Long-term outcomes of patients undergoing emergency surgery for corrosive injury of the upper digestive tract

PURPOSE

Emergency surgery can save patients' lives in cases of severe caustic injury. However, the long-term outcomes are not well understood.

METHODS

Patients who underwent emergency organ resection for severe corrosive acid injury were included. Subsequently, digestive tract reconstruction was performed to fit patients. Long-term outcomes were analyzed.

RESULTS

Fifty patients underwent emergency digestive tract resection. The operative mortality rate was 6% (of 3/50). One of the 50 patients underwent successful immediate reconstruction. Of the 46 survivors with digestive tract discontinuity, 32 (70%) underwent subsequent reconstructive surgery, 10 (22%) died while awaiting reconstruction due to deterioration in their psychiatric and nutritional status, and 4 (9%) were unfit for reconstructive surgery. No operative mortality occurred during reconstruction. Among the 32 patients who underwent reconstruction, 30 (94%) achieved nutritional autonomy. Nutritional independence was achieved in 62% of the patients (31/50). At a median duration of 58 months, the median survival time of the 50 patients was 158 months. Patients who underwent reconstruction had a significantly better overall survival than those who did not (p < 0.0001).

CONCLUSIONS

Emergency surgery remains the standard treatment for corrosive ingestion of complicated digestive tract injuries. However, only 60% of survivors can undergo subsequent digestive reconstruction and achieve long-term nutritional autonomy and a survival outcome.

Comparative Analysis of Complications Following Distal Resections for Neuroendocrine Tumors and Adenocarcinoma: Unveiling the Differences

BACKGROUND Adenocarcinomas and pancreatic neuroendocrine tumors (pNETs) display some similarities and differences. The aim of this study was to compare preoperative data and morphological parameters, and to assess postoperative complications after resection. MATERIAL AND METHODS Data of 162 patients who underwent distal pancreatic resection for neuroendocrine or adenocarcinoma tumor were retrospectively analyzed. After applying inclusion and exclusion criteria, 131 patients were included in the study. The preoperative data analyzed included age, sex, and ASA-PS (American Society of Anesthesiologists Physical Status) grade. The diameter of the pancreatic duct and the texture of the pancreas were analyzed. Postoperative data included grading (G1-G3), the presence of PanIN (pancreatic intraepithelial neoplasia), infiltration of structures, and postoperative complications. RESULTS Patients with adenocarcinoma were statistically older and had a higher ASA-PS class than patients with NET (P<0.001). Statistically significantly more patients with adenocarcinoma had a histopathological diagnosis of G3 (p<0.001). In patients with adenocarcinomas infiltration of structures occurred more frequently. Pancreatic duct diameter ≥3 mm was more common in patients with adenocarcinoma (P=0.045). Clinically significant pancreatic fistulas were more frequent in patients with neuroendocrine tumors (P=0.044). CONCLUSIONS Adenocarcinomas in the pancreatic body and tail are more aggressive, they cause more frequent infiltration of structures, and more often metastasize to lymph nodes compared to NETs. NETs tend to have softer pancreatic texture and higher incidence of clinically significant pancreatic fistulas, but postoperative complications of Clavien-Dindo grade ≥III occur at a similar rate in both groups.

Presence of postlaryngectomy pseudodiverticulum on barium swallow does not affect early dietary progression

BACKGROUND

The presence of a pseudodiverticulum of the anterior pharyngeal wall, or prominent "pharyngeal bar," is a well-known phenomenon that occurs following total laryngectomy, which can be visualized by nasolaryngoscopy or videofluoroscopy. Among the different techniques of pharyngeal reconstruction, there is higher incidence following primary vertical multilayered closure. It has been postulated to cause dysphagia and lack of dietary progression despite a paucity of data. However, the direct impact of pseudodiverticulum is less clear and anecdotally its presence and severity does not necessarily correlate with dysphagia.

METHODS

A retrospective case series was performed of all consecutive patients who underwent total laryngectomy or laryngopharyngectomy between 2015 and 2022 at two tertiary head and neck institutions. All patients underwent routine videofluoroscopy postoperatively for swallow assessment. The presence of pseudodiverticulum on postoperative contrast swallow study was recorded to investigate the relationship with patient's ability to tolerate oral intake at 3 months discharge from the hospital.

RESULTS

Of 50 laryngectomized patients (mean age 63.8 ± 10.0, 86% male), the main closure techniques were primary vertical (n = 9, 18%), primary T-closure (n = 14, 28%), and flap reconstruction (n = 27, 54%). Pseudodiverticulum was identified in 19 cases (38%). 43 patients underwent primary surgery and 30 had adjuvant radiotherapy. The presence of pseudodiverticulum was significantly associated with vertical primary closure versus non-vertical (T-closure or flap reconstruction) techniques (χ2 (df 1) = 7.4, p = 0.007, OR = 5.7, 95% CI 1.3-24.7). Pseudodiverticulum was not associated with an increased inability to tolerate solid intake or full diet compared to patients without pseudodiverticulum. 26.3% of patients with pseudodiverticulum were on full diet compared to 25.8% of patients without. The vertical closure technique showed no difference in ability to maintain solid intake compared with non-vertical closure; however, no patients were on full diet. Only one patient in the pseudodiverticulum group required surgical management during the study period for retention.

CONCLUSION

The presence of a pseudodiverticulum does not appear to be significantly associated with a need for postoperative dietary modification. The authors postulate that postlaryngectomy dysphagia is multifactorial with sensorimotor aperistalsis of the pharynx and cricopharyngeal stenosis. While a pseudodiverticulum is a common phenomenon, patients did not require modification of diet at higher rates than those without, and they seldom require intervention.

Perioperative and extended outcomes of patients undergoing parastomal hernia repair following cystectomy and ileal conduit

PURPOSE

To report perioperative and long-term postoperative outcomes of cystectomy patients with ileal conduit (IC) urinary diversion undergoing parastomal hernia (PSH) repair.

METHOD

We reviewed patients who underwent cystectomy and IC diversion between 2003 and 2022 in our center. Baseline variables, including surgical approach of PSH repair and repair technique, were captured. Multivariable Cox regressionanalysis was performed to test for the associations between different variables and PSH recurrence.

RESULTS

Thirty-six patients with a median (IQR) age of 79 (73-82) years were included. The median time between cystectomy and PSH repair was 30 (14-49) months. Most PSH repairs (32/36, 89%) were performed electively, while 4 were due to small bowel obstruction. Hernia repairs were performed through open (n=25), robotic (10), and laparoscopic approaches (1). Surgical techniques included direct repair with mesh (20), direct repair without mesh (4), stoma relocation with mesh (5), and stomarelocation without mesh (7). The 90-day complication rate was 28%. In a median follow-up of 24 (7-47) months, 17 patients (47%) had a recurrence. The median time to recurrence was 9 (7-24) months. On multivariable analysis, 90-day complication following PSH repair was associated with an increased risk of recurrence.

CONCLUSIONS

In this report of one of the largest series of PSH repair in the Urology literature, 47% of patients had a recurrence following hernia repair with a median follow-up time of 2 years. There was no significant difference in recurrence rates when comparing repair technique or the use of open or minimally invasive approaches.

Superior mesenteric artery syndrome following spine surgery in idiopathic adolescent scoliosis: a systematic review

Superior mesenteric artery syndrome (SMAS) is a rare and unpredictable complication after correction spine surgery for adolescent idiopathic scoliosis (AIS). The management of this condition is poorly investigated, with controversial outcomes. This investigation systematically reviewed current evidence on pathogenesis, risk factors, management, and outcomes of SMAS following correction spine surgery for AIS. The present systematic review was conducted according to the 2020 PRISMA statement. All the included investigations reported SMAS presentation following scoliosis correction surgery in AIS. 29 articles with 61 eligible patients were included in this review. The mean age of the patients was 15.8 ± 7.2 years. The mean weight was 45.3 ± 8.0 kg, the mean height 159.6 ± 13.6 cm, and the mean BMI 16.5 ± 2.9 kg/m2. The mean duration of the treatment for SMAS was 21.6 ± 10.3 days. The mean interval between spine surgery and symptoms of SAMS was 69 days, with high between-studies variability (3 days to 4 years). Prompt identification of risk factors and an early diagnosis are necessary to manage SMAS and reduce the risk of complications. Additional investigations are required to establish risk factors and diagnostic criteria.Level of evidence Level IV, systematic review.

Monitoring Multi-Drug Resistant Klebsiella pneumoniae in Kitagata Hot Spring, Southwestern Uganda: A Public Health Implication

Background

The concerning frequency of K. pneumoniae in various recreational settings, is noteworthy, especially regarding multi-drug resistant (MDR) strains. This superbug is linked to the rapid spread of plasmids carrying these resistance genes. The objective of this study was to evaluate the spatiotemporal prevalence of MDR-K. pneumoniae in the Kitagata hot spring, Southwestern Uganda.

