Comparing Low Volume Versus Conventional Volume of Polyethylene Glycol for Bowel Preparation during Colonoscopy: A Randomised Controlled Trial

BACKGROUND

Polyethylene glycol (PEG) solution is widely used as a colonoscopic bowel cleaning agent, although some patients are intolerant due to the need for ingesting large solution volumes and unpleasant taste. A low-volume solution may enhance patient tolerability and compliance in bowel preparation. Accordingly, this study compared the effectiveness of two difference PEG volumes for bowel preparation before colonoscopy in terms of bowel cleanliness, completeness of colonoscopy, patient tolerability and colonoscopy duration.

METHODS

Using a prospective randomised controlled single-blinded study design, 164 patients scheduled for colonoscopy were allocated to two groups (n = 82 patients in each) to receive either the conventional PEG volume (3 L, control group) or the low volume (2 L, intervention group). The Boston Bowel Preparation Scale (BBPS), a validated scale for assessing bowel cleanliness during colonoscopy, was used to score bowel cleanliness in three colon segments. Secondarily, colonoscopy completeness, tolerability to drinking PEG and the duration of colonoscopy were compared between the groups.

RESULTS

There were no statistically significant differences between the two intervention groups in terms of bowel cleanliness (P = 0.119), colonoscopy completion (P = 0.535), tolerability (P = 0.190) or the amount of sedation/analgesia required (midazolam, P = 0.162; pethidine, P = 0.708). Only the duration of colonoscopy differed between the two groups (longer duration in the control group, P = 0.039).

CONCLUSION

Low-volume (2 L) PEG is as effective as the standard 3 L solution in bowel cleaning before colonoscopy; however, the superiority of either solution could not be established.

A rare case of appendiceal polyp from screening colonoscopy – A case report

Background: Appendiceal adenomatous polyps are rare and present diagnostic challenges. The reported incidence of these polyps during autopsy ranges from 0.004% to 0.08%. The identification of appendiceal polyps during colonoscopy is uncommon, and there is limited literature on this subject. This case highlights the importance of thorough assessment of the appendix during colonoscopy. Case Presentation: A patient with a history of chronic constipation presented with complaints of per rectal bleeding and rectal pain. The patient had previously undergone a surveillance colonoscopy several years ago, which showed normal findings. During the current colonoscopy, a 0.5 cm x 0.5 cm polyp was identified at the appendiceal orifice. Discussion: Appendiceal polyps are rare findings during colonoscopy, and their detection can be difficult due to the anatomical location of the appendix. The significance of these polyps lies in their potential to cause complications such as malignancy, intussusception, or chronic appendicitis. While guidelines for the follow-up of patients with appendiceal orifice polyps are limited, this case emphasizes the need for careful examination of the appendix during colonoscopy. Conclusion: A thorough assessment of the appendix during colonoscopy is essential for detecting appendiceal polyps and preventing potential complications. Further research and clearer follow-up guidelines are needed for patients with appendiceal opening polyps.

Time for a paradigm shift in shared decision-making in trauma and emergency surgery? Results from an international survey

BACKGROUND

Shared decision-making (SDM) between clinicians and patients is one of the pillars of the modern patient-centric philosophy of care. This study aims to explore SDM in the discipline of trauma and emergency surgery, investigating its interpretation as well as the barriers and facilitators for its implementation among surgeons.

METHODS

Grounding on the literature on the topics of the understanding, barriers, and facilitators of SDM in trauma and emergency surgery, a survey was created by a multidisciplinary committee and endorsed by the World Society of Emergency Surgery (WSES). The survey was sent to all 917 WSES members, advertised through the society's website, and shared on the society's Twitter profile.

RESULTS

A total of 650 trauma and emergency surgeons from 71 countries in five continents participated in the initiative. Less than half of the surgeons understood SDM, and 30% still saw the value in exclusively engaging multidisciplinary provider teams without involving the patient. Several barriers to effectively partnering with the patient in the decision-making process were identified, such as the lack of time and the need to concentrate on making medical teams work smoothly.

DISCUSSION

Our investigation underlines how only a minority of trauma and emergency surgeons understand SDM, and perhaps, the value of SDM is not fully accepted in trauma and emergency situations. The inclusion of SDM practices in clinical guidelines may represent the most feasible and advocated solutions.

