedness by 69 clinicians (23 [33%] women; 46 [67%] men; 41 from HICs, 22 from MICs, and six from LICs) from 32 countries. The multidomain SPI included 11 indicators on facilities and consumables, two on staffing, two on prioritisation, and eight on systems. Hospitals were scored from 23 (least prepared) to 115 points (most prepared). In the second phase, surgical preparedness was measured in 1632 hospitals by 4714 clinicians from 119 countries. 745 (45•6%) of 1632 hospitals were in MICs or LICs. The mean SPI score was 84•5 (95% CI 84•1-84•9), which varied between HIC (88•5 [89•0-88•0]), MIC (81•8 [82•5-81•1]), and LIC (66•8 [64•9-68•7]) settings. In the third phase, 1217 (74•6%) hospitals did not maintain their expected SVR during the COVID-19 pandemic, of which 625 (51•4%) were from HIC, 538 (44•2%) from MIC, and 54 (4•4%) from LIC settings. In the mixed-effects model, a 10-point increase in SPI corresponded to a 3•6% (95% CI 3•0-4•1; p<0•0001) increase in SVR. This was consistent in HIC (4•8% [4•1-5•5]; p<0•0001), MIC (2•8 [2•0-3•7]; p<0•0001), and LIC (3•8 [1•3-6•7%]; p<0•0001) settings. Interpretation The SPI contains 23 indicators that are globally applicable, relevant across different system stressors, vary at a subnational level, and are collectable by front-line teams. In the case study of COVID-19, a higher SPI was associated with an increased planned surgical volume ratio independent of country income status, COVID-19 burden, and hospital type. Hospitals should perform annual self-assessment of their surgical preparedness to identify areas that can be improved, create resilience in local surgical systems, and upscale capacity to address elective surgery backlogs.

Research paper thumbnail of Validation of the OAKS prognostic model for acute kidney injury after gastrointestinal surgery

BJS Open, 2022

BackgroundPostoperative acute kidney injury (AKI) is a common complication of major gastrointesti... more BackgroundPostoperative acute kidney injury (AKI) is a common complication of major gastrointestinal surgery with an impact on short- and long-term survival. No validated system for risk stratification exists for this patient group. This study aimed to validate externally a prognostic model for AKI after major gastrointestinal surgery in two multicentre cohort studies.MethodsThe Outcomes After Kidney injury in Surgery (OAKS) prognostic model was developed to predict risk of AKI in the 7 days after surgery using six routine datapoints (age, sex, ASA grade, preoperative estimated glomerular filtration rate, planned open surgery and preoperative use of either an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker). Validation was performed within two independent cohorts: a prospective multicentre, international study (‘IMAGINE’) of patients undergoing elective colorectal surgery (2018); and a retrospective regional cohort study (‘Tayside’) in major abdominal surg...

Research paper thumbnail of Timing of surgery following SARS‐CoV‐2 infection: an international prospective cohort study

Anaesthesia, 2021

SummaryPeri‐operative SARS‐CoV‐2 infection increases postoperative mortality. The aim of this stu... more SummaryPeri‐operative SARS‐CoV‐2 infection increases postoperative mortality. The aim of this study was to determine the optimal duration of planned delay before surgery in patients who have had SARS‐CoV‐2 infection. This international, multicentre, prospective cohort study included patients undergoing elective or emergency surgery during October 2020. Surgical patients with pre‐operative SARS‐CoV‐2 infection were compared with those without previous SARS‐CoV‐2 infection. The primary outcome measure was 30‐day postoperative mortality. Logistic regression models were used to calculate adjusted 30‐day mortality rates stratified by time from diagnosis of SARS‐CoV‐2 infection to surgery. Among 140,231 patients (116 countries), 3127 patients (2.2%) had a pre‐operative SARS‐CoV‐2 diagnosis. Adjusted 30‐day mortality in patients without SARS‐CoV‐2 infection was 1.5% (95%CI 1.4–1.5). In patients with a pre‐operative SARS‐CoV‐2 diagnosis, mortality was increased in patients having surgery wi...