Methods

A laboratory-based descriptive longitudinal study was conducted between May and July 2023. During rainy and dry seasons, we collected eighty water samples in the morning and evening from the hot spring. The temperature at each point was measured prior to sample collection, and two samples were obtained at varying depths. 5 mL of each homogenized sample were pre-enriched in brain heart infusion broth, and subsequently in both blood and violet red bile agar. The Kirby-Bauer disk diffusion method was performed, followed by the detection of carbapenemase (CR) and extended-spectrum β-lactamase (ESBL) production. Polymerase chain reaction showed resistance genes viz. bla TEM, bla CTX-M and bla KPC. Data were analyzed using SPSS-20 to obtain chi-square tests and regression analysis.

Results

K. pneumoniae accounted for 30.0% of isolates obtained from Kitagata hot springs, with all isolates classified as multi-drug resistant. All isolates were resistant to ampicillin, rifampicin, ceftazidime, and azithromycin (79.2%). Additionally, 95.8% of isolates harbored bla TEM gene alone and both bla TEM and bla CTX genes, followed by bla KPC alone (33.3%), with 25% harboring all three resistance genes. During the dry season, K. pneumoniae had a higher prevalence (35.0%) compared to the wet season (25.0%). The prevalence of MDR-K. pneumoniae significantly increased over the course of the study. The presence of the three studied resistance genes in the isolates showed a positive correlation with the second phase of sample collection and the dry season but exhibited a negative correlation with temperature, except for isolates harboring either bla TEM alone or bla TEM+KPC+CTX genes.

Conclusion

Kitagata hot spring serves as a hotspot for continuous dissemination and acquisition of MDR-K. pneumoniae harboring resistance genes that encode for ESBL and CR production. The healthcare sector ought to implement an ongoing monitoring and surveillance system as well as robust antimicrobial resistance stewardship programs aimed at delivering health education to the community.

Postoperative Multimodal Analgesia Strategy for Enhanced Recovery After Surgery in Elderly Colorectal Cancer Patients

Enhanced Recovery After Surgery (ERAS) protocols have substantially proven their merit in diminishing recuperation durations and mitigating postoperative adverse events in geriatric populations undergoing colorectal cancer procedures. Despite this, the pivotal aspect of postoperative pain control has not garnered the commensurate attention it deserves. Typically, employing a multimodal analgesia regimen that weaves together nonsteroidal anti-inflammatory drugs, opioids, local anesthetics, and nerve blocks stands paramount in curtailing surgical complications and facilitating reduced convalescence within hospital confines. Nevertheless, this integrative pain strategy is not devoid of pitfalls; the specter of organ dysfunction looms over the geriatric cohort, rooted in the abuse of analgesics or the complex interplay of polypharmacy. Revolutionary research is delving into alternative delivery and release modalities, seeking to allay the inadvertent consequences of analgesia and thereby potentially elevating postoperative outcomes for the elderly post-colorectal cancer surgery populace. This review examines the dual aspects of multimodal analgesia regimens by comparing their established benefits with potential limitations and offers insight into the evolving strategies of drug administration and release.

Ultrasound imaging of bowel obstruction in infants and children

We review the etiologies of bowel obstruction in infants and children that can be identified on ultrasound (US) including perforated appendicitis, intussusception, foreign body ingestion, colonic volvulus, intra-abdominal mass lesions, internal hernia, and stricturing inflammatory bowel disease. US can potentially identify the cause of bowel obstruction in these age groups, without the need for additional cross-sectional imaging, and can aid in patient management including interventional and surgical planning. Hence, it is important to be familiar with the sonographic imaging findings of bowel obstruction in infants and children.

Comparing stapler and sutured mesh fixation techniques for laparoscopic TAPP repair: a study on chronic groin pain on 3-year follow-up

Trans-abdominal preperitoneal (TAPP) and totally extraperitoneal (TEP) repairs are the available surgeries for inguinal hernias, with both methods of laparoscopic repairs requiring mesh applications. This study analyzes the correlation between sutured versus stapler mesh fixation in a laparoscopic TAPP for unilateral groin hernia regarding chronic pain during 3-year follow-up. A total of 130 patients with laparoscopic hernia undergoing TAPP repair were randomized into 2 groups based on their fixation technique-one with sutures and the other with stapler. Postoperative complications and chronic groin pain were noted for each technique. Equal number of participants was present in the stapler and suture groups, with the majority having an ASA score of one. The mean age was 42.50 ± 13.86 years, and the body mass index (BMI) was 27.47 ± 5.88. The stapler group presented a shorter mean operative time than the suture group. However, the stapler group had a significantly higher mean VAS score than the suture group. Most participants in the suture group (89.2%) had LOS for 1 day, while a 2-day LOS was significantly higher in the stapler group (12.3%) than in the suture group (9.2%). No patient reported mesh erosion, conversion, recurrence, testicular atrophy, and mesh infection. Early postoperative pain was more in stapler group along with long hospital stay, but both were non-significant. Chronic postoperative pain results and recurrence incidences over 3-year follow-up were also similar. Re-admission rates were minimal, no significant complications occurred.

Colorectal adenocarcinoma of the interposed colon after esophagectomy in infancy: a case report

Colorectal carcinomas are a rare but possible complication in an interposed colonic segment used for reconstruction after esophagectomy. We report the case of a patient who underwent colonic interposition surgery in childhood due to esophageal atresia and was diagnosed with colorectal adenocarcinoma of the interposed colon ~57 years later. The patient underwent gastric pull-up after thoraco-abdominal resection of the colonic interposition en bloc with the adjacent remaining esophagus.

Managing the Open Abdomen: Selecting an Appropriate Treatment Strategy

Significance: The laparotomy is a common surgical procedure with a wide range of indications. Ideally, once the goals of surgery were achieved, the incision edges could then be approximated and the abdomen primarily closed. However, in some circumstances, it may be impossible to achieve primary closure, and instead the abdomen is intentionally left open. This review discusses the indications and objectives for the open abdomen (OA), summarizes the most common techniques for temporary abdominal closure, and illustrates treatment algorithms grounded in the current recommendations from specialty experts. Recent Advances: Still a relatively young technique, multiple strategies, and technologies have emerged to manage the OA. So too have the recommendations evolved, based on updated classifications that take wound characteristics into account. Recent studies have also brought greater clarity on recommendations for managing infection and malnutrition to support improved clinical outcomes. Critical Issues: The status of the OA can change rapidly depending on the patient's condition, the wound quality, and many other factors. Thus, there is a significant need for comprehensive treatment strategies that can be adapted to these developing circumstances. Future Directions: Treatment recommendations should be continuously updated as new technologies are introduced and old techniques fall out of use.

Single Stage Deltopectoral Flap for Reconstruction of the Soft Tissue Defects of Neck

Conventional deltopectoral flap is a two-staged procedure that needs a prolonged hospital stay, adding to treatment cost as well as patient discomfort and may delay adjuvant treatment. A modified deltopectoral flap, as a single-stage procedure, can overcome these shortcomings. This is a retrospective chart review of prospectively collected clinical data from a tertiary care hospital. The patients who had undergone a deltopectoral flap for the reconstruction of the neck defects at our hospital between July 2017 and July 2021 were considered for analysis. We present our results with a single-stage deltopectoral flap that was used to reconstruct medium-to-large-size defects of the neck, along with clinical illustrations as appropriate. This study was approved by the Institutional Ethical Committee (number: IEC 702-2021). A total of six patients received single-stage deltopectoral flap during the study period, of which five were for oncosurgical defects, and one had necrotizing fasciitis. The healing and overall outcome were optimal in all cases, with no flap loss. In two of these cases, the donor site was closed primarily, and in the rest, a split-thickness skin graft was used. Our results reiterate the tremendous practical value of a single-stage deltopectoral flap in the primary reconstruction of medium- to large-sized surgical defects of the neck, even in this era of free tissue transfer.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-024-04641-8.

Early versus late closure of protective loop ileostomy: functional significant results in a preliminary analysis

BACKGROUND

Protective loop ileostomy (PLI), commonly performed in rectal cancer surgery, is one of the most reliable methods to reduce the risk of sepsis associated with anastomotic complications. The correct timing of PLI closure is not well defined. Recently, most surgeons proposed to close early the PLI. The aim of this study was to evaluate the impact of the timing of stoma closure on postoperative outcomes.

METHODS

We analyzed prospectively data of patients who received PLI anterior resection for rectal cancer between January 2020 to June 2022. Patients were divided into 2 groups according to the timing of stoma closure, until four weeks (EC group) and more than four weeks (LC group). Outpatient clinic follow-up, perioperative data, postoperative complications and evidence of anterior resection syndrome with the Low-Anterior Resection Score (LARS) score were recorded.

RESULTS

In the EC group 24 patients were included while 27 patients were considered for LC group. There were no differences between the groups with respect to all parameters, except for recourse to adjuvant therapy, higher for LC group. Perioperative analyzed characteristics were similar among groups. There was no statistically significant difference between the EC group and the LC group for complication rate. LARS score was higher in the LC group for score >20 and >30.