Pneumaturia and faecaluria: Symptoms leading to a life-saving diagnosis

BACKGROUND

Colonic diverticulosis is often asymptomatic, but it can complicate bleeding, abscess and stricture. Pneumaturia and faecaluria are unexpected manifestations of colonic diverticulitis complicated by colovesical fistula formation.

CASE PRESENTATION

This case report highlighted a 57-year-old man who presented with lower abdominal pain which was associated with pneumaturia and fecaluria. He was diagnosed with colovesical fistula after being misdiagnosed with other diseases from various clinic visits. Direct fluoroscopy was performed and a diverticular fistula of the sigmoid colon was confirmed by computed tomography of the abdomen. Hartmann's procedure and resection of the posterior wall of the bladder were resected.

CONCLUSION

Pneumaturia and faecaluria are common but distinct manifestations of complicated diverticular diseases. Attention should be paid to general practitioners to achieve proper referral, hence early treatment and prevention of disease-related complications.

Rare and unusual case of polyarteritis nodosa involving the gastrointestinal tract leading to bowel gangrene

Polyarteritis nodosa (PAN) is a systemic necrotising vasculitis preferentially targeting medium-sized arteries and not related with glomerulonephritis or small vessel involvement. Clinical manifestations of PAN are multisystem. The gastrointestinal, renal, cardiac, musculoskeletal, skin and central nervous systems may be involved. The aetiology remains unknown, and the ensuing vasculitis may lead to aneurysm formation and thrombosis in any organs of the body with resultant ischaemia. PAN of the intestines is a relatively common manifestation of this disease but rarely causes bowel ischaemia resulting in necrosis. Here we report a case of a young Chinese patient who presented with an acute abdomen requiring surgery and made good recovery post operatively. He remains free of symptoms while on steroid therapy.

Current Trend and Outcomes on Immunonutrition in Medical and Surgical Fields: An Updated Perspective

Immunonutrition, which involves the targeted use of specific nutrients to enhance immune function and mitigate inflammation, has recently become a mainstay for both medical and surgical benefits. This review explores the evolution, mechanisms, and clinical applications of immunonutrition, with a focus on essential nutrients, such as omega-3 fatty acids, glutamine, arginine, and vitamins. These immunonutrients modulate immune responses, reduce pro-inflammatory cytokines, and support tissue repair. Clinical evidence indicates that immunonutrition reduces postoperative complications, shortens the duration of hospitalisation, and lowers the rate of infection, mainly in high-risk surgical patients and those with cancer or chronic diseases. In this regard, nutrients such as glutamine and omega-3 fatty acids have improved the nutritional status and recovery of cancer patients, while omega-3 fatty acids and antioxidant vitamins have exerted an anti-inflammatory effect, improving heart health in patients with cardiovascular disease. Immunonutrition has bright prospects in the management of infectious diseases, where certain nutrients, including vitamin D and zinc, aid in fighting immune defences and reducing the severity of infection. Future studies should investigate the molecular mechanisms underlying immunonutrition and its role in personalised nutrition. This could revolutionise dietary interventions based on genetic and proteomic profiling.

Management of inflammatory bowel disease in the emergency setting: the MIBODI international survey and evidence-based practices

AIM

This study aimed to evaluate the impact of the WSES-AAST guidelines in clinical practice and to investigate the knowledge, attitudes, and practices of emergency surgeons in managing the complications of ulcerative colitis (UC) and Crohn's disease (CD).

METHODS

The MIBODI survey is a cross-sectional study among WSES members designed as an international web-based survey, according to the Checklist for Reporting Results of Internet E-Surveys, to collect data on emergency surgeons' knowledge, attitudes, and practices concerning the management of patients presenting with acute complications of CD and UC. The questionnaire was composed of 30 questions divided into five sections: (1) demographic data, (2) primary evaluation, (3) non-operative management, (4) operative management, and (5) perianal sepsis management.

RESULTS

Two hundred and forty-two surgeons from 48 countries agreed to participate in the survey. The response rate was 24.2% (242/1000 members on WSES mail list). Emergency surgeons showed high adherence to recommendations for 6 of the 21 assessed items, with a "correct" response rate greater than or equal to 60%, according to WSES-AAST recommendations. Nine critical issues were highlighted, with correct answers at a rate of less than 50%.

CONCLUSIONS

Inflammatory bowel disease is a complex disease that requires a multidisciplinary approach with close collaboration between gastroenterologists and surgeons. Emergency surgeons play a crucial role in managing complications related to IBD. One year after publication, the MIBODI study showed significant global implementation of the WSES-AAST guidelines in clinical practice, offering an imperative tool in the improved management of IBD in emergency and urgent settings.