Research paper thumbnail of Death following pulmonary complications of surgery before and during the SARS-CoV-2 pandemic

British Journal of Surgery, 2021

Background This study aimed to determine the impact of pulmonary complications on death after sur... more Background This study aimed to determine the impact of pulmonary complications on death after surgery both before and during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. Methods This was a patient-level, comparative analysis of two, international prospective cohort studies: one before the pandemic (January–October 2019) and the second during the SARS-CoV-2 pandemic (local emergence of COVID-19 up to 19 April 2020). Both included patients undergoing elective resection of an intra-abdominal cancer with curative intent across five surgical oncology disciplines. Patient selection and rates of 30-day postoperative pulmonary complications were compared. The primary outcome was 30-day postoperative mortality. Mediation analysis using a natural-effects model was used to estimate the proportion of deaths during the pandemic attributable to SARS-CoV-2 infection. Results This study included 7402 patients from 50 countries; 3031 (40.9 per cent) underwent surgery be...

Research paper thumbnail of SARS‐CoV‐2 infection and venous thromboembolism after surgery: an international prospective cohort study

Anaesthesia, 2021

SummarySARS‐CoV‐2 has been associated with an increased rate of venous thromboembolism in critica... more SummarySARS‐CoV‐2 has been associated with an increased rate of venous thromboembolism in critically ill patients. Since surgical patients are already at higher risk of venous thromboembolism than general populations, this study aimed to determine if patients with peri‐operative or prior SARS‐CoV‐2 were at further increased risk of venous thromboembolism. We conducted a planned sub‐study and analysis from an international, multicentre, prospective cohort study of elective and emergency patients undergoing surgery during October 2020. Patients from all surgical specialties were included. The primary outcome measure was venous thromboembolism (pulmonary embolism or deep vein thrombosis) within 30 days of surgery. SARS‐CoV‐2 diagnosis was defined as peri‐operative (7 days before to 30 days after surgery); recent (1–6 weeks before surgery); previous (≥7 weeks before surgery); or none. Information on prophylaxis regimens or pre‐operative anti‐coagulation for baseline comorbidities was no...

Research paper thumbnail of Machine learning risk prediction of mortality for patients undergoing surgery with perioperative SARS-CoV-2: the COVIDSurg mortality score

British Journal of Surgery, 2021

To support the global restart of elective surgery, data from an international prospective cohort ... more To support the global restart of elective surgery, data from an international prospective cohort study of 8492 patients (69 countries) was analysed using artificial intelligence (machine learning techniques) to develop a predictive score for mortality in surgical patients with SARS-CoV-2. We found that patient rather than operation factors were the best predictors and used these to create the COVIDsurg Mortality Score (https://covidsurgrisk.app). Our data demonstrates that it is safe to restart a wide range of surgical services for selected patients.

Research paper thumbnail of Embolization of the superior rectal artery: another management option for hemorrhoids

Techniques in Coloproctology, 2020

OBJECTIVES: To compare the biomechanical properties of a new nitinol intramedullary scaffold impl... more OBJECTIVES: To compare the biomechanical properties of a new nitinol intramedullary scaffold implant with those of volar plates for the treatment of dorsally comminuted extra-articular distal radius fractures using an established model.

Research paper thumbnail of Delaying surgery for patients with a previous SARS-CoV-2 infection

British Journal of Surgery, 2020

Research paper thumbnail of Embolization of superior rectal arteries for transfusion dependent haemorrhoidal bleeding in severely cardiopathic patients: a new field of application of the “emborrhoid” technique

Techniques in Coloproctology, 2018

Research paper thumbnail of Safety and Efficacy of Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) Used for Analgesia After Bariatric Surgery: A Retrospective Case-Control Study

Obesity Surgery, 2018

Background Non-steroidal anti-inflammatory drugs (NSAIDs) are cornerstone in multimodal analgesia... more Background Non-steroidal anti-inflammatory drugs (NSAIDs) are cornerstone in multimodal analgesia protocols. This point is of great value in morbidly obese patients due to the high prevalence of restrictive pulmonary disease and obstructive sleep apnea. The aim of this study was to test the hypothesis that NSAIDs do not increase acute bariatric surgery complications while optimizing postoperative analgesia. Methods Databases of two medical centers were retrospectively reviewed to find all patients who underwent bariatric surgery between 1 January 2017 and 31 December 2017. Inclusion criteria were BMI greater than 30 kg/m 2 and age of 16-75 years old. Patients who suffered from severe organ failure or coagulation disorders were excluded. Patient's demographics, obesity-related diseases (diabetes, hypertension, dyslipidemia), postoperative pain scores, and morphine consumption in PACU, as well as early and late surgical complications, were collected. Patients included from the first institution (where NSAIDs analgesia was prohibited: control group) were compared to patients from the second institution (where NSAIDs analgesia was mandatory: case group). Results The study population included 270 patients, 134 in the control group, and 136 in the case group. NSAIDs usage produced better analgesia with significant reduction in morphine consumption and PACU length of stay. Also, incidence of surgical complications was the same in the two groups. Conclusions NSAIDs administration do not increase postoperative complication rate after bariatric surgery. Although NSAID administration provided better analgesia and shorter PACU stay, future prospective studies are needed to confirm these encouraging results and to evaluate their impact on postoperative rehabilitation.