CONCLUSIONS

Timing of PLI closure was not a significant independent predictor of post-closure complications rate. LARS incidence was significantly related to longer time of closure, with probably late recovery of motility function, but this should be confirmed by randomized studies.

New Trauma Score versus Kampala Trauma Score II in predicting mortality following road traffic crash: a prospective multi-center cohort study

INTRODUCTION

Mortality due to injuries disproportionately impact low income countries. Knowledge of who is at risk of poor outcomes is critical to guide resource allocation and prioritization of severely injured. Kampala Trauma Score (KTS), developed in 1996 and last modified in 2002 as KTS II, is still widely being used to predict injury outcomes in resource-limited settings with no further revisions in the past two decades, despite ongoing criticism of some of its parameters. The New Trauma Score (NTS), a recent development in 2017, has shown potential in mortality prediction, but a dearth of evidence exist regarding its performance in the African population.

OBJECTIVES

To compare NTS to the modified Kampala Trauma Score (KTS II) in the prediction of 30-day mortality, and injury severity amongst patients sustaining road traffic crashes in Ugandan low-resource settings.

METHODS

Multi-center prospective cohort study of patients aged 15 years and above. Of the 194 participants, 85.1% were males with a mean age of 31.7 years. NTS and KTS II were determined for each participant within 30-minutes of admission and followed-up for 30 days to determine their injury outcomes. The sensitivity, specificity, and area under receiver operating characteristics curve (AUC) for predicting mortality were compared between the two trauma scores using SPSS version 22. Ethical clearance: Research and Ethics Committee of Kampala International University Western Campus (Ref No: KIU-2022-125).

RESULTS

The injury severity classifications based on NTS vs. KTS II were mild (55.7% vs. 25.8%), moderate (29.9% vs. 30.4%), and severe (14.4% vs. 43.8%). The mortality rates for each injury severity category based on NTS vs. KTS II were mild (0.9% v 0%), moderate (20.7% vs. 5.1%), and severe (50% vs. 28.2%). The AUC was 0.87 for NTS (95% CI 0.808-0.931) vs. 0.86 (95% CI 0.794-0.919) for KTS II respectively. The sensitivity of NTS vs. KTS II in predicting mortality was 92.6% (95% CI: 88.9-96.3) vs. 70.4% (95% CI: 63.0-77.8) while the specificity was 70.7% (95% CI: 64.2-77.2) vs. 78.4% (95% CI: 72.1-84.7) at cut off points of 17 for NTS and 6 for KTS II respectively.

CONCLUSIONS

NTS was more sensitive but its specificity for purposes of 30-day mortality prediction was lower compared to KTS II. Thus, in low-resourced trauma environment where time constraints and pulse oximeters are of concern, KTS II remains superior to NTS.

A systematic review and meta-analysis of thoracic epidural analgesia versus other analgesic techniques in patients post-oesophagectomy

BACKGROUND

Oesophageal cancer surgery represents a high perioperative risk of complications to patients, such as postoperative pulmonary complications (PPCs). Postoperative analgesia may influence these risks, but the most favourable analgesic technique is debated. This review aims to provide an updated evaluation of whether thoracic epidural analgesia (TEA) has benefits compared to other analgesic techniques in patients undergoing oesophagectomy surgery. Our hypothesis is that TEA reduces pain scores and PPCs compared to intravenous opioid analgesia in patients post-oesophagectomy.

METHODS

Electronic databases PubMed, Excerpta Medica Database (EMBASE) and Cochrane Central Register of Controlled Trials (CENTRAL) were searched for randomised trials of analgesic interventions in patients undergoing oesophagectomy surgery. Only trials including thoracic epidural analgesia compared with other analgesic techniques were included. The primary outcome was a composite of respiratory infection, atelectasis and respiratory failure (PPCs), with pain scores at rest and on movement as secondary outcomes. Data was pooled using random effect models and reported as relative risks (RR) or mean differences (MD) with 95% confidence intervals (CIs).

RESULTS

Data from a total of 741 patients in 10 randomised controlled trials (RCTs) from 1993 to 2023 were included. Nine trials were open surgery, and one trial was laparoscopic. Relative to intravenous opioids, TEA significantly reduced a composite of PPCs (risk ratio (RR) 3.88; 95% confidence interval (CI) 1.98-7.61; n = 222; 3 RCTs) and pain scores (0-100-mm visual analogue scale or VAS) at rest at 24 h (MD 9.02; 95% CI 5.88-12.17; n = 685; 10 RCTs) and 48 h (MD 8.64; 95% CI 5.91-11.37; n = 685; 10 RCTs) and pain scores on movement at 24 h (MD 14.96; 95% CI 5.46-24.46; n = 275; 4 RCTs) and 48 h (MD 16.60; 95% CI 8.72-24.47; n = 275; 4 RCTs).

CONCLUSIONS

Recent trials of analgesic technique in oesophagectomy surgery are restricted by small sample size and variation of outcome measurement. Despite these limitations, current evidence indicates that thoracic epidural analgesia reduces the risk of PPCs and severe pain, compared to intravenous opioids in patients following oesophageal cancer surgery. Future research should include minimally invasive surgery, non-epidural regional techniques and record morbidity, using core outcome measures with standardised endpoints.

TRIAL REGISTRATION

Prospectively registered on PROSPERO (CRD42023484720).

Impact of microscopic deposits of yolk sac tumor on recurrence of mature sacrococcygeal teratoma

INTRODUCTION

Sacrococcygeal teratomas (SCT) with malignant histology frequently recur and are treated aggressively, but risk factors and surveillance protocols are less established for mature tumors. In particular, prior studies have not investigated whether microscopic deposits of yolk sac tumor (YST) in otherwise mature teratomas lead to higher recurrence rates.

METHODS

We reviewed patients with mature SCTs resected at our institution from 2011 to 2021 and analyzed tumor characteristics, treatment, and outcomes.

RESULTS

We identified 56 patients with mature SCT, of which 9 (16%) demonstrated microscopic YST. Following surgery, 7/56 (13%) patients developed local recurrence at a mean of 1.2 ± 0.7 years, while no patients developed metastases. Recurrence was more likely in patients with microscopic YST [5/9 (56%) vs. 2/47 (4%), p = 0.021] and positive margins [6/24 (35%) vs. 1/32 (3.1%), p = 0.030]. A solid tumor component tended to increase recurrence risk as well [6/29 (21%) vs. 1/27 (4%), p = 0.053]. Five patients demonstrated malignant recurrence and were all detected by a rising alpha-fetoprotein (AFP), while two patients demonstrated recurrence of mature teratoma and were detected on surveillance magnetic resonance imaging (MRI).

CONCLUSIONS

Microscopic foci of YST may increase recurrence risk for patients with mature SCT. Such patients might benefit from closer postoperative surveillance with serial AFP measurements and MRI.

Association of albumin, neutrophil-lymphocyte ratio and lymphocytes with clinical stage in cervical cancer patients

OBJECTIVE

To determinate the association between of albumin, neutrophil-lymphocyte ratio and lymphocytes (NLR) with clinical stage in cervical cancers.

METHODS

Design a retrospective cross-sectional study of consecutive subjects diagnosed with cervical cancer for the first time. The Bethesda system was used for histological diagnosis and the subjects were stratified with the FIGO system, considering stages IA to IIB as localized; while, IIIA and IVB as advanced stages. Albumin, NLR and lymphocytes were evaluated as inflammatory biomarkers and the cut-off points generated by the ROC curves were albumin < 3 mg/dL, NLR ≥ 2.0 and lymphocytes < 1.2 103/ul. The association was calculated by Odds Ratios (OR) with 95% confidence intervals.

RESULTS

A total of 152 patients were analyzed, with mean age of 49.3 ± 14.0 years. Epidermoid cancer was the most frequent in 70.6% and 51.3% were classified as advanced clinical stages. A bivariate analysis showed significant relationships between advanced clinical stages and albumin < 3 mg/dL with OR 5.72 (CI95% 2.62-12.4; p < 0.001); for NLR ≥ 2.0 an OR 2.53 (CI95% 1.34-4.89; p = 0.005) and for lymphocytes < 1.2 103/ul of OR 3.39 (CI95% = 1.73-6.65; p < 0.001).

CONCLUSIONS

Albumin levels < 3 mg/dL, NLR ≥ 2.0 and lymphocytes < 1.2 103/ul, were associated with advanced stages in subjects with cervical cancer.

Usefulness of the one-step technique in functional end-to-end anastomosis for colonic surgery: results of a prospective multicentre cohort study from the Japanese KYCC group

BACKGROUND

Although functional end-to-end anastomosis (FEEA) using a stapler in the colorectal field has been recognised worldwide, the technique varies by surgeon, and the safety of anastomosis using different techniques is unknown.

