Laparoscopic peritoneal lavage versus sigmoidectomy for perforated diverticulitis with purulent peritonitis: three-year follow-up of the randomised LOLA trial

Background

This study aimed to compare laparoscopic lavage and sigmoidectomy as treatment for perforated diverticulitis with purulent peritonitis during a 36 month follow-up of the LOLA trial.

Methods

Within the LOLA arm of the international, multicentre LADIES trial, patients with perforated diverticulitis with purulent peritonitis were randomised between laparoscopic lavage and sigmoidectomy. Outcomes were collected up to 36 months. The primary outcome of the present study was cumulative morbidity and mortality. Secondary outcomes included reoperations (including stoma reversals), stoma rates, and sigmoidectomy rates in the lavage group.

Results

Long-term follow-up was recorded in 77 of the 88 originally included patients, 39 were randomised to sigmoidectomy (51%) and 38 to laparoscopic lavage (49%). After 36 months, overall cumulative morbidity (sigmoidectomy 28/39 (72%) versus lavage 32/38 (84%), p = 0·272) and mortality (sigmoidectomy 7/39 (18%) versus lavage 6/38 (16%), p = 1·000) did not differ. The number of patients who underwent a reoperation was significantly lower for lavage compared to sigmoidectomy (sigmoidectomy 27/39 (69%) versus lavage 17/38 (45%), p = 0·039). After 36 months, patients alive with stoma in situ was lower in the lavage group (proportion calculated from the Kaplan–Meier life table, sigmoidectomy 17% vs lavage 11%, log-rank p = 0·0268). Eventually, 17 of 38 (45%) patients allocated to lavage underwent sigmoidectomy.

Conclusion

Long-term outcomes showed that laparoscopic lavage was associated with less patients who underwent reoperations and lower stoma rates in patients alive after 36 months compared to sigmoidectomy. No differences were found in terms of cumulative morbidity or mortality. Patient selection should be improved to reduce risk for short-term complications after which lavage could still be a valuable treatment option.

Graphical abstract

[Underexposed, potential lethal gastrointestinal adverse events associated with clozapine use]

Clozapine is an effective antipsychotic with antidopaminergic, anticholinergic and antiserotonergic effects. Due to potential adverse events, agranulocytosis being the most feared, patients using clozapine need to be closely monitored. A lesser known but equally common and potential lethal adverse effect is clozapine-induced gastrointestinal hypomotility (CIGH), which can cause a paralytic ileus, gut mucosal ischemia or aspiration pneumonia. We saw a male patient, aged 61 years, who used clozapine and suffered from CIGH, leading to frequent episodes of paralytic ileus requiring GE surgery. The case underlines the importance of timely recognition and treatment of clozapine-induced gastrointestinal hypomotility.

Yield of Screening for COVID-19 in Asymptomatic Patients Before Elective or Emergency Surgery Using Chest CT and RT-PCR (SCOUT): Multicenter Study

OBJECTIVE

To determine the yield of preoperative screening for COVID-19 with chest CT and RT-PCR in patients without COVID-19 symptoms.

SUMMARY OF BACKGROUND DATA

Many centers are currently screening surgical patients for COVID-19 using either chest CT, RT-PCR or both, due to the risk for worsened surgical outcomes and nosocomial spread. The optimal design and yield of such a strategy are currently unknown.

METHODS

This multicenter study included consecutive adult patients without COVID-19 symptoms who underwent preoperative screening using chest CT and RT-PCR before elective or emergency surgery under general anesthesia.

RESULTS

A total of 2093 patients without COVID-19 symptoms were included in 14 participating centers; 1224 were screened by CT and RT-PCR and 869 by chest CT only. The positive yield of screening using a combination of chest CT and RT-PCR was 1.5% [95% confidence interval (CI): 0.8-2.1]. Individual yields were 0.7% (95% CI: 0.2-1.1) for chest CT and 1.1% (95% CI: 0.6-1.7) for RT-PCR; the incremental yield of chest CT was 0.4%. In relation to COVID-19 community prevalence, up to ∼6% positive RT-PCR was found for a daily hospital admission rate >1.5 per 100,000 inhabitants, and around 1.0% for lower prevalence.

CONCLUSIONS

One in every 100 patients without COVID-19 symptoms tested positive for SARS-CoV-2 with RT-PCR; this yield increased in conjunction with community prevalence. The added value of chest CT was limited. Preoperative screening allowed us to take adequate precautions for SARS-CoV-2 positive patients in a surgical population, whereas negative patients needed only routine procedures.