Research paper thumbnail of T1 colon cancer in the era of screening: risk factors and treatment

Techniques in Coloproctology, 2017

Background The aim of this study was to identify risk factors for lymph node positivity in T1 col... more Background The aim of this study was to identify risk factors for lymph node positivity in T1 colon cancer and to carry out a surgical quality assurance audit. Methods The sample consisted of consecutive patients treated for early-stage colon lesions in 15 colorectal referral centres between 2011 and 2014. The study investigated 38 factors grouped into four categories: demographic information, preoperative data, indications for surgery and post-operative data. A univariate and multivariate logistic regression analysis was performed to analyze the significance of each factor both in terms of lymph node (LN) harvesting and LN metastases. Results Out of 507 patients enrolled, 394 patients were considered for analysis. Thirty-five (8.91%) patients had positive LN. Statistically significant differences related to total LN harvesting were found in relation to central vessel ligation and segmental resections. Cumulative distribution demonstrated that the rate of positive LN increased starting at 12 LN harvested and reached a plateau at 25 LN.

Research paper thumbnail of Enhanced recovery after surgery (ERAS) pathway vs traditional care in laparoscopic rectal resection: a single-center experience

Techniques in Coloproctology, 2016

AbstractBackground The aim of this study was to compare the outcome of an enhanced recovery after... more AbstractBackground The aim of this study was to compare the outcome of an enhanced recovery after surgery (ERAS) pathway with traditional perioperative care in laparoscopic rectal resection.MethodsA retrospective analysis of prospectively collected data was conducted. Single-center consecutive patients who underwent laparoscopic rectal surgery after an ERAS program were compared with patients who received traditional care over an 8-year period. Primary and total length of stay, and readmission, morbidity and mortality rates were analyzed. For ERAS group, the actual adherence to protocol was also evaluated.ResultsTwo hundred and ninety-seven patients, 162 in the ERAS group and 135 in conventional care, were studied. Median primary and total length of stay were significantly shorter in the ERAS group (9 vs 12 days; p = 0.0001; 10 vs 12 days; p = 0.01; respectively). The ERAS group experienced a faster recovery of bowel function than the traditional care group (p = 0.0001). A similar morbidity rate was observed in the two groups (32.3 % in ERAS vs 36.1 % in traditional care p = 0.41). Readmission rates were 4.9 % in the ERAS versus 1.5 % in the traditional care group (p = 0.19). There was no mortality in either group. Overall mean compliance with the ERAS protocol was 85.7 % (range 54.4–100 %).ConclusionsThe introduction of the ERAS protocol in laparoscopic rectal resection led to a reduction in primary and total length of hospital stay without an increase in morbidity or readmission rates when compared to traditional care.

Research paper thumbnail of PD-0467: Adaptive, preoperative radiotherapy with image guided Tomotherapy concomitant with chemotherapy in rectal cancer

Radiotherapy and Oncology, 2015

S230 3rd ESTRO Forum 2015 Conclusions: This meta-analysis demonstrates Level-II evidence of the h... more S230 3rd ESTRO Forum 2015 Conclusions: This meta-analysis demonstrates Level-II evidence of the high diagnostic performance of MRI in staging hilar/mediastinal LNs in NSCLC on both per-patient and pernodal basis. Relative to FDG-PET/CT, pulmonary MRI is able to reach higher sensitivity at similar specificity, encouraging future prospective studies on treatment decision-making and selective nodal irradiation in NSCLC. However, before pulmonary MRI can replace FDG-PET/CT in NSCLC radiotherapy, thorough assessment of geometric distortion in MR images is mandatory.