METHODS

This multicentre prospective observational cohort study was conducted by the KYCC Study Group in Yokohama, Japan, and included patients who underwent colonic resection at seven centres between April 2020 and March 2022. This study compared the incidence of surgery-related abdominal complications (SAC: anastomotic leakage [AL], anastomotic bleeding, intra-abdominal abscess, enteritis, ileus, surgical site infection, and other abdominal complications) between two different methods of FEEA (one-step [OS] method: simultaneous anastomosis and bowel resection; two-step [TS] method: anastomosis after bowel resection). Complications of Clavien-Dindo classification grade 2 or higher were assessed.

RESULTS

Among 293 eligible cases, the OS and TS methods were used in 194 (66.2%) and 99 (33.8%) patients, respectively. The baseline characteristics were similar between the groups. The OS method used fewer staplers (three vs. four staplers, p < 0.00001). There were no significant differences in SAC rate between the OS (19.1%) and the TS (16.2%) groups (p = 0.44). The OS group had four cases (2.1%) of AL (two patients; grade 3, two patients; grade 2) while the TS group had one case (1.0%) of grade 2 AL (p = 0.67). Multivariate logistic regression analysis showed that male sex (odds ratio [OR] 3.95; p < 0.00001), an open surgical approach (OR 2.36; p = 0.03), and longer operative duration (OR,2.79; p = 0.002) were independent predictors of complications, whereas the OS method was not an independent predictor (OR 1.17; p = 0.66).

CONCLUSIONS

The OS and the TS technique for stapled colonic anastomosis in a FEEA had a similar postoperative complication rate.

TRIAL REGISTRATION NUMBER

UMIN000039902 (registration date 23 March 2020).

Construction and validation of a nomogram for predicting survival in elderly patients with severe acute pancreatitis: a retrospective study from a tertiary center

PURPOSE

There is a lack of adequate models specifically designed for elderly patients with severe acute pancreatitis (SAP) to predict the risk of death. This study aimed to develop a nomogram for predicting the overall survival of SAP in elderly patients.

METHODS

Elderly patients diagnosed with SAP between January 1, 2017 and December 31, 2022 were included in the study. Risk factors were identified through least absolute shrinkage and selection operator regression analysis. Subsequently, a novel nomogram model was developed using multivariable logistic regression analysis. The predictive performance of the nomogram was evaluated using metrics such as the receiver operating characteristic curve, calibration curve, and decision curve analysis (DCA).

RESULTS

A total of 326 patients were included in the analysis, with 260 in the survival group and 66 in the deceased group. Multivariate logistic regression indicated that age, respiratory rate, arterial pH, total bilirubin, and calcium were independent prognostic factors for the survival of SAP patients. The nomogram demonstrated a performance comparable to sequential organ failure assessment (P = 0.065). Additionally, the calibration curve showed satisfactory predictive accuracy, and the DCA highlighted the clinical application value of the nomogram.

CONCLUSION

We have identified key demographic and laboratory parameters that are associated with the survival of elderly patients with SAP. These parameters have been utilized to create a precise and user-friendly nomogram, which could be an effective and valuable clinical tool for clinicians.

Hydatid cyst in the gluteal muscle-an unusual location

Echinococcus sp. is an intestinal parasite of canids and felids that can infect humans after contaminated ingestion. Through the portal circulation, the eggs can metastasize to the liver, lungs and, more infrequently, other organs. We present a hydatid cyst located on the gluteus muscles, a very unusual location.

Collaborative Human-Computer Vision Operative Video Analysis Algorithm for Analyzing Surgical Fluency and Surgical Interruptions in Endonasal Endoscopic Pituitary Surgery: Cohort Study

BACKGROUND

The endonasal endoscopic approach (EEA) is effective for pituitary adenoma resection. However, manual review of operative videos is time-consuming. The application of a computer vision (CV) algorithm could potentially reduce the time required for operative video review and facilitate the training of surgeons to overcome the learning curve of EEA.

OBJECTIVE

This study aimed to evaluate the performance of a CV-based video analysis system, based on OpenCV algorithm, to detect surgical interruptions and analyze surgical fluency in EEA. The accuracy of the CV-based video analysis was investigated, and the time required for operative video review using CV-based analysis was compared to that of manual review.

METHODS

The dominant color of each frame in the EEA video was determined using OpenCV. We developed an algorithm to identify events of surgical interruption if the alterations in the dominant color pixels reached certain thresholds. The thresholds were determined by training the current algorithm using EEA videos. The accuracy of the CV analysis was determined by manual review, and the time spent was reported.

RESULTS

A total of 46 EEA operative videos were analyzed, with 93.6%, 95.1%, and 93.3% accuracies in the training, test 1, and test 2 data sets, respectively. Compared with manual review, CV-based analysis reduced the time required for operative video review by 86% (manual review: 166.8 and CV analysis: 22.6 minutes; P<.001). The application of a human-computer collaborative strategy increased the overall accuracy to 98.5%, with a 74% reduction in the review time (manual review: 166.8 and human-CV collaboration: 43.4 minutes; P<.001). Analysis of the different surgical phases showed that the sellar phase had the lowest frequency (nasal phase: 14.9, sphenoidal phase: 15.9, and sellar phase: 4.9 interruptions/10 minutes; P<.001) and duration (nasal phase: 67.4, sphenoidal phase: 77.9, and sellar phase: 31.1 seconds/10 minutes; P<.001) of surgical interruptions. A comparison of the early and late EEA videos showed that increased surgical experience was associated with a decreased number (early: 4.9 and late: 2.9 interruptions/10 minutes; P=.03) and duration (early: 41.1 and late: 19.8 seconds/10 minutes; P=.02) of surgical interruptions during the sellar phase.

CONCLUSIONS

CV-based analysis had a 93% to 98% accuracy in detecting the number, frequency, and duration of surgical interruptions occurring during EEA. Moreover, CV-based analysis reduced the time required to analyze the surgical fluency in EEA videos compared to manual review. The application of CV can facilitate the training of surgeons to overcome the learning curve of endoscopic skull base surgery.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06156020; https://clinicaltrials.gov/study/NCT06156020.

Non-mesh inguinal hernia repair: Review

Hernioplasty stands as one of the most common abdominal surgical interventions. The "gold standard" treatment for inguinal hernias remains Lichtenstein mesh hernioplasty. Nonetheless, clinical practice continues to grapple with issues concerning complications such as recurrence, chronic postoperative pain, and infection. The myriad types of surgery lead to conflicting opinions regarding the superiority and drawbacks of inguinal canal plastic surgery methods. This article presents current data on the surgical treatment of non-mesh inguinal hernias, delineating the most prevalent techniques while exploring their respective advantages and disadvantages. Additionally, the researchers' experiences are analyzed in detail.

The Predictive Value of the Verbal Glasgow Coma Scale in Traumatic Brain Injury: A Systematic Review

BACKGROUND

Traumatic brain injury (TBI) is a major global health concern, imposing significant burdens on individuals and healthcare systems. The Glasgow Coma Scale (GCS), a widely utilized instrument for evaluating neurological status, includes 3 variables: motor, verbal, and eye opening. The GCS plays a crucial role in TBI severity stratification. While extensive research has explored the predictive capabilities of the overall GCS score and its motor component, the Verbal Glasgow Coma Scale (V-GCS) has garnered less attention.

OBJECTIVE

To examine the predictive accuracy of the V-GCS in assessing outcomes in patients with TBI, with a particular focus on functional outcome and mortality. In addition, we intend to compare its predictive performance with other components of the GCS.

METHODS

A systematic review, based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, was conducted utilizing the PubMed, Scopus, and Web of Science databases. Inclusion criteria encompassed 10 clinical studies involving patients with TBI, wherein the level of consciousness was assessed using the verbal GCS score. Predominant statistical measures employed were odds ratios (ORs) and area under the curve (AUC).

RESULTS

Recorded findings consistently underscore that lower V-GCS scores are associated with adverse functional outcomes and mortality in patients with TBI. Despite the predictive accuracy of the V-GCS, the Motor Glasgow Coma Scale (M-GCS) emerges as a superior predictor.

CONCLUSION

In the context of TBI outcome prediction, the V-GCS demonstrates its efficacy as a prognostic tool. However, the M-GCS exhibits superior performance compared with the V-GCS. These insights underscore the multifaceted nature of TBI assessment and emphasize the necessity of considering distinct components of the Glasgow Coma Scale for comprehensive evaluation. Further research is warranted to refine and improve the application of these predictive measures in clinical practice.