Honey clinical applications in complementary medicine: A critical review

Context: Honey has been employed for its therapeutic attributes since ancient eras, with a history of medicinal utilization, and recent studies have highlighted its diverse clinical applications. The medicinal benefits of honey can be ascribed to various mechanisms, encompassing its osmotic and acidic characteristics, hydrogen peroxide generation, and particular bioactive compounds. While honey generally has a good safety profile, rare risks exist, particularly in infants under one year of age. More rigorous clinical trials and standardized protocols are needed to establish its optimal dosage, application methods, and specific indications. Economic considerations and regional variations in honey composition and quality should also be considered. Aims: To provide an overview of the clinical uses of honey in the medical field, emphasizing its effectiveness and potential therapeutic benefits. Methods: A comprehensive literature search was conducted to gather relevant studies on the clinical applications of honey. The search encompassed various databases and included studies published with the range from May 2001 to May 2023. The selected studies were critically reviewed to extract pertinent information for this critical review. Results: Natural honey comes from two types of honey-producing bees: honeybees and stingless bees. Honey constitutes a multifaceted amalgamation of sugars, enzymes, minerals, vitamins, and bioactive compounds, all contributing to its therapeutic attributes. It exhibits antibacterial, anti-inflammatory, wound healing, and antioxidant effects. In wound management, honey promotes healing, reduces infection rates, and minimizes scarring. It also shows promise in treating bacterial and fungal infections. Furthermore, honey has effectively alleviated symptoms associated with respiratory tract infections, gastrointestinal disorders, and dermatological conditions. Conclusions: Honey possesses multifaceted clinical applications in the medical field. Its diverse therapeutic properties and minimal adverse effects make it an attractive option for various conditions. However, further research is necessary to solidify its role in evidence-based clinical practice, including conducting more rigorous clinical trials, establishing standardized protocols, and considering economic and regional factors.

The Burden of Surgical Site Infection at Hospital Universiti Sains Malaysia and Related Postoperative Outcomes: A Prospective Surveillance Study

Surgical site infections (SSIs) are the most common healthcare-associated infections that occur among surgical patients. Surgical site infections result in longer hospital stays, hospital readmissions, and higher death and morbidity rates. The current study was designed to highlight the importance of such surveillance studies in a Malaysian surgical population with a motive to evaluate and revise concurrent infection control and prevention policies by exploring the burden of surgical site infection and identifying its associated risk factors for future considerations. In this prospective observational cohort study, a total of 216 patients admitted to a surgical ward were identified and studied. Of these 216 patients, 142 elective procedures and 74 emergency procedures were included in the study, of which 13 patients (9.2%) undergoing elective procedures and 15 (20.3%) patients undergoing emergency procedures were SSI positive (OR: 2.5, p = 0.02). Among surgical site infections, 21 were superficial and 7 were deep incisional SSI. No case of organ/space SSI was identified. The time taken for SSIs to develop ranged from 2-17 days with a median of 6 days. Risk factors such as presence of comorbidities (p = 0.011), major co-existing medical diagnosis ≥2 (p = 0.02), and pre-existing infection (p = 0.027) were statistically significant. SSI-positive patients experienced an increase in the post-operative length of hospital stay. In the current population, it was seen that identifying patients who were at high risk of malnutrition via MUST and the NNIS risk index will help clinicians in identifying high risk patients and in managing their patients appropriately. Identifying patients who were at high risk of malnutrition will also improve postoperative outcomes considerably.

Colorectal cancer and potential predictors of never screened for faecal occult blood test: a narrative review

Colorectal cancer (CRC) is a major public health threat. Therefore, CRC screening uptake has been a focus with the established precancerous lesion and the strong association of early detection with staging and survival of the disease. However, CRC screening is relatively low in many countries. This article briefly discussed the current situation of CRC, recommendations, and current uptake of CRC screening in various countries. Besides that, this article also highlights the potential factors that help to predict the CRC screening uptake worldwide. Identification of those factors could guide policymakers to develop an effective strategy to improve the CRC screening uptake and ultimately improve the health outcome of the population.