Enhanced PeriOperative Care and Health protection programme for the prevention of surgical site infections after elective abdominal surgery (EPOCH): study protocol of a randomised controlled, multicentre, superiority trial

INTRODUCTION

Surgical site infections (SSI) are a common postoperative complication. During the development of the new WHO guidelines on SSI prevention, also in the Netherlands was concluded that perioperative care could be optimised beyond the current standard practice. We selected a limited set of readily available, cheap and evidence-based interventions from these new guidelines that are not part of standard practice in the Netherlands and formulated an Enhanced PeriOperative Care and Health bundle (EPOCH). Here, we describe the protocol for an open-label, randomised controlled, parallel-group, superiority trial to test the effect of the EPOCH bundle added to (national) standard care in comparison to standard care alone on the incidence of SSI.

METHODS AND ANALYSIS

EPOCH consists of intraoperative high fractional inspired oxygen (0.80); goal-directed fluid therapy; active preoperative, intraoperative and postoperative warming; perioperative glucose control and treatment of severe hyperglycaemia (>10 mmol^l-1) and standardised surgical site handling. Patients scheduled for elective abdominal surgery with an incision larger than 5 cm are eligible for inclusion. Participants are randomised daily, 1:1 according to variable block sizes, and stratified per participating centre to either EPOCH added to standard care or standard care only. The primary endpoint will be SSI incidence according to the Centers for Disease Control and Prevention (CDC) definition within 30 days as part of routine clinical follow-up. Four additional questionnaires will be sent out over the course of 90 days to capture disability and costs. Other secondary endpoints include anastomotic leakage, incidence of incisional hernia, serious adverse events, hospital readmissions, length of stay and cost effectiveness. Analysis of the primary endpoint will be on an intention-to-treat basis.

ETHICS AND DISSEMINATION

Ethics approval is granted by the Amsterdam UMC Medical Ethics Committee (reference 2015_121). Results will be disseminated through peer-reviewed journals and summaries shared with stakeholders. This protocol is published before analysis of the results.

TRIAL REGISTRATION NUMBER

Registered in the Dutch Trial Register: NL5572.

[A woman with a lumbar swelling]

We present the case of a 57-year-old woman with a large (7 x 5 cm), asymptomatic lumbar swelling. A lumbar MRI scan revealed a hernia of the superior lumbar triangle (Grynfeltt-Lesshaft hernia). Thus far, 300 cases have been described in the literature. Therapeutic options include surgical and conservative treatment.

The linea arcuata hernia: a report of two cases

Two male patients presented to the surgical outpatient clinic with a paramedian abdominal bulge. In the first patient, the hardly known diagnosis linea arcuata hernia (LAH) had been missed at a previous exploration 8 years ago. In the second patient, pre-operative imaging showed an abdominal wall hernia. Diagnostic laparoscopy revealed an LAH. In both cases, the hernia was repaired with a mesh graft.

[Diversity of complaints in manifesting carcinoma of the gallbladder]

A man of 47 years with hypercholesterolaemia had no complaints but the family doctor suspected cholecystolithiasis because of abnormal results of the haematological study. Ultrasonography of the abdomen revealed a polyp in the gallbladder. The patient underwent laparoscopic cholecystectomy. Pathological examination revealed that the polyp was a carcinoma. No evidence for a recurrence was found during a return visit after 2 years. A woman of 74 years was admitted to the hospital due to persistent rectal bleeding. She had fever, loss of appetite, nausea and weight loss. A bleeding duodenal ulcer was identified during gastroduodenoscopy. Laparotomy was performed due to haemodynamic instability. During the operation an abnormal gallbladder was found with infiltration in and perforation of the duodenum. The gallbladder was resected and the perforation of the duodenum was sutured. Pathological examination revealed carcinoma of the gallbladder. A palliative policy was adhered to; the patient died 1 month later. Carcinoma ofthe gallbladder is an uncommon but highly fatal malignancy. Several risk factors have been identified and treatment is primarily surgical.

[Ultrasound guided percutaneous thrombin injection for treatment of a pseudoaneurysm after inguinal or brachial catheterization; good results in 14 patients]

OBJECTIVE

Evaluation of percutaneous ultrasound guided thrombin injection for treatment of postcatheterization pseudoaneurysms.

DESIGN

Prospective.

METHOD

In the period 1 April 1999-30 June 2000, all patients with postcatheterization pseudoaneurysms were included and primarily treated with ultrasound guided percutaneous thrombin injection. Under ultrasound guidance a 22 gauge needle was percutaneously positioned within the pseudoaneurysm and a thrombin solution was slowly injected to induce thrombosis. Distal pulses and ankle-brachial indexes were measured before and after the procedure. Colour Doppler ultrasound examination was repeated after 1 day, 1 week and 6 weeks.