Research paper thumbnail of A nationwide audit of the use of radiotherapy for rectal cancer in Italy

Techniques in Coloproctology, 2010

Background There is good evidence that radiotherapy is beneficial in advanced rectal cancer, but ... more Background There is good evidence that radiotherapy is beneficial in advanced rectal cancer, but its application in Italy has not been investigated. Methods We conducted a nationwide survey among members of the Italian Society of Colo-Rectal Surgery (SICCR) on the use of radiation therapy for rectal cancer in the year 2005. Demographic, clinical and pathologic data were retrospectively collected with an online database. Italy was geographically divided into 3 regions: north, center and south which included the islands. Hospitals performing 30 or more surgeries per year were considered high volume. Factors related to radiotherapy delivery were identified with multivariate analysis. Results Of 108 centers, 44 (41%) responded to the audit. We collected data on 682 rectal cancer patients

Research paper thumbnail of Anal endosonography: a survey of equipment, technique and diagnostic criteria adopted in nine Italian centers

Techniques in Coloproctology, 2007

Research paper thumbnail of Association between Waste Management and Cancer in Companion Animals

Journal of Veterinary Internal Medicine, 2009

BACKGROUND: Increased cancer rates have been documented in people residing in areas around Naples... more BACKGROUND: Increased cancer rates have been documented in people residing in areas around Naples characterized by illegal dumping and incineration of waste. HYPOTHESIS: Risk of cancer in dogs and cats is associated with waste management. ANIMALS: Four hundred and fifty-three dogs and cats with cancer and 1,554 cancer-free animals. METHODS: Hospital-based case-control study in Naples (low danger) and nearby cities having a history of illegal waste dumping (high danger). Odds ratio (OR) between high-and low-danger areas was calculated for all tumors and various malignancies in dogs and cats. RESULTS: An increased risk for cancer development was identified in dogs but not in cats residing in high-danger areas (OR: 1.55; 95% confidence interval: 1.18-2.03; P < .01). A 2.39-fold increased risk of lymphoma (P < .01) accounted for the greater tumor frequency in dogs residing in high-danger areas. The risk of mast cell tumor and mammary cancer did not differ in dogs residing in high-or low-danger areas. CONCLUSIONS AND CLINICAL IMPORTANCE: Waste emission from illegal dumping sites increases cancer risk in dogs residing in high-danger areas. An increased prevalence of lymphoma has been previously recognized in humans living close to illegal waste dumps. Thus, epidemiological studies of spontaneous tumors in dogs might suggest a role for environmental factors in canine and human carcinogenesis and can predict health hazards for humans

Research paper thumbnail of The multi-societal European consensus on the terminology, diagnosis and management of patients with synchronous colorectal cancer and liver metastases: an E-AHPBA consensus in partnership with ESSO, ESCP, ESGAR, and CIRSE

Research paper thumbnail of Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

British Journal of Surgery

Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The a... more Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains...

Research paper thumbnail of The MIS-COVID-AGICT Study: Trend of Minimally Invasive Surgery for Gastrointestinal Cancer Treatment During the First Waves of the COVID-19 Pandemic in Italy. Subgroup Analysis from the COVID-AGICT Study: COVID-19 and Advanced Gastrointestinal Cancer Surgical Treatment

Journal of Laparoendoscopic & Advanced Surgical Techniques

Research paper thumbnail of Emergency surgical treatment of colonic acute diverticulitis: a multicenter observational study on behalf of the Italian society of colorectal surgery (SICCR) Lombardy committee

Updates in Surgery

Colonic diverticulitis can be treated conservatively, but some cases require surgery. Patients ca... more Colonic diverticulitis can be treated conservatively, but some cases require surgery. Patients can undergo Hartmann's procedure (H) or resection with primary anastomosis (RA), with or without diverting stoma. This multicenter observational retrospective study aims to evaluate the adherence to current guidelines by assessing the rate of RA and H in Lombardy, Italy, and to analyze differences in patients' features. This study included data collected from nine surgical units performing emergency surgery in Lombardy, in 2019 and 2021. Data for each year were retrospectively collected through a survey among Italian Society of Colorectal Surgery (SICCR) Lombardy members. Additional data were about: Hinchey's classification, laparoscopic (VLS) or converted procedures, procedures with more than two operators, procedures in which the first operator was older than 40 years, night or weekend procedures, older-than-80 patients, COVID-19 positivity (just 2021). The total number of operations performed was 254, 115 RA and 130 H (45.3% and 51.2%, diff. 12%, p = 0.73), and 9 (3.5%) other procedures. RAs were more frequent for Hinchey 1 and 2 patients, whereas Hs were more frequent for Hinchey 3 and 4. RAs without ileostomy were significantly less than Hs (66 vs. 130, p = 0.04). Laparoscopy was more used for RA compared to H (57 vs. 21, p = 0.03), whereas no difference was found between RA and H with respect to conversion rate, the presence of more than two operators in the team, the presence of a first operator older than 40 years, night or weekend operations, and for older-than-80 patients. This study confirms the adherence to current guidelines for the treatment of acute colonic diverticulitis in Lombardy, Italy. It can be considered as a preliminary survey with interesting results that may open the way to a further prospective observational study to clarify some aspects in the management of this disease.

