Goodbye Hartmann trial: a prospective, international, multicenter, observational study on the current use of a surgical procedure developed a century ago

BACKGROUND

Literature suggests colonic resection and primary anastomosis (RPA) instead of Hartmann's procedure (HP) for the treatment of left-sided colonic emergencies. We aim to evaluate the surgical options globally used to treat patients with acute left-sided colonic emergencies and the factors that leading to the choice of treatment, comparing HP and RPA.

METHODS

This is a prospective, international, multicenter, observational study registered on ClinicalTrials.gov. A total 1215 patients with left-sided colonic emergencies who required surgery were included from 204 centers during the period of March 1, 2020, to May 31, 2020. with a 1-year follow-up.

RESULTS

564 patients (43.1%) were females. The mean age was 65.9 ± 15.6 years. HP was performed in 697 (57.3%) patients and RPA in 384 (31.6%) cases. Complicated acute diverticulitis was the most common cause of left-sided colonic emergencies (40.2%), followed by colorectal malignancy (36.6%). Severe complications (Clavien-Dindo ≥ 3b) were higher in the HP group (P < 0.001). 30-day mortality was higher in HP patients (13.7%), especially in case of bowel perforation and diffused peritonitis. 1-year follow-up showed no differences on ostomy reversal rate between HP and RPA. (P = 0.127). A backward likelihood logistic regression model showed that RPA was preferred in younger patients, having low ASA score (≤ 3), in case of large bowel obstruction, absence of colonic ischemia, longer time from admission to surgery, operating early at the day working hours, by a surgeon who performed more than 50 colorectal resections.

CONCLUSIONS

After 100 years since the first Hartmann's procedure, HP remains the most common treatment for left-sided colorectal emergencies. Treatment's choice depends on patient characteristics, the time of surgery and the experience of the surgeon. RPA should be considered as the gold standard for surgery, with HP being an exception.

The wound area as a parameter guiding the timing of abdominal closure in the management of patients undergoing open abdominal procedures

OBJECTIVE

Surgical site infections (SSI) are incomparably troublesome and complicated, and some of them require an open abdomen (OA) procedure. While deciding the timing of abdominal closure, wound area calculation method and laboratory parameters can be used to guide the timing of abdominal closure after OA procedures.

PATIENTS AND METHODS

The records of the patients who had undergone open abdomen during their treatment course and were followed up with vacuum-assisted closure (VAC) technique between December 2015 and December 2019 were retrospectively analyzed. The laboratory results before the first VAC application and the results after the VAC change were compared to determine a predictive parameter. The ImageJ program was used in five patients to compare the size of the wounds at the time of the decision to close them and before the first VAC application.

RESULTS

102 patients were analyzed. The ratio of the last wound area to the wound area at the time of the first VAC application in five patients was 0.30, 0.41, 0.34, 0.27, 0.46 (mean: 0.36, standard deviation: 0.078) which were measured and calculated by ImageJ software.

CONCLUSIONS

We think that the concept of wound reduction ratio, which was calculated by a computer program, can be used as a concrete equivalent of the wound closure eligibility criteria decided by clinical experience.

Does Monocyte Chemoattractant Protein-1 Levels determine the prognosis of COVID-19 disease in kidney transplant recipients?

Background

In the normal population, a high MCP-1 level is an important biomarker for the progression of COVID-19 disease. This study aimed to investigate whether MCP-1 level can determine the disease prognosis in kidney transplant (KT) patients with COVID-19.

Methods

A total of 89 patients, including 49 KT patients (Group 1) diagnosed with COVID-19 who required hospitalization, and 40 KT patients who did not have COVID-19 disease (Group 2), were included. Demographic characteristics and laboratory results of the patients were recorded. The serum reserved for MCP-1 was stored at -80 degrees and studied blindly by a single microbiologist at the end of the study.

Results

While the mean age of the patients was 51.0 (40.0-59.50) years in Group 1, it was 48.0 (40.75-54.75) years in Group 2(P>0.05). In terms of the female gender, it was 36 (73.5%) and 27 (67.5%) in Group 1 and Group 2, respectively (P>0.05). Similarly, there was no significant difference between the two groups regarding primary disease and basal graft function (p>0.05). There was a statistically significant difference in inflammation indicators in Group 1 compared to Group 2(P<0.05). A correlation was found between inflammation indicators and COVID-19(P<0.05). However, no significant correlation was detected between COVID-19 disease and MCP-1 levels in both groups (P>0.05). Also, according to basal MCP-1 levels, we did not find a significant difference between survival and non-survival patients (164,0pg/mL (146,0-202,0) vs 156,0 pg/mL (143,0-173,0), respectively  (p>0.05).