RESULTS

Fourteen patients were included: 6 men and 8 women, age range 50-79 year (mean: 66 year). Thirteen of 14 pseudoaneurysms, 12 femoral and 2 brachial pseudoaneurysms, were successfully treated with thrombin injection. Twelve pseudoaneurysms thrombosed after 1 injection. Because of recurrence 2 patients needed a second injection. One patient developed a recurrence after 2 injections and was referred for surgical treatment. Doses of thrombin needed varied between 150-1000 units. The whole procedure took 15 minutes on average. One patient developed a superficial infection 2 weeks after treatment at the site of the thrombosed pseudoaneurysm which needed incision and drainage in the outpatient department. No thromboembolic complications were found.

CONCLUSION

Percutaneous thrombin injection appears to be an effective and safe procedure for the treatment of postcatheterization pseudoaneurysms.

Gastrointestinal symptoms during long-distance walking

PURPOSE

Gastrointestinal (GI) symptoms are common during prolonged intense exercise. To examine whether GI symptoms are also common during prolonged exercise of lower intensity, we obtained data on incidence, duration, and severity of GI symptoms during four consecutive days walking with a total distance of 203 km for men and 164 km for women.

METHODS

The research population consisted of 79 men and 76 women, aged 30-49 yr, who responded to a questionnaire and a diary concerning anthropometric data, activity pattern, dietary intake, and GI symptoms.

RESULTS

The results show that 24% of the subjects experienced one or more symptoms. Nausea, headache, and flatulence were the most frequent symptoms. Nine subjects dropped out during the race, two of whom indicated that they stopped as a result of one or more GI symptoms. Logistic regression analysis revealed that the occurrence of GI symptoms was a significant exercise-limiting factor. Univariate analysis showed that incidence and duration of GI symptoms were significantly related to the subjects' experience (number of prior participations to the event), body weight loss during walking, and several components of the diet before and during the event. A significant relationship between GI symptoms and age, gender, training status, and walking speed could not be found.

CONCLUSIONS

We conclude that GI symptoms during long-distance walking can impair exercise performance, although these symptoms occur less frequently and are less severe in comparison with prolonged intense exercise.

Laboratory investigations in the diagnosis of septicaemia and malaria

During a three month prospective study, 229 in-patients with fever, admitted to St. Mary's Hospital, Mumias, were examined for bacterial and malarial causes of fever. Blood cultures taken from patients appeared to contain true pathogens in 51 (22%) cases. Nine different bacterial species were identified from positive blood cultures of which four predominated: Salmonella typhi (46%), Streptococcus pneumoniae (19%), Salmonella enteritidis (12%), Salmonella typhimurium (8%). S. enteritidis and S. typhimurium isolates were mostly multi-antibiotic resistant, compared to S. typhi isolates which were relatively susceptible to the antibiotics used in the hospital. Only 70% of the S. pneumoniae isolates were susceptible to penicillin. Among 227 patients in whom a thick blood-film for malaria parasites and HIV serology were performed, only 25 (11%) revealed malaria parasites. HIV-1 antibodies were detected in 51 (22%) patients. Without appropriate laboratory examinations, the majority of the diagnoses would have been missed and no optimal treatment would have been administered. This may increase resistance to antimalarials and antibiotics.

[Outpatient sports clinic, first impressions]

OBJECTIVE

To review the first year of the outpatient sports clinic in Utrecht University Hospital (AZU), and to demonstrate the feasibility of such a sports clinic.

DESIGN

Retrospective study (period: April 1993-March 1994).

SETTING

University Hospital Utrecht, the Netherlands.

METHODS

The patients attended the sports clinic either on referral or on their own initiative. The specialist directly entered the patients' data onto a registration form.

RESULTS

Over a period of one year 461 consultations where given to 271 patients. The patients' average age was 31 years. The commonest sports were soccer, running and tennis. The lower limb was the commonest site of injury (79%) and overuse injuries predominated. For 57% of the patients therapy was instituted, which consisted in 67% of the cases of physiotherapy and in 13% of operative intervention.

CONCLUSION

The outpatient sports clinic appears to be visited in particular by senior athletes with chronic complaints caused by surmenage injuries or with residual complaints following acute injuries. Future intramural sports medicine will have to deal not only with treatment of injuries as presented at the sports clinic, but also with prevention of chronic complaints resulting from acute injuries in this group of athletes.