Research paper thumbnail of Elective surgery system strengthening: development, measurement, and validation of the surgical preparedness index across 1632 hospitals in 119 countries

The Lancet

Background The 2015 Lancet Commission on global surgery identified surgery and anaesthesia as ind... more Background The 2015 Lancet Commission on global surgery identified surgery and anaesthesia as indispensable parts of holistic health-care systems. However, COVID-19 exposed the fragility of planned surgical services around the world, which have also been neglected in pandemic recovery planning. This study aimed to develop and validate a novel index to support local elective surgical system strengthening and address growing backlogs. Methods First, we performed an international consultation through a four-stage consensus process to develop a multidomain index for hospital-level assessment (surgical preparedness index; SPI). Second, we measured surgical preparedness across a global network of hospitals in high-income countries (HICs), middle-income countries (MICs), and low-income countries (LICs) to explore the distribution of the SPI at national, subnational, and hospital levels. Finally, using COVID-19 as an example of an external system shock, we compared hospitals' SPI to their planned surgical volume ratio (SVR; ie, operations for which the decision for surgery was made before hospital admission), calculated as the ratio of the observed surgical volume over a 1-month assessment period between June 6 and Aug 5, 2021, against the expected surgical volume based on hospital administrative data from the same period in 2019 (ie, a pre-pandemic baseline). A linear mixed-effects regression model was used to determine the effect of increasing SPI score. Findings In the first phase, from a longlist of 103 candidate indicators, 23 were prioritised as core indicators of elective surgical system preparedness by 69 clinicians (23 [33%] women; 46 [67%] men; 41 from HICs, 22 from MICs, and six from LICs) from 32 countries. The multidomain SPI included 11 indicators on facilities and consumables, two on staffing, two on prioritisation, and eight on systems. Hospitals were scored from 23 (least prepared) to 115 points (most prepared). In the second phase, surgical preparedness was measured in 1632 hospitals by 4714 clinicians from 119 countries. 745 (45•6%) of 1632 hospitals were in MICs or LICs. The mean SPI score was 84•5 (95% CI 84•1-84•9), which varied between HIC (88•5 [89•0-88•0]), MIC (81•8 [82•5-81•1]), and LIC (66•8 [64•9-68•7]) settings. In the third phase, 1217 (74•6%) hospitals did not maintain their expected SVR during the COVID-19 pandemic, of which 625 (51•4%) were from HIC, 538 (44•2%) from MIC, and 54 (4•4%) from LIC settings. In the mixed-effects model, a 10-point increase in SPI corresponded to a 3•6% (95% CI 3•0-4•1; p<0•0001) increase in SVR. This was consistent in HIC (4•8% [4•1-5•5]; p<0•0001), MIC (2•8 [2•0-3•7]; p<0•0001), and LIC (3•8 [1•3-6•7%]; p<0•0001) settings. Interpretation The SPI contains 23 indicators that are globally applicable, relevant across different system stressors, vary at a subnational level, and are collectable by front-line teams. In the case study of COVID-19, a higher SPI was associated with an increased planned surgical volume ratio independent of country income status, COVID-19 burden, and hospital type. Hospitals should perform annual self-assessment of their surgical preparedness to identify areas that can be improved, create resilience in local surgical systems, and upscale capacity to address elective surgery backlogs.

Research paper thumbnail of Validation of the OAKS prognostic model for acute kidney injury after gastrointestinal surgery

BJS Open, 2022

BackgroundPostoperative acute kidney injury (AKI) is a common complication of major gastrointesti... more BackgroundPostoperative acute kidney injury (AKI) is a common complication of major gastrointestinal surgery with an impact on short- and long-term survival. No validated system for risk stratification exists for this patient group. This study aimed to validate externally a prognostic model for AKI after major gastrointestinal surgery in two multicentre cohort studies.MethodsThe Outcomes After Kidney injury in Surgery (OAKS) prognostic model was developed to predict risk of AKI in the 7 days after surgery using six routine datapoints (age, sex, ASA grade, preoperative estimated glomerular filtration rate, planned open surgery and preoperative use of either an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker). Validation was performed within two independent cohorts: a prospective multicentre, international study (‘IMAGINE’) of patients undergoing elective colorectal surgery (2018); and a retrospective regional cohort study (‘Tayside’) in major abdominal surg...