Conclusion

MCP-1, an indicator of inflammation, was not found to be a predictor of prognosis of COVID-19 disease in kidney recipients.

Open versus laparoscopic technique in peptic ulcus perforation, how effective are score systems?Single-center experience and literature review

BACKGROUND

One of the most common peptic ulcer complications is perforation (PUP) which also remains an important cause of morbidity and mortality. In this study, it was aimed to compare the results of patients who had similar pre-operative scoring index results (Boey, Charlson Comorbidity Index (CCI) and Mannheim Peritonitis Index (MPI), and type of surgery.

METHODS

Pre-operative Boey, CCI, and MPI scores were calculated by retrospectively examining the files of patients who were operated under emergency conditions with the diagnosis of PUP. The patients divided into two groups those who underwent laparoscopic surgery/Group-1 and open surgery/Group-2.

RESULTS

There was no statistical difference between the groups in terms of demographic data, hospital admission time, and length of hospital stay. The operation time was found to be longer in the laparoscopic group (110,2 SD20,6/75-150 min) than open group (54,2 SD15,7/30-120 min) (p<0.001). Morbidity was less in laparoscopic group (4% versus 14.6%) (p<0.001).

CONCLUSION

The laparoscopic method may be used safely in PUP due to the lower post-operative complication rates and known advantages of minimally invasive surgery.

Short and mid‐term SARS‐CoV‐2 antibody response after inactivated COVID‐19 vaccine in hemodialysis and kidney transplant patients

The efficacy of the inactivated severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) vaccine has not been fully elucidated across the whole spectrum of patients on kidney replacement therapy. We aimed to characterize the long‐term antibody response of inactivated SARS‐CoV‐2 vaccine administered in kidney transplant recipients (KTRs) and hemodialysis (HD) patients. We performed this prospective observational study in 50 HD, 64 KTR, and 41 healthy control groups (HG) given two doses of CoronaVac. We measured anti‐Spike antibodies after 28 days of every vaccine dose, 3rd and 6th months after the first dose, and compared them between cohorts. After two doses, an anti‐spike immunoglobulin G of ≥50 AU/ml was present in HD, KTR, and HG as 44%, 7.2%, and 58.5%, respectively (p < 0.001). Furthermore, the proportion of antibody titers peaked at 86.5%, 23%, and 97.6% (p < 0.001) at the 3rd month and decreased significantly at the 6th month in most HD and HG participants, whereas this effect was not observed in KTRs from basal until the 6th month (p < 0.001). During the follow‐up, the incidence of coronavirus disease 2019 disease was higher (p < 0.003) in KTRs compared to the other groups, but there was no requirement for an intensive care unit and no death was recorded. We found a negative correlation between antibody seroconversion and age (p < 0.016). The antibody response following inactivated vaccine in dialysis patients is almost comparable to controls for 6 months. In contrast, kidney transplant patients have a poor response. These findings reinforce the need to discuss the vaccination strategy in immunocompromised patients, including the third dose with homologous or heterologous vaccines.

Incativated COVID‐19 vaccine has been shown to be effective in the normal population. However, its effectiveness in uremic patients and kidney transplant recipients is controversial.

Based on our results, inactivated COVID‐19 vaccine is safe and effective in the short and mid‐term in hemodialysis patients as well as in the normal population, but not in kidney recipients.

The incidence of COVID‐19 disease after CoronaVac was significantly higher in kidney transplant recipients compered with hemodialysis and normal population.

These findings reinforce the need to discuss the vaccination strategy in immunocompromised patients, including the third dose with homologous or heterologous vaccines.

Isolated recto-vaginal septum injury during parturition: Single-center experience

BACKGROUND

Traumatic rectal injuries are uncommon and can originate due to various causes. Rectal injuries have a high mor-bidity, regardless of cause, and detection at the time of occurrence is important to prevent fistula formation and/or stoma. In this article, treatment approaches in patients with isolated rectovaginal septum injury without perineal and sphincter injury during sponta-neous vaginal delivery are presented and the current literature is reviewed.

METHODS

The records of spontaneous vaginal deliveries that resulted in live births between January 2015 and January 2020 were analyzed retrospectively at our center. The records of patients with isolated rectovaginal septum injury were evaluated in terms of demographic and obstetric data, trauma, classification of injury, and early and late results.