Endoscopic application of magnetic compression anastomosis: a review

Magnetic compression anastomosis (MCA) is a new method that provides sutureless passage construction for tubular organs. Due to the high recurrence rate of conventional endoscopic treatment and the high morbidity and mortality of surgical procedures, the MCA technique shows promise. The aim of this review is to comprehensively examine the literature related to the use of MCA in different gastrointestinal diseases over the past few years, categorizing them according to the anastomotic site and describing in detail the various methods of magnet delivery and the clinical outcomes of MCA. MCA is an innovative technique, and its use represents an advancement in the field of minimally invasive interventions. Comparison studies have shown that the anastomosis formed by MCA is comparable to or better than surgical sutures in terms of general appearance and histology. Although most of the current research has involved animal studies or studies with small populations, the safety and feasibility of MCA have been preliminarily demonstrated. Large prospective studies involving populations are still needed to guarantee the security of MCA. For technologies that have been initially used in clinical settings, effective measures should also be implemented to identify, even prevent, complications. Furthermore, specific commercial magnets must be created and optimized in this emerging area.

Which components of behavioral weight management programs are essential for weight loss in people living with obesity? A rapid review of systematic reviews

The optimal treatment and organization of care for people with obesity is one of the greatest challenges facing today's health services. While surgery and pharmacotherapy offer effective treatment options for some people with obesity, behavioral interventions are important to support long-term behavioral change. However, little is known about the most effective components of behavioral interventions, and this is especially the case for people with complex or severe obesity (i.e. body mass index [BMI] > 35 kg/m2). Accordingly, the current rapid review aimed to identify which behavior change techniques (BCTs) are effective for weight loss in adults with (severe) obesity. A secondary aim was to review the effects of BCTs on dietary behaviors and physical activity, and psychological outcomes, recognizing that behavioral interventions commonly target these. A search of Scopus, Ovid Medline, and Web of Science resulted in 1227 results, with 22 reviews eligible for inclusion. The most commonly reported BCTs were self-monitoring and goal setting, but these had variable effects on weight in adults with obesity. Combining these BCTs with other self-regulatory techniques led to increased weight loss. Further, for adults with severe obesity, so-called 'nudge' techniques and self-regulatory techniques were associated with greater weight loss. Three reviews also found that while self-monitoring increased physical activity, behavioral commitments increased changes to dietary behaviors. BCTs were not associated with psychological well-being. The review confirms that behavioral interventions have an impact in weight management, including for individuals with more complex or severe obesity, but highlights the need for further investigation of their use within clinical settings.

Analgesia efficacy of erector spinae plane block in laparoscopic abdominal surgeries: a systemic review and meta-analysis

BACKGROUND

Multimodal analgesia is now widely practised to minimise postoperative opioid consumption while optimising pain control. The aim of this meta-analysis was to assess the analgesic efficacy of erector spinae plane block (ESPB) in patients undergoing laparoscopic abdominal surgeries. This will be determined by perioperative opioid consumption, subjective pain scores, and incidences of postoperative nausea and vomiting.

METHODS

The authors systemically searched electronic databases for randomised controlled trials (RCTs) published up to February 2023 comparing ESPB with other adjuvant analgesic techniques in laparoscopic abdominal surgeries. Nine randomised controlled trials encompassing 666 subjects were included in our study.

RESULTS

ESPB was shown to reduce postoperative opioid consumption [mean difference (MD) of -5.95 mg (95% CI: -8.86 to -3.04; P <0.0001); I2 =89%], intraoperative opioid consumption MD of -102.4 mcg (95% CI: -145.58 to -59.21; P <0.00001); I2 =39%, and incidence of nausea [RR 0.38 (95% CI: 0.25-0.60; P <0.0001); I2 =0%] and vomiting [RR 0.32 (95% CI: 0.17-0.63; P =0.0009); I2 =0%] in laparoscopic abdominal surgeries. Subgroup analysis on laparoscopic colorectal surgeries further showed reduction in postoperative pain scores MD of -0.68 (95% CI: -0.94 to -0.41); P <0.00001; I2 =0%].

CONCLUSIONS

This study concludes that ESPB is a valuable technique with proven efficacy to potentially promote faster postoperative recovery through optimising pain control while minimising opioid requirements.

A Four-Arm Randomized Clinical Trial of Topical Pain Control for Sentinel Node Radiotracer Injections in Patients with Breast Cancer

BACKGROUND

Radioactive tracer injections for breast cancer sentinel lymph node mapping can be painful. In this randomized trial, we compared four approaches to topical pain control for radiotracer injections.

METHODS

Breast cancer patients were randomized (9 April 2021-8 May 2022) to receive the institutional standard of ice prior to injection (n = 44), or one of three treatments: ice plus a vibrating distraction device (Buzzy®; n = 39), 4% lidocaine patch (n = 44), or 4% lidocaine patch plus ice plus Buzzy® (n = 40). Patients completed the Wong-Baker FACES® pain score (primary outcome) and a satisfaction with pain control received scale (secondary). Nuclear medicine technologists (n = 8) rated perceived pain control and ease of administration for each patient. At study conclusion, technologists rank-ordered treatments. Data were analyzed as intention-to-treat. Wilcoxon rank-sum tests were used to compare pain scores of control versus pooled treatment arms (primary) and then control to each treatment arm individually (secondary).

RESULTS

There were no differences in pain scores between the control and treatment groups, both pooled and individually. Eighty-five percent of patients were 'satisfied/very satisfied' with treatment received, with no differences between groups. No differences in providers' perceptions of pain were observed, although providers perceived treatments involving Buzzy© more difficult to administer (p < 0.001). Providers rated lidocaine patch as the easiest, with ice being second.

CONCLUSION

In this randomized trial, no differences in patient-reported pain or satisfaction with treatment was observed between ice and other topical treatments. Providers found treatments using Buzzy® more difficult to administer. Given patient satisfaction and ease of administration, ice is a reasonable standard.

Palliative Care for Pediatric Urology

Palliative care in the field of urology has largely been limited to adult oncologic conditions. Although there is a plethora of established literature suggesting the advantageous impact of palliative care, there is limited integration of palliative care in adult urology. This underutilization is further exacerbated in pediatric urology, and palliative care in pediatric urology remains an underexplored area despite the prevalence of several life-limiting conditions in this patient population. This paper highlights the potential need for palliative care intervention in a variety of urologic conditions in the pediatric population, including congenital lower urinary tract obstruction, neurogenic bladder dysfunction, exstrophy-epispadias complex, and congenital bilateral renal agenesis. Each condition poses unique challenges that can be addressed with the inclusion of a palliative care team, including decision-making spanning prenatal-neonatal-pediatric periods, acute and chronic symptom management, family relations, body image issues, risk of recurrent hospitalizations and surgeries, and potentially fatal complications. Alongside standard urologic interventions, palliative care can serve as an additional means of addressing physical and psychosocial symptoms experienced by pediatric urology patients to enhance the quality of life of patients and their families.

Remission of type 2 diabetes: position statement of the Italian society of diabetes (SID)

The primary cause of the pandemic scale of type 2 diabetes (T2D) is the excessive and/or abnormal accumulation of adiposity resulting from a chronic positive energy balance. Any form of weight loss dramatically affects the natural history of T2D, favoring prevention, treatment, and even remission in the case of significant weight loss. However, weight regain, which is often accompanied by the recurrence or worsening of obesity complications such as T2D, is an inevitable biological phenomenon that is an integral part of the pathophysiology of obesity. This can occur not only after weight loss, but also during obesity treatment if it is not effective enough to counteract the physiological responses aimed at restoring adiposity to its pre-weight-loss equilibrium state. Over the past few years, many controlled and randomized studies have suggested a superior efficacy of bariatric surgery compared to conventional therapy in terms of weight loss, glycemic control, and rates of T2D remission. Recently, the therapeutic armamentarium in the field of diabetology has been enriched with new antihyperglycemic drugs with considerable efficacy in reducing body weight, which could play a pathogenetic role in the remission of T2D, not through the classical incretin effect, but by improving adipose tissue functions. All these concepts are discussed in this position statement, which aims to deepen the pathogenetic links between obesity and T2D, shift the paradigm from a "simple" interaction between insulin resistance and insulin deficiency, and evaluate the efficacy of different therapeutic interventions to improve T2D management and induce diabetes remission whenever still possible.

Unusual causes of Small bowel obstruction: a review of the literature and revisited cross-sectional imaging checklist

Intestinal obstruction is a common surgical emergency with high morbidity and mortality. Patients presenting with features of small bowel obstruction need urgent evaluation to avoid complications such as bowel gangrene, perforation, or peritonitis. Imaging is necessary in most cases of suspected bowel obstruction, to take an appropriate decision, for apt patient management. Among the common causes of small bowel obstruction, adhesions, external herniae, malignancies, and Crohn's disease top the chart. Imaging helps in determining the presence of obstruction, the severity of obstruction, transition point, cause of obstruction, and associated complications such as strangulation, bowel gangrene, and peritonitis. This review is based on the cases with unusual causes of bowel obstruction encountered during our routine practice and also on the extensive literature search through the standard textbooks and electronic databases. Through this review we want our readers to have sound knowledge of the imaging characteristics of the uncommon yet important causes of bowel obstruction. We have also revisited and structured a checklist to simplify the approach while reporting a suspected case of small bowel obstruction. Imaging plays a key role in the diagnosis of small bowel obstruction and in determining the cause and associated complications. Apart from the common causes of small bowel obstruction, we should also be aware of the uncommon causes of small bowel obstruction and their imaging characteristics to make an accurate diagnosis and for apt patient management.