Colorectal cancer in patient younger than 50-year-old in Kelantan: Two case reports

Although young-onset colorectal cancer (CRC) is commonly linked to genetic predispositions such as Lynch syndrome, there has been an increasing trend in the prevalence of sporadic type youngonset CRC. We highlighted two cases of young patients diagnosed with CRC. Both patients came at the late stage of presentation with right sided colon tumour and local lymph nodes involvement. Loss of MLH1 expression with positive BRAF V600E was seen on immunohistochemistry staining. Additionally, they have no chronic disease or familial history of malignancy. The follow-up surveillance CT scan and the surveillance colonoscopy of case 1 showed no local recurrence and distant metastasis. However, another patient defaulted on the subsequent follow-up. In this report, we review the clinicopathological characteristics of these two cases and discuss the importance of the screening for the BRAF V600E and the four MMR proteins to characterise the sporadic and hereditary subgroups of young-onset CRC.

A rare presentation of retroperitoneal liposarcoma presented with jejunal intussusception: An interesting radiological findings

A jejunal intussusception as a presentation of retroperitoneal liposarcoma (RLPS) is a rare occurrence. The majority of RLPS are presented as an abdominal mass, however, having a jejunal obstruction is an interesting case. The aim is to describe the management of jejunal intussusception secondary to atypical lipomatous tumours with concurrent RLPS. A 61-year-old lady presented with a sudden onset of intestinal obstruction with 1 month of constitutional symptoms and an enlarging right lumbar mass. Computed tomography showed a small bowel intussusception with diffuse peritoneal and retroperitoneal lipomatosis. Emergency exploratory laparotomy, segmental bowel resection, and partial excision of intraperitoneal mesenteric lipoma were performed. A stage En-bloc resection of the RLPS and right nephrectomy was done later. However, she refused for subsequent surgery. A complete resection is the gold standard in managing RLPS. In this report, the management is rendered not to the standard as the patient first presented with intestinal obstruction requiring emergency reduction with a piecemeal resection. A stage surgery was required to determine a promising prognosis, but the patient refused such surgery. A small bowel intussusception in adults is rare but is mostly caused by a tumor or neoplasm. Early recognition of the complexity of the case should be preempted and referred to the tertiary team for further definitive surgery. Patient exhaustion from the subsequent surgery might hamper the only management available for the case.

Factors associated with delay in seeking care for breast symptoms

BACKGROUND

Breast cancer is the most common cancer in women worldwide. Early detection and intervention are associated with better prognosis and survival. The study aim was to investigate the factors associated with delayed presentation among women with breast symptoms.

METHODS

After ethics approval, a cross-sectional study was conducted from January to October 2020 in women with new breast cancer symptoms at their first visit to our clinic. The "Delayed Presentation" questionnaires in the Malay language were used and distributed among the participants. Demographic data and presentation time were recorded. Presentation time was defined as the duration of symptoms prior to visiting any health care facilities. Respondents with presentation times > 90 days comprised the delayed group. The potential factors associated with the delayed presentation were analyzed using cross-tabulation and multiple logistic regression.

RESULTS

There were 106 respondents to the questionnaire, with a mean age of 34.0 (SD: 11.2) years, and 73.6% (n = 78) were < 39 years old. A total of 35.8% (n = 38) visited the local government clinic first and only 28.3% (n = 30) came to the BestARi clinic directly. The reasons for presentation were a palpable breast lump on breast self-examination (75.5%, n = 80), mastalgia (15.1%, n = 16), nipple discharge (5.7%, n = 6), skin changes (0.9%, n = 1), and others (2.8%, n = 3). Among the respondents, 10.4% (n = 11) had alternative treatments prior to presentation to a hospital. The mean presentation time was 98.9 (SD: 323.7) days. Most of the participants (61.3%, n = 65) presented to us within 1 month. The delayed presentation group accounted for 19.8% (n = 21) of the respondents. The factor that was significantly associated with delayed presentation was the participants' perception of symptoms as not dangerous (adjusted OR 3.05, 95% CI 1.11, 8.38).

CONCLUSIONS

The percentage of delayed presentations among our patients was lower than the percentage reported in a previous study. Interpretation of a symptom as harmless by the respondent was the only factor significantly associated with delayed presentation.

The dilemma in management of desmoid tumour: A case report

Introduction

Desmoid tumours are rare benign tumours. The tumours may develop sporadically or they may be linked to familial adenomatous polyposis (FAP) in Gardner’s syndrome.

Aim

This article highlights a young lady with an intra-abdominal desmoid tumour that manifested as an acute abdomen and we discuss our management strategy.