RESULTS

Isolated septum injuries were detected 12 women (0.06%). Of the isolated rectovaginal septum injuries, 9 (75%) were clas-sified as Type III, 2 (16.6%) as Type IV, and 1 (8.3%) as a Type V injury according to the Rosenshein classification. Transvaginal repair was performed because all of the injuries underwent early surgical intervention, were limited, and exploration through the vagina was possible.

CONCLUSION

Rectal examination should be performed simultaneously with a detailed perineal examination after vaginal delivery. For birth-related rectal injuries detected early in appropriate patients, a primary repair without diversion stoma may be the best option.

Correlation between venous blood gas indices and radiological involvements of COVID-19 patients at first admission to emergency department

BACKGROUND

The purpose of this study was to investigate the relation between venous blood gas and chest computerized tomography findings and the clinical conditions of COVID-19 pneumonia.

METHODS

A total of 309 patients admitted to the emergency department and subsequently confirmed COVID-19 cases was examined. Patients with pneumonia symptoms, chest computerized tomography scan, venous blood gas findings, and confirmed COVID-19 on reverse transcription-polymerase chain reaction (PCR) were consecutively enrolled. Multiple linear regression was used to predict computerized tomography and blood gas findings by clinical/laboratory data.

RESULTS

The median age of patients was 51 (interquartile range 39-66), and 51.5% were male. The mortality rate at the end of follow-up was 18.8%. With respect to survival status of patients pCO2 and HCO3 levels and total computerized tomography score values were found to be higher in the surviving patients (p<0.001 and p=0.003, respectively), whereas pH and lactate levels were higher in patients who died (p=0.022 and p=0.001, respectively). With logistic regression analysis, total tomography score was found to be significantly effective on mortality (p<0.001). The diffuse and random involvement of the lungs had a significant effect on mortality (p<0.001, 95%CI 3.853-38.769, OR 12.222 and p=0.027; 95%CI 1.155-11.640, OR 3.667, respectively). With linear regression analysis, the effect of pH and lactate results were found to have a positive effect on total tomography score (p=0.003 and p<0.001, respectively), whereas pCO2 was found to have a negative effect (p=0.029).

CONCLUSION

There was correlation between venous blood gas indices and radiologic scores in COVID-19 patients. Venous blood gas taken in emergency department can be a fast, applicable, minor-invasive, and complementary test in terms of diagnosing COVID-19 pneumonia and predicting the prognosis of disease.

Comparison of Balloon Trocar versus Telescopic Dissection Method for TEP Inguinal Hernia Repair

OBJECTIVE

To compare the outcomes between two methods of dissection (balloon trocar vs. telescopic dissection) used in total extra-peritoneal (TEP) inguinal hernia repair.

STUDY DESIGN

Comparative study.

PLACE AND DURATION OF STUDY

Department of General Surgery, Faculty of Medicine, Sakarya University, conducted between January 2018 and January 2020.

METHODOLOGY

The study included patients who underwent elective TEP inguinal hernia repair. Preoperative and early postoperative results were compared, after the patients had been divided into a balloon trocar group (Group 1) and telescopic dissection group (Group 2). The technique performed depended on equipment availability. Permission was obtained from the Institutional Review Board. The study data are presented as descriptive statistics (mean, standard deviation, median, first quartile, third quartile, frequency and percentage); p-value <0.05 was considered significant.

RESULTS

A total of 189 patients were included; 95 patients in Group 1 and 94 patients in Group 2. No significant differences in age, gender, body mass index, body weight, ASA performance status, operating time, duration of hospitalisation or postoperative bleeding values were observed between the groups (p >0.05). European Hernia Society Quality of Life pain score values ​​ were higher in Group 2 than Group 1 (p = 0.016).

CONCLUSION

Telescopic dissection was cheaper than balloon dissection. The bleeding values and operating time were similar between the two methods, but telescopic dissection caused more postoperative pain. Key Words: Inguinal hernia, Telescopic dissection, Balloon dissection, Total extra-peritoneal (TEP) surgery.

WHY DIAGNOSTIC LAPAROSCOPY

INTRODUCTION

Abdominal pain requires rapid diagnosis and treatment, especially in emergency circumstances. Sometimes the diagnosis of the disease cannot be accomplished with laboratory and imaging methods, and an invasive procedure such as diagnostic laparoscopy may be required to obtain a diagnosis. Diagnostic laparoscopy is also performed therapeutically, but laparotomy is inevitable in some cases. The aim of the study is to evaluate the role of diagnostic laparoscopy in diagnosis and treatment and to retrospectively examine the factors that force the surgeon to perform a laparotomy.