Manufacturing and validation of small-diameter vascular grafts: A mini review

The field of small-diameter vascular grafts remains a challenge for biomaterials scientists. While decades of research have brought us much closer to developing biomimetic materials for regenerating tissues and organs, the physiological challenges involved in manufacturing small conduits that can transport blood while not inducing an immune response or promoting blood clots continue to limit progress in this area. In this short review, we present some of the most recent methods and advancements made by researchers working in the field of small-diameter vascular grafts. We also discuss some of the most critical aspects biomaterials scientists should consider when developing lab-made small-diameter vascular grafts.

Inflammation accelerating intestinal fibrosis: from mechanism to clinic

Intestinal fibrosis is a prevalent complication of IBD that that can frequently be triggered by prolonged inflammation. Fibrosis in the gut can cause a number of issues, which continue as an ongoing challenge to healthcare systems worldwide. The primary causes of intestinal fibrosis are soluble molecules, G protein-coupled receptors, epithelial-to-mesenchymal or endothelial-to-mesenchymal transition, and the gut microbiota. Fresh perspectives coming from in vivo and in vitro experimental models demonstrate that fibrogenic pathways might be different, at least to some extent, independent of the ones that influence inflammation. Understanding the distinctive procedures of intestinal fibrogenesis should provide a realistic foundation for targeting and blocking specific fibrogenic pathways, estimating the risk of fibrotic consequences, detecting early fibrotic alterations, and eventually allowing therapy development. Here, we first summarize the inflammatory and non-inflammatory components of fibrosis, and then we elaborate on the underlying mechanism associated with multiple cytokines in fibrosis, providing the framework for future clinical practice. Following that, we discuss the relationship between modernization and disease, as well as the shortcomings of current studies. We outline fibrosis diagnosis and therapy, as well as our recommendations for the future treatment of intestinal fibrosis. We anticipate that the global review will provides a wealth of fresh knowledge and suggestions for future fibrosis clinical practice.

Efficiency of hospitals in COVID-19 era: a case study of an affected country

BACKGROUND

The COVID-19 pandemic has affected all aspects of human life and society and has damaged the global economy. Health systems and hospitals were not exempted from this situation. The performance of hospitals during the COVID-19 pandemic was affected by policies related to the pandemic and other factors. This study aimed to investigate hospital performance indicators such as admissions and revenue.

METHODS

The medical records of patients with selected orthopedic and general surgical diseases were studied in two government hospitals in the capital city of Urmia in the second quarter of 2019, with the same period in 2020. Data were extracted based on the number of medical records, including length of stay, hospitalization type, sex, age, insurance, number of deaths, and readmissions from the medical records department. Payment amounts were collected from the revenue department and Hospital Information System. Two performance indicators, two result indicators, and two control indicators were used. Mean disease-specific revenue, total revenue, length of stay, and bed occupancy rate were calculated for both periods. Data were analyzed using SPSS (version 16) and the Mann-Whitney statistical test.

RESULTS

2140 cases were studied in the two disease groups. An increase was observed in the number of hospitalizations and average length of stay during the pandemic. The mean disease-specific revenue in the quarter of 2020 was higher than in 2019. However, total revenue decreased, and the difference in the mean of total revenue was significant for the two years (P = 0.00) in teaching center. The number of readmissions remained unchanged throughout in the pandemic. The number of deaths due to general surgery diseases in 2020 compared to the same period in 2019 was associated with a relative increase.

CONCLUSIONS

The COVID-19 pandemic increased the slope of health care costs. The analysis of the studied variables as performance, result, and control indicators showed that hospitalization rate, bed occupancy rate, and total revenue followed a similar and decreasing pattern in the selected hospitals during the COVID-19 pandemic. Hospitals should adopt appropriate strategies so that, in conditions identical to the COVID-19 pandemic, their performance is accompanied by proper management of resources, efficiency, and minimal reduction in revenue.

Cholecystitis-related cystic artery pseudoaneurysm: Case report

The pseudoaneurysms of the cystic artery (CAP) are very uncommon. They usually develop as a result of an acute cholecystitis or after a cholecystectomy. Among the complications, we can find hemorrhaging, biliary blockage, and haemobilia. Limited understanding of the illness makes managing specific cases difficult. We describe a case of a cystic artery pseudoaneurysm complicating an acute cholecystitis that was successfully treated by transcatheter arterial embolization.

Comparative Efficacy of Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting in the Treatment of Ischemic Heart Disease: A Systematic Review and Meta-Analysis of Recent Randomized Controlled Trials

Background

Ischemic heart disease (IHD) is a major global health issue and a leading cause of death. This study compares the effectiveness of percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in the management of IHD, focusing on their impact on revascularization, myocardial infarction (MI), and post-procedural stroke. This study aimed to evaluate and compare the effectiveness of PCI and CABG in treating IHD based on an exhaustive literature review of the past 5 years, emphasizing recent advancements and outcomes in IHD management.

Methods

A comprehensive literature review analyzed 32 randomized controlled trials (RCTs) retrieved from databases such as PubMed, Cochrane Library, and Google Scholar. The study specifically assessed the incidences of revascularization, stroke, and MI in patients treated with either PCI or CABG. The comparison between CABG and PCI exclusively focused on lesions with a SYNTAX score exceeding 32.

Results

Our findings highlight CABG's significant efficacy over PCI in reducing revascularization and MI. The aggregated Mantel-Haenszel (M-H) value for revascularization was 1.85 (95% confidence interval (CI): 1.65 - 2.07), signifying CABG's advantage. Additionally, CABG demonstrated superior performance in diminishing MI occurrences (M-H = 2.71, 95% CI: 1.13 - 6.53). In contrast, PCI was more effective in reducing stroke (M-H = 0.80, 95% CI: 0.60 - 1.10).

Conclusion

The study confirms CABG's superiority in reducing revascularization and MI in IHD patients, highlighting PCI's effectiveness in reducing stroke risk. These findings underscore the importance of personalized treatment strategies in IHD management and emphasize the need for ongoing research and evidence-based guidelines to aid in treatment selection for IHD patients.

Comparison of Intercostal and Subxiphoid Left Pleural Drain After Coronary Artery Bypass Grafting (CABG) Surgery: A Systematic Review and Meta-Analysis

Coronary artery bypass grafting (CABG), a prevalent surgery for coronary artery disease, often involves left internal mammary artery harvesting, necessitating left pleural drain insertion. This can lead to pain, discomfort, and respiratory issues. This analysis compares outcomes between subxiphoid and intercostal left pleural drain insertion. Following the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines, this systematic review and meta-analysis involved searches in MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), Scopus, Google Scholar, and Clinical Trial Registry. Studies were selected based on primary outcomes (postoperative ventilator support duration and pain score) and secondary outcomes (percentage predicted vital capacity (VC), forced VC (FVC), and partial pressure of oxygen (PO2) in arterial blood gas (ABG) analysis). Statistical analysis used a random effect model, pooled risk ratio, and I2 heterogeneity. Nine studies (seven randomized and two nonrandomized) with 412 patients met the inclusion criteria. Pooled analysis indicated reduced ventilation time and postoperative pain with the subxiphoid drain compared to the intercostal drain. Spirometry parameters showed improved VC, FVC, and PO2 in ABG analysis. This meta-analysis suggests that subxiphoid pleural drain insertion in CABG patients is associated with shorter ventilation times, lower pain scores, and improved pulmonary function compared to intercostal drain placement.

Meta-analysis on axillary lymph node metastasis rate in ductal carcinoma in situ with microinvasion

OBJECTIVE

To address the question of axillary lymph node staging in ductal carcinoma in situ with microinvasion (DCIS-MI), we retrospectively evaluated axillary lymph nodes metastasis (ALNM) rate in a cohort of postsurgical DCIS-MI patients. By analyzing these data, we aimed to generate clinically relevant insights to inform treatment decision-making for this patient population.

METHODS

A systematic search was conducted on PubMed, Web of Science, Embase, The Cochrane Library, CNKI, Wanfang Database, Wipe, and China Biomedical Literature Database to identify relevant publications in any language. All the analyses were performed using Stata 16.0 software.

RESULTS

Among the 28 studies involving 8279 patients, the pooled analysis revealed an ALNM rate of 8% (95% CI, 7% to 10%) in patients with DCIS-MI. Furthermore, the rates of axillary lymph node macrometastasis, micrometastasis, and ITC in patients with DCIS-MI were 2% (95% CI, 2% to 3%), 3% (95% CI, 2% to 4%), and 2% (95% CI, 1% to 3%), respectively. Moreover, 13 studies investigated the non-sentinel lymph node (Non-SLN) metastasis rate, encompassing a total of 1236 DCIS-MI cases. The pooled analysis identified a Non-SLN metastasis rate of 33% (95% CI, 14% to 55%) in patients with DCIS-MI.