Research paper thumbnail of Timing of surgery following SARS‐CoV‐2 infection: an international prospective cohort study

Anaesthesia, 2021

SummaryPeri‐operative SARS‐CoV‐2 infection increases postoperative mortality. The aim of this stu... more SummaryPeri‐operative SARS‐CoV‐2 infection increases postoperative mortality. The aim of this study was to determine the optimal duration of planned delay before surgery in patients who have had SARS‐CoV‐2 infection. This international, multicentre, prospective cohort study included patients undergoing elective or emergency surgery during October 2020. Surgical patients with pre‐operative SARS‐CoV‐2 infection were compared with those without previous SARS‐CoV‐2 infection. The primary outcome measure was 30‐day postoperative mortality. Logistic regression models were used to calculate adjusted 30‐day mortality rates stratified by time from diagnosis of SARS‐CoV‐2 infection to surgery. Among 140,231 patients (116 countries), 3127 patients (2.2%) had a pre‐operative SARS‐CoV‐2 diagnosis. Adjusted 30‐day mortality in patients without SARS‐CoV‐2 infection was 1.5% (95%CI 1.4–1.5). In patients with a pre‐operative SARS‐CoV‐2 diagnosis, mortality was increased in patients having surgery wi...

Research paper thumbnail of Death following pulmonary complications of surgery before and during the SARS-CoV-2 pandemic

British Journal of Surgery, 2021

Background This study aimed to determine the impact of pulmonary complications on death after sur... more Background This study aimed to determine the impact of pulmonary complications on death after surgery both before and during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. Methods This was a patient-level, comparative analysis of two, international prospective cohort studies: one before the pandemic (January–October 2019) and the second during the SARS-CoV-2 pandemic (local emergence of COVID-19 up to 19 April 2020). Both included patients undergoing elective resection of an intra-abdominal cancer with curative intent across five surgical oncology disciplines. Patient selection and rates of 30-day postoperative pulmonary complications were compared. The primary outcome was 30-day postoperative mortality. Mediation analysis using a natural-effects model was used to estimate the proportion of deaths during the pandemic attributable to SARS-CoV-2 infection. Results This study included 7402 patients from 50 countries; 3031 (40.9 per cent) underwent surgery be...

Research paper thumbnail of SARS‐CoV‐2 infection and venous thromboembolism after surgery: an international prospective cohort study

Anaesthesia, 2021

SummarySARS‐CoV‐2 has been associated with an increased rate of venous thromboembolism in critica... more SummarySARS‐CoV‐2 has been associated with an increased rate of venous thromboembolism in critically ill patients. Since surgical patients are already at higher risk of venous thromboembolism than general populations, this study aimed to determine if patients with peri‐operative or prior SARS‐CoV‐2 were at further increased risk of venous thromboembolism. We conducted a planned sub‐study and analysis from an international, multicentre, prospective cohort study of elective and emergency patients undergoing surgery during October 2020. Patients from all surgical specialties were included. The primary outcome measure was venous thromboembolism (pulmonary embolism or deep vein thrombosis) within 30 days of surgery. SARS‐CoV‐2 diagnosis was defined as peri‐operative (7 days before to 30 days after surgery); recent (1–6 weeks before surgery); previous (≥7 weeks before surgery); or none. Information on prophylaxis regimens or pre‐operative anti‐coagulation for baseline comorbidities was no...

Research paper thumbnail of Machine learning risk prediction of mortality for patients undergoing surgery with perioperative SARS-CoV-2: the COVIDSurg mortality score

British Journal of Surgery, 2021

To support the global restart of elective surgery, data from an international prospective cohort ... more To support the global restart of elective surgery, data from an international prospective cohort study of 8492 patients (69 countries) was analysed using artificial intelligence (machine learning techniques) to develop a predictive score for mortality in surgical patients with SARS-CoV-2. We found that patient rather than operation factors were the best predictors and used these to create the COVIDsurg Mortality Score (https://covidsurgrisk.app). Our data demonstrates that it is safe to restart a wide range of surgical services for selected patients.