MATERIAL AND METHODS

Patients over the age of 18 who underwent diagnostic laparoscopy in the general surgery clinic of Sakarya University Training and Research Hospital between January 2013 and December 2019 were retrospectively evaluated. Patients under 18 years of age and patients diagnosed before surgery were excluded. Demographic data of the patients, whether there was a conversion from laparoscopy to laparotomy, postoperative morbidity, and mortality were recorded.

RESULTS

The data of 347 patients in total were evaluated retrospectively between the specified dates. 216 of the patients were previously diagnosed, laparoscopic procedures performed for staging purposes and they were not included in the study. The remaining 131 patients were included in the study. 68 of the patients were women and 63 were men. 79.4% of the patients were diagnostic laparoscopies performed due to emergency circumstances, and 20.6% for abdominal pain evaluation. While the procedure was concluded laparoscopically in 64.9% of the patients, the operation was continued by performing laparotomy in 35.1%.

CONCLUSION

Despite the increase in the variety and frequency of use of imaging modalities, a laparoscopic intervention is an essential approach in both diagnosis and treatment when the diagnosis is doubtful, especially in emergency cases in appropriate cases.

Which appendicitis scoring system is most suitable for pregnant patients? A comparison of nine different systems

BACKGROUND

Acute appendicitis is the most common non-gynecological emergency during pregnancy. The diagnosis of appendicitis during pregnancy is challenging due to changes in both physiological and laboratory variables. Guidelines suggest patients with suspected acute appendicitis should be stratified based on clinical scoring systems, to optimize the use of diagnostic imaging and prevent unnecessary surgery. Surgeons require additional information beyond that provided by imaging studies before deciding upon exploratory laparoscopy in patients with a high suspicion of appendicitis. Various scoring methods have been evaluated for the diagnosis of acute appendicitis. However, there is no consensus on a method to use during pregnancy, and a detailed comparison of existing scoring methods for this purpose has not yet been conducted. The purpose of this study was to evaluate the efficacy of the most popular scoring systems applied to diagnose acute appendicitis during pregnancy.

METHODS

This single-center retrospective study included 79 pregnant patients who were admitted to the emergency department with abdominal pain between May 2014 and May 2019. The patients were diagnosed with acute appendicitis and underwent an appendectomy. As a control group, the study also included 79 non-pregnant patients who underwent appendectomy within the last 1.5 years. To ensure that the groups were similar, women in the case group were stratified according to age, and the proportions of women in the strata were determined. The women in the control group were similarly stratified. Women were randomly selected from the strata to prevent bias. Both laboratory and examination findings required for each scoring method were obtained and assessed separately for each patient. Negative appendectomy rates were evaluated according to pathology results. Categorical variables were compared using the chi-square test. A p value < 0.05 was considered to indicate significance. Receiver operator characteristic curve analysis was used to identify the best threshold value and to assess the performance of the test scores in terms of diagnosing appendicitis.

RESULTS

Among all scoring systems, the Tzanakis score was most efficacious at predicting appendicitis in non-pregnant women. The positive predictive value (PPV) of the Tzanakis score was 90.6%, whereas the negative predictive value (NPV) was 46.7%. The RIPASA score performed the best among the scoring systems in pregnant women. It was associated with a PPV of 94.40%, NPV of 44%, and sensitivity and specificity of 78.46% and 78.57%, respectively.

CONCLUSION

Although the RIPASA score can be used to efficaciously diagnose acute appendicitis in pregnant women, a specific scoring system is needed for diagnosis during the gestation period.

Cushing's Syndrome Presenting with Hyponatremia

We present a case of Cushing's syndrome that presented with hyponatremia. A 64-year-old obese woman presented to the hospital emergency service complaining of a high fever, hypertension, and generalized oedema. During the examination, the patient suddenly became confused and lost consciousness. She was admitted to the intensive care unit. In addition, blood was drawn to measure the cortisol and ACTH levels, and urine samples were sent for analysis. Adenoctomy was performed through unilateral surgical treatment. Postoperatively, many of the complications arising from Cushing's syndrome disappeared. She healed quickly, and her complaints over the last 10 years disappeared completely within a few months.