CONCLUSION

The SLNB for patients with DCIS-MI is justifiable and could provide a novel therapeutic basis for systemic treatment decisions.

An unusual case of acute cholecystitis complicated by haemobilia and Mirizzi-like obstruction: a case report and review of literature

Introduction

Cystic artery pseudoaneurysm rupture presents a rare yet potentially fatal aetiology for upper gastrointestinal (GI) bleed. While uncommon, its incidence has been rising with increased hepatobiliary surgical interventions, predominantly attributed to iatrogenic injury and rarely secondary to acute cholecystitis. Clinical manifestations typically include epigastric pain, upper GI haemorrhage, and obstructive jaundice. Due to its rarity, it is often excluded from initial differential diagnoses.

Case report

This is an unusual case of a 54-year-old male who presented with acute cholecystitis complicated by haemobilia and Mirizzi-like obstruction, in the setting of cystic artery pseudoaneurysm rupture. Initially, urgent transcatheter angiographic embolization of the cystic artery was performed to achieve hemodynamic stability. However, a triphasic computed tomography (CT) scan revealed the first attempt was unsuccessful, necessitating a second embolization. Subsequent imaging confirmed satisfactory embolization; however, a small area of liver necrosis was observed adjacent to the gallbladder. The patient was stable at discharge from the hospital and had an uncomplicated interval cholecystectomy.

Discussion

This case highlights the complexity and challenges associated with diagnosing and managing cystic artery pseudoaneurysm rupture. Diagnosis often relies on arterial phase contrast-enhanced CT scan. While no guideline currently exist, management typically involves achieving hemodynamic stability through Transcatheter angiographic embolization, followed by interval cholecystectomy.

Conclusion

Early recognition and intervention are crucial in managing cystic artery pseudoaneurysm rupture to prevent life-threatening haemorrhagic shock. Clinicians need to consider this rare condition in patients with upper GI bleeding and abnormal liver function tests.

Retrospective cross-sectional study to evaluate outcome of loco-regional flaps in head and neck reconstruction in Sudanese patients

Introduction

The soft tissue of the head and neck region poses both esthetic and functional aspects and must be retorted simultaneously, as any defect will be easy recognizable and will affect the quality of patient's life. Reconstruction by local- regional flap still the most popular approach used and outcome also better than other options.

Objectives

To assess the outcome of loco-regional flaps in head and neck reconstruction in Sudanese patients.

Patients and methods

Retrospective cross-sectional, multicenteric study (Soba University Hospital, Khartoum North Teaching Hospital and an associated specialized hospital) - Khartoum, Sudan, 84 patients underwent head/neck reconstruction during the period from 2017 up to 2021 were included.

Results

Out of 84 patients, 47.6% were female and 52.4% were male. The etiology of head and neck defects in the majority (69%) was neoplastic, and in 11.9% it was trauma. According to site of defect, in 23.8% of patients was Cheek unit, 21.4% was nasal site, and 16.7% was neck site. Surgery in 85.7% of patients were primary, while in 14.3 was delayed. Fasciocutaneous flaps were used in 64.3%, followed by myocutaneous flap in 28.6%; functional outcome was excellent in 61.9%, adequate in 35.7%, and was inadequate in only 2.4%. The majority of patients 66.2% did not develop any complications.

Conclusion

Loco-regional flaps are ideally useful in covering head and neck defects. It has an acceptable esthetic and functional outcome in the majority of cases. It can be considered as a reliable option for reconstruction especially in resource constrained centers.

The Effect of a Short Training Course of Hysteroscopic Myoma Resection on the Non-Technical Skills of Gynecologic Surgeons

Objective

To assess the impact of a hysteroscopic myoma resection (HMR) two-day training course on non-technical (cognitive) surgical skills among gynecologists.

Materials and methods

A 2-day educational course was held in which 95 consultant gynecologic surgeons and beginner infertility fellowship residents took part. Among all 80 participants (84.2%) had ever performed diagnostic hysteroscopy and 30 (31.3%) had performed non-resectoscopic operative hysteroscopy. The training program included instructive speeches, simulated surgical presentations, and a live hands-on myomectomy workshop. Non-technical skills were assessed two times, once before and the other after the course through two written tests with 10 multiple-choice questions for each.

Results

Concerning the 95 participants, 43 (47.3%) took the pre-course test and all of them (100%) took the post-course one. The mean score improved significantly from 3 (interquartile range [IQR], 0-4.0) to 7 (IQR, 5.0- 8.0) [bootstrap p<0.0001] for each of the randomly chosen pairings. The majority of candidates showed significantly improved cognitive skills after the HMR course despite their poor cognitive skills before the course. According to further analysis, there were significant enhancements in grades for all topics, especially regarding the basic principles of the procedure and management of complications (bootstrap p<0.0001). The odds ratio for the pre- versus post-course mean test results was 5.23. Due to the confidentiality stipulation, the pre- and post-course scores were not matched.

Conclusion

A two-day continuing medical educational course could be efficient in improving the nontechnical (cognitive) skills for HMR.

Use of Dermal Substitute Matrices for Coverage of Exposed Limb Vascular Repairs: A Literature Review

Background

Prompt coverage of vascular repairs in the extremities is needed to protect from desiccation and trauma. In the absence of local soft tissues to provide early coverage pending demarcation of the tissues and the zone of injury, there is no clear data in the literature on the ideal coverage method. This article is the first to review the use of dermal substitutes for temporary coverage of extremity vascular repairs pending definitive coverage.

Methods

We conducted a review of the literature to identify previous articles indexed in PubMed and Ovid using these search terms: [(skin) OR (artificial skin) OR (Integra) OR (dermal substitute) OR (dermal substitute matrix) OR (dermal regeneration) OR (dermal regeneration matrix) OR (dermal regeneration template)] AND [(bypass) OR (graft) OR (vascular surgery) OR (revascularization) OR (salvage) OR (limb salvage) OR (vascular repair) OR (artery repair) OR (arterial repair)] AND [(limb) OR (extremity) OR (leg) OR (arm) OR (vascular injury) OR (amputation)].

Results

Of the 32 articles retrieved for initial review, five case reports with six patients of dermal substitute use for direct coverage of extremity repairs were identified. In all cases, the dermal substitute was able to provide stable coverage pending definitive coverage or was allowed to heal secondarily.

Conclusions

Dermal substitute matrices are a potential means of temporary coverage of exposed extremity vascular repairs when there is a paucity of local soft tissues pending more definitive coverage.

Evaluation of clinical profiles, surgical experience and outcomes of ileosigmoid knotting in low-resource setup: A retrospective cohort study at Jimma University Medical Center

BACKGROUND

Bowel obstruction is a mechanical or functional blockade of intestinal contents from evacuation to the adjacent distal bowel or external environment. It poses significant morbidity and mortality in both high-income and low-to-middle-income countries. Ileosigmoid knotting is a special form of obstruction where the small bowel often ileum wraps around the sigmoid colon or vice versa. It is the severest form of bowel obstruction, involving both the small and large bowels in a compound manner. It is common where sigmoid volvulus is common and geographic areas with a bulky diet.

METHODS

An institution-based retrospective cohort study was employed among purposively selected 40 surgical patients with ileosigmoid knotting records from July 2020 to July 2023 at Jimma University Medical Center. To estimate and compare the survival probabilities, the Kaplan-Meir method and log-rank test were used. A Cox-regression analysis was fitted to identify independent predictors of time to death.

RESULTS

Among a cohort of 40 patients followed for 347 person-days at Jimma University Medical Center, 11 (27.5%) had died. The overall incidence rate of death was 3.2 (95% CI 1.8, 5.7) per 100 person-days. In multivariable Cox-regression analysis, age (AHR = 1.15; 95% CI: 1.04-1.28), shock at presentation (AHR = 30.50: 95% CI 1.25-742.54), comorbidities (AHR = 5.81; 95% CI 1.19-28.23), pulse rate intraoperatively (AHR = 1.19; 95% CI: 1.01-1.40), postoperative pulse rate (AHR = 1.07; 95% CI: 1.01-1.14) were independently associated with time to death.

CONCLUSION

The incidence of death among surgical patients with ileosigmoid knotting was high and also had a shorter median survival time. Age, shock at presentation, comorbidities, pulse rate intraoperatively, and postoperative pulse rate were found to be statistically significant predictors of time to death and outcome among surgical patients with Ileosigmoid knotting.

Potential causes of delays in paediatric perforated appendicitis: A prospective interview study

AIM

Delays in care may be a driver of inequities in perforated appendicitis rates. The goal of this study was to explore potential causes of delay in care for children with perforated appendicitis.