Research paper thumbnail of Embolization of the superior rectal artery: another management option for hemorrhoids

Techniques in Coloproctology, 2020

OBJECTIVES: To compare the biomechanical properties of a new nitinol intramedullary scaffold impl... more OBJECTIVES: To compare the biomechanical properties of a new nitinol intramedullary scaffold implant with those of volar plates for the treatment of dorsally comminuted extra-articular distal radius fractures using an established model.

Research paper thumbnail of Delaying surgery for patients with a previous SARS-CoV-2 infection

British Journal of Surgery, 2020

Research paper thumbnail of Embolization of superior rectal arteries for transfusion dependent haemorrhoidal bleeding in severely cardiopathic patients: a new field of application of the “emborrhoid” technique

Techniques in Coloproctology, 2018

Research paper thumbnail of Safety and Efficacy of Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) Used for Analgesia After Bariatric Surgery: A Retrospective Case-Control Study

Obesity Surgery, 2018

Background Non-steroidal anti-inflammatory drugs (NSAIDs) are cornerstone in multimodal analgesia... more Background Non-steroidal anti-inflammatory drugs (NSAIDs) are cornerstone in multimodal analgesia protocols. This point is of great value in morbidly obese patients due to the high prevalence of restrictive pulmonary disease and obstructive sleep apnea. The aim of this study was to test the hypothesis that NSAIDs do not increase acute bariatric surgery complications while optimizing postoperative analgesia. Methods Databases of two medical centers were retrospectively reviewed to find all patients who underwent bariatric surgery between 1 January 2017 and 31 December 2017. Inclusion criteria were BMI greater than 30 kg/m 2 and age of 16-75 years old. Patients who suffered from severe organ failure or coagulation disorders were excluded. Patient's demographics, obesity-related diseases (diabetes, hypertension, dyslipidemia), postoperative pain scores, and morphine consumption in PACU, as well as early and late surgical complications, were collected. Patients included from the first institution (where NSAIDs analgesia was prohibited: control group) were compared to patients from the second institution (where NSAIDs analgesia was mandatory: case group). Results The study population included 270 patients, 134 in the control group, and 136 in the case group. NSAIDs usage produced better analgesia with significant reduction in morphine consumption and PACU length of stay. Also, incidence of surgical complications was the same in the two groups. Conclusions NSAIDs administration do not increase postoperative complication rate after bariatric surgery. Although NSAID administration provided better analgesia and shorter PACU stay, future prospective studies are needed to confirm these encouraging results and to evaluate their impact on postoperative rehabilitation.

Research paper thumbnail of T1 colon cancer in the era of screening: risk factors and treatment

Techniques in Coloproctology, 2017

Background The aim of this study was to identify risk factors for lymph node positivity in T1 col... more Background The aim of this study was to identify risk factors for lymph node positivity in T1 colon cancer and to carry out a surgical quality assurance audit. Methods The sample consisted of consecutive patients treated for early-stage colon lesions in 15 colorectal referral centres between 2011 and 2014. The study investigated 38 factors grouped into four categories: demographic information, preoperative data, indications for surgery and post-operative data. A univariate and multivariate logistic regression analysis was performed to analyze the significance of each factor both in terms of lymph node (LN) harvesting and LN metastases. Results Out of 507 patients enrolled, 394 patients were considered for analysis. Thirty-five (8.91%) patients had positive LN. Statistically significant differences related to total LN harvesting were found in relation to central vessel ligation and segmental resections. Cumulative distribution demonstrated that the rate of positive LN increased starting at 12 LN harvested and reached a plateau at 25 LN.

Research paper thumbnail of Enhanced recovery after surgery (ERAS) pathway vs traditional care in laparoscopic rectal resection: a single-center experience