Case study

A 24-year-old lady with a known FAP who had undergone a panproctocolectomy with an ileal pouch-anal anastomosis and total thyroidectomy, later was complicated with acute abdomen for symptomatic desmoid tumour. Computed tomography of the abdomen showed a large intraperitoneal heterogenous mass with small bowel displacement and was confirmed by magnetic resonance imaging. An exploratory laparotomy and en-bloc resection of the tumour with an end ileostomy were performed.

Results and discussion

Intra-abdominal desmoid tumours usually present as a painless slow-growing mass, however, in severe form, it can cause bowel ischemia, intestinal obstruction, or deterioration of function in the ileoanal anastomosis, among post total colectomy. Surgery is indicated upfront in specific clinical scenarios namely complications (occlusion, perforation, or bleeding) or major cosmetic issues.

Conclusions

Desmoid tumour, despite being benign, is challenging to manage due to its compressing nature. As a key point, the diagnosis of a desmoid tumour should be suspected and followed up closely in patients with a previous history of FAP in combination with extracolonic manifestation.

Down Regulated Expression Levels of miR-27b and miR-451a as a Potential Biomarker for Triple Negative Breast Cancer Patients Undergoing TAC Chemotherapy

BACKGROUND

Triple negative breast cancer (TNBC) is associated with poor prognosis, aggressive phenotype(s) of tumours, partial chemotherapy response, and lack of clinically proven therapies. MicroRNAs (miRNAs) can target and modulate key genes that are involved in TNBC chemotherapy. Deregulated miRNA expression is highly involved in anti-cancer drug resistance phenotype and thus, miRNAs tend to be promising candidates for prediction of chemotherapy response and recurrence.

AIM

This study aimed to investigate the expression levels of selected miRNAs (miR-21, miR-27b, miR-34a, miR-182, miR-200c and miR-451a) in cancerous and normal adjacent tissues of TNBC patients and to correlate with the clinicopathological data.

METHODS

Forty-one (41) FFPE tissue block of histopathologically confirmed TNBC patients was collected. Total RNA from the cancerous and adjacent non-cancerous tissues were isolated, transcribed, and pre-amplified. The relative expression level of miRNAs in tumour and normal adjacent tissues of TNBC patients was analysed using qRT-PCR.

RESULTS

Out of six miRNAs studied, the relative expression of miR-27b and miR-451a were found to be significantly lower in cancerous as compared to normal adjacent tissues of TNBC patients. In addition, a significant down regulation of miR-451a was also observed in infiltrating ductal carcinoma subtype, stages I and II, in both grade II and III, premenopausal and postmenopausal as well as in those with positive axillary lymph node metastases.

CONCLUSION

The results suggest the possible utilization of miR-27b and miR-451a expression levels as potential predictive risk markers for TNBC patients undergoing TAC chemotherapy.

An In vitro Study of Orthosiphon stamineus (Misai Kucing) Standardized Water Extract as a Chemolytic Agent in Urolithiasis

BACKGROUND

Orthosiphon stamineus was reported to have diuretic effects in experimental rats, and this leads to inhibition of kidney stones through the abundant levels of minerals and flavonoids in it. This study aimed to determine the in vitro effects of O. stamineus water extract as a potential chemolytic agent in urolithiasis.

MATERIALS AND METHODS

In this prospective experiment, a total of 15 stone samples collected from patients who underwent stone extraction were used in each concentration (4 mg/ml, 2 mg/ml, and 1 mg/ml) of the O. stamineus extract and control solution. The effects of pH change in the chemolysis of the stones were assessed using the O. stamineus extract 4 mg/ml under pH 7 and 8.

RESULTS

The percentage weight reduction of calcium oxalate stone was highest in the 4 mg/ml concentration. O. stamineus extract 4 mg/ml showed a better effect in terms of chemolytic action on calcium oxalate stone than the potassium citrate solution (70% vs. 41%). Regarding the calcium oxalate stone, the percentage weight reduction has shown about 70% in the pH 5, 48% in pH 7, and <10% in pH 8. The percentage weight reduction of uric acid stone was determined as 47%, 11%, and 14% for pH 5, 7, and 8, respectively. The percentage weight reduction of combination stone was 40%, 60%, and 80% in the pH 5, pH 7, and pH 8, respectively. Data analysis showed that the percentage weight reduction of combination stone was significantly different between acidic, neutral, and alkaline conditions (P = 0.027).

CONCLUSIONS

In this in vitro study, we are able to show that O. stamineus water extract do have some dissolving capability of urinary stones.