METHODS

We conducted an interview study of caregivers of children admitted with perforated appendicitis to a children's hospital between December 2022 and March 2023. Semi-structured interviews based on an iteratively revised interview guide were conducted in-person during the child's admission. All interviews were transcribed, coded and underwent a process of thematic analysis.

RESULTS

We reached thematic saturation after 12 interviews. The median age for children was 13.5 years, 50% were male, 83% of caregivers self-identified as White, and one interview required an interpreter. Through thematic analysis, four major themes for potential causes of delay emerged. The first theme of symptom recognition includes delays related to recognising the symptoms, their severity and the need for medical evaluation. The second theme - accessing care - describes delays that occur after a decision was made to seek care until the child was evaluated. The third theme includes delays that occur in making the diagnosis after evaluation. The last theme captures potential delays in definitive treatment after a diagnosis of appendicitis is made.

CONCLUSION

We identify four major themes from the patient and family perspective, each with multiple sub-themes, for potential delays in definitive care for children with perforated appendicitis. Additional research is needed to further characterise these potential delays and quantify their role in contributing to inequities in perforation rates.

Horizontal pharyngeal closure during total laryngectomy reduces rates of pharyngocutaneous fistula

PURPOSE

Pharyngocutaneous fistula (PCF) is a possible complication following total laryngectomy (TL), with a mean incidence of 17%. We intended to investigate the effect of pharyngeal closure type during TL on the prevention of PCF.

METHODS

We retrospectively reviewed patients that underwent TL with a horizontal pharyngeal closure over a 10-year period. The frequency of PCF clinically, dysphagia, total oral diet, postoperative dilatation of the neopharynx and voice problems were tabulated.

RESULTS

Seventy-seven subjects underwent TL due to laryngeal tumor without pharyngeal extension. Of them, 45 underwent a salvage TL. PCF occurred in 1/77 subjects. The rest of the subjects (76/77) did not develop a PCF, neither in the early nor in the late postoperative phase. All subjects (15/77) that underwent implantation of a voice prosthesis were satisfied with their voice. No subject complained about dysphagia. Every subject achieved total oral diet.

CONCLUSION

The horizontal pharyngeal closure is a safe pharyngeal closure technique during TL, reduces PCF rates (< 2%), results in excellent voice rehabilitation and swallowing function, and can also be used during salvage TL instead of a major pectoral flap. This type of closure should be used only in selected patients with laryngeal disease without pharyngeal extension.

Association between obesity and risk of delayed discharge and unplanned readmission for day surgery: A systematic review and meta-analysis

AIMS

This work aims to investigate the association between obesity and risk of delayed discharge and unplanned readmission in day surgery patients.

BACKGROUND

Day surgeries are well received and developing rapidly. Associations between obesity and delayed discharge and unplanned readmission, which are clinically relevant outcomes in day surgeries, are complex.

DESIGN

A systematic review and meta-analysis was conducted.

DATA SOURCES

The PubMed, Web of Science, EMBASE, Cochrane Library, CNKI, VIP, and Wan Fang databases were comprehensively searched from inception until January 2021.

REVIEW METHODS

Two independent reviewers assessed the studies and extracted data. Pooled estimates were obtained using a random-effects model.

RESULTS

Eleven articles published between 2007 and 2020 were finally included. Obesity appeared not to increase the risk of delayed discharge. However, morbid obesity seemed to be associated with a higher risk of delayed discharge. The meta-analysis revealed no relationship between higher body mass index (BMI) and unplanned readmission for day surgery patients.

CONCLUSIONS

Obesity appeared not to increase the risk of delayed discharge except in patients with morbid obesity. Additionally, a higher BMI was not associated with increased risk of unplanned readmission after day surgery. Future studies are required to address this issue further in different types of surgery and areas.

Utilization and Outcomes of Roux-en-Y Gastric Bypass Surgery Following the Affordable Care Act in the United States

BACKGROUND

The passage of the Affordable Care Act (ACA) in 2010 marked a pivotal moment in American health care policy, significantly expanding access to health care services. This study aims to explore the relationship between the ACA and the utilization and outcomes of Roux-en-Y Gastric Bypass (RYGB) surgery.

METHODS

Using data from the National Inpatient Sample (NIS) Database, this retrospective study compares the pre-ACA period (2007-2009) with the post-ACA period (2017-2019), encompassing patients who had RYGB. Multivariable logistic analysis was done accounting for patient's characteristics, comorbidities, and hospital type.

RESULTS

In the combined periods, there were 158 186 RYGB procedures performed, with 30.0% transpiring in pre-ACA and 70.0% in the post-ACA. Post-ACA, the proportion of uninsured patients decreased from 4.8% to 3.6% (P < .05), while Black patients increased from 12.5% to 18.5% (P < .05). Medicaid-insured patients increased from 6.8% to 18.1% (P < .05), and patients in the poorest income quartile increased from 20% to 26% (P < .05). Patients in the post-ACA period were less likely to have longer hospital stays (OR = .16: 95% CI .16-.17, P < .01), in-hospital mortality (OR = .29: 95% CI .18-.46, P < .01), surgical site infection (OR = .25: 95% CI .21-.29, P < .01), postop hemorrhage (OR = .24: 95% CI .21-.28, P < .01), and anastomotic leak (OR = .14: 95% CI .10-.18, P < .01) than those in the pre-ACA period.

DISCUSSION

Following the implementation of the ACA, utilization of bariatric surgery significantly increased, especially among Black patients, Medicaid beneficiaries, and low-income patients. Moreover, despite the inclusion of more high-risk surgical patients in the post-ACA period, there were better outcomes after surgery.

Diabetic foot ulcer is associated with cardiovascular-related mortality and morbidity - a systematic review and meta-analysis of 8062 patients

OBJECTIVES

To conduct a systematic review and meta-analysis of prevalence of cardiovascular-related morbidity and mortality in patients with diabetic foot ulcers (DFU), as well as compare risks of cardiovascular-related morbidity and mortality between diabetic patients with and without DFU.

METHODS

A systematic search was conducted on Medline, Embase, and Cochrane databases for randomized controlled trials and observational studies which explored the association between DFU and cardiovascular-related morbidity & mortality, or compared differences in hazard ratios of cardiovascular diseases between diabetics with and without DFU. Frequentist, pairwise meta-analysis was performed on studies with two comparator arms, whereas single-arm studies reporting pooled incidences of cardiovascular-related mortality and morbidity were calculated based on exact binomial distributions. A random-effect meta-analysis model was used with heterogenicity of studies assessed using I2, τ2, and χ2 statistics.

RESULTS

10 studies were identified and included in the systematic review & meta-analysis of 8602 patients. DFU was consistently found to have significant association with cardiovascular-related morbidity and mortality, with pooled prevalences of all cause cardiovascular-related morbidity (37.1%), IHD (44.7%), CHF (25.1%), CAD (11.7%), and CVA (10.9%), and all cause cardiovascular-related mortality (14.6%), fatal IHD (6.2%), fatal CHF (3.67%), fatal CAD (7.92%), and fatal CVA (1.99%). Diabetic patients with DFU were found to have significantly increased risk of IHD (RR 1.25), CVA (RR 2.03), and all-cause cardiovascular-related mortality (RR 2.59) compared to those without DFU.

CONCLUSIONS

The presence of DFU is associated with major adverse cardiac events. The alarming rates of cardiovascular-related morbidity and mortality in DFU patients highlight its potential role as a marker of cardiovascular complications and should prompt early clinical investigation and management.

The implementation of an inflammatory bowel disease-specific enhanced recovery after surgery protocol: an observational cohort study

BACKGROUND

The implementation of Enhanced Recovery After Surgery (ERAS) protocols has resulted in improved postoperative outcomes in colorectal cancer surgery. The evidence regarding feasibility and impact on outcomes in surgery for inflammatory bowel disease (IBD) is limited.

METHODS

We performed a retrospective observational cohort study, comparing patient trajectories before and after implementing an IBD-specific ERAS protocol at Zealand University Hospital. We assessed the occurrence of serious postoperative complications of Clavien-Dindo grade 3 or higher as our primary outcome, with postoperative length of stay in days and rate of readmissions as secondary outcomes, using χ2, Mann-Whitney test, and odds ratios adjusted for sex and age.

RESULTS

From 2017 to 2023, 394 patients were operated on for IBD and included in our study. In the ERAS cohort, 39/250 patients experienced a postoperative complication of Clavien-Dindo grade 3 or higher compared to 27/144 patients in the non-ERAS cohort (15.6% vs. 18.8%, p = 0.420) with an adjusted odds ratio of 0.73 (95% CI 0.42-1.28). There was a significantly shorter postoperative length of stay (median 4 vs. 6 days, p < 0.001) in the ERAS cohort compared to the non-ERAS cohort. Readmission rates remained similar (22.4% vs. 16.0%, p = 0.125).

CONCLUSIONS

ERAS in IBD surgery was associated with faster patient recovery, but without an impact on the occurrence of serious postoperative complications and rate of readmissions.