Techniques in Coloproctology, 2016

AbstractBackground The aim of this study was to compare the outcome of an enhanced recovery after... more AbstractBackground The aim of this study was to compare the outcome of an enhanced recovery after surgery (ERAS) pathway with traditional perioperative care in laparoscopic rectal resection.MethodsA retrospective analysis of prospectively collected data was conducted. Single-center consecutive patients who underwent laparoscopic rectal surgery after an ERAS program were compared with patients who received traditional care over an 8-year period. Primary and total length of stay, and readmission, morbidity and mortality rates were analyzed. For ERAS group, the actual adherence to protocol was also evaluated.ResultsTwo hundred and ninety-seven patients, 162 in the ERAS group and 135 in conventional care, were studied. Median primary and total length of stay were significantly shorter in the ERAS group (9 vs 12 days; p = 0.0001; 10 vs 12 days; p = 0.01; respectively). The ERAS group experienced a faster recovery of bowel function than the traditional care group (p = 0.0001). A similar morbidity rate was observed in the two groups (32.3 % in ERAS vs 36.1 % in traditional care p = 0.41). Readmission rates were 4.9 % in the ERAS versus 1.5 % in the traditional care group (p = 0.19). There was no mortality in either group. Overall mean compliance with the ERAS protocol was 85.7 % (range 54.4–100 %).ConclusionsThe introduction of the ERAS protocol in laparoscopic rectal resection led to a reduction in primary and total length of hospital stay without an increase in morbidity or readmission rates when compared to traditional care.

Research paper thumbnail of PD-0467: Adaptive, preoperative radiotherapy with image guided Tomotherapy concomitant with chemotherapy in rectal cancer

Radiotherapy and Oncology, 2015

S230 3rd ESTRO Forum 2015 Conclusions: This meta-analysis demonstrates Level-II evidence of the h... more S230 3rd ESTRO Forum 2015 Conclusions: This meta-analysis demonstrates Level-II evidence of the high diagnostic performance of MRI in staging hilar/mediastinal LNs in NSCLC on both per-patient and pernodal basis. Relative to FDG-PET/CT, pulmonary MRI is able to reach higher sensitivity at similar specificity, encouraging future prospective studies on treatment decision-making and selective nodal irradiation in NSCLC. However, before pulmonary MRI can replace FDG-PET/CT in NSCLC radiotherapy, thorough assessment of geometric distortion in MR images is mandatory.

Research paper thumbnail of A nationwide audit of the use of radiotherapy for rectal cancer in Italy

Techniques in Coloproctology, 2010

Background There is good evidence that radiotherapy is beneficial in advanced rectal cancer, but ... more Background There is good evidence that radiotherapy is beneficial in advanced rectal cancer, but its application in Italy has not been investigated. Methods We conducted a nationwide survey among members of the Italian Society of Colo-Rectal Surgery (SICCR) on the use of radiation therapy for rectal cancer in the year 2005. Demographic, clinical and pathologic data were retrospectively collected with an online database. Italy was geographically divided into 3 regions: north, center and south which included the islands. Hospitals performing 30 or more surgeries per year were considered high volume. Factors related to radiotherapy delivery were identified with multivariate analysis. Results Of 108 centers, 44 (41%) responded to the audit. We collected data on 682 rectal cancer patients

Research paper thumbnail of Anal endosonography: a survey of equipment, technique and diagnostic criteria adopted in nine Italian centers

Techniques in Coloproctology, 2007

Research paper thumbnail of Association between Waste Management and Cancer in Companion Animals

Journal of Veterinary Internal Medicine, 2009

BACKGROUND: Increased cancer rates have been documented in people residing in areas around Naples... more BACKGROUND: Increased cancer rates have been documented in people residing in areas around Naples characterized by illegal dumping and incineration of waste. HYPOTHESIS: Risk of cancer in dogs and cats is associated with waste management. ANIMALS: Four hundred and fifty-three dogs and cats with cancer and 1,554 cancer-free animals. METHODS: Hospital-based case-control study in Naples (low danger) and nearby cities having a history of illegal waste dumping (high danger). Odds ratio (OR) between high-and low-danger areas was calculated for all tumors and various malignancies in dogs and cats. RESULTS: An increased risk for cancer development was identified in dogs but not in cats residing in high-danger areas (OR: 1.55; 95% confidence interval: 1.18-2.03; P < .01). A 2.39-fold increased risk of lymphoma (P < .01) accounted for the greater tumor frequency in dogs residing in high-danger areas. The risk of mast cell tumor and mammary cancer did not differ in dogs residing in high-or low-danger areas. CONCLUSIONS AND CLINICAL IMPORTANCE: Waste emission from illegal dumping sites increases cancer risk in dogs residing in high-danger areas. An increased prevalence of lymphoma has been previously recognized in humans living close to illegal waste dumps. Thus, epidemiological studies of spontaneous tumors in dogs might suggest a role for environmental factors in canine and human carcinogenesis and can predict health hazards for humans