Intra-abdominal Contamination Research Articles

EP554 - Sigmoid Diverticular Perforation Mimicking Boerhaave Syndrome – A Case Report

Abstract Introduction Subcutaneous emphysema is a rare presenting complaint and can represent severe underlying pathology. Atypical occurrences of abdominal emphysema in diverticular perforations have been reported but emphysema within the thorax and neck due to sigmoid perforation is rare. We present an elderly male patient who presented with neck surgical emphysema secondary to diverticular perforation. Case presentation A 78-year-old man presented with two days history of shortness of breath and two weeks history of abdominal pain worse on coughing, newly hoarse voice, one episode of vomiting and fever. His past medical history included palliative malignant melanoma, ischaemic heart disease, asthma and chronic kidney disease. At presentation, he was tachycardic and had 95% oxygen saturation. Physical examination revealed extensive upper body subcutaneous emphysema and tender lower abdomen. Admission blood tests showed white cell count of 9.8 x 109 and C-reactive protein of 148mg/L. Urgent contrast CT scan with oral contrast excluded oesophageal perforation but demonstrated perforated sigmoid diverticulum. Due to the patient’s extensive co-morbidities and limited intra-abdominal contamination, he was managed conservatively. Discussion The patient initially had CT chest with IV contrast followed by CT with oral contrast, encompassing the abdomen and pelvis, leading to the accurate diagnosis. The presumed path of gas tracking from the perforation through the diaphragmatic hiatus contributed to the delay in reaching the correct diagnosis. In cases where patients present with subcutaneous emphysema in the upper body, particularly when CT thorax with oral contrast has ruled out oesophageal perforation, clinical suspicion for intra-abdominal causes should persist. Despite the presence of significant surgical emphysema, this patient demonstrated a favourable response to conservative measures.

The Open Abdomen After Intra-abdominal Contamination in Emergency General Surgery

IntroductionDelayed fascial closure (DFC) is an increasingly utilized technique in emergency general surgery (EGS), despite a lack of data regarding its benefits. We aimed to compare the clinical outcomes of DFC versus immediate fascial closure (IFC) in EGS patients with intra-abdominal contamination. MethodsThis retrospective study was conducted using the 2013-2020 American College of Surgeons National Surgical Quality Improvement Program database. Adult EGS patients who underwent an exploratory laparotomy with intra-abdominal contamination [wound classification III (contaminated) or IV (dirty)] were included. Patients with agreed upon indications for DFC were excluded. A propensity-matched analysis was performed. The primary outcome was 30-d mortality. ResultsWe identified 36,974 eligible patients. 16.8% underwent DFC, of which 51.7% were female, and the median age was 64 y. After matching, there were 6213 pairs. DFC was associated with a higher risk of mortality (15.8% versus 14.2%, P = 0.016), pneumonia (11.7% versus 10.1%, P = 0.007), pulmonary embolism (1.9% versus 1.6%, P = 0.03), and longer hospital stay (11 versus 10 d, P < 0.001). No significant differences in postoperative sepsis and deep surgical site infection rates between the two groups were observed. Subgroup analyses by preoperative diagnosis (diverticulitis, perforation, and undifferentiated sepsis) showed that DFC was associated with longer hospital stay in all subgroups, with a higher mortality rate in patients with diverticulitis (8.1% versus 6.1%, P = 0.027). ConclusionsIn the presence of intra-abdominal contamination, DFC is associated with longer hospital stay and higher rates of mortality and morbidity. DFC was not associated with decreased risk of infectious complications. Further studies are needed to clearly define the indications of DFC.

Intracorporeal anastomosis in minimally invasive right hemicolectomy: a nationwide survey of the Korean Society of Coloproctology.

We investigated the current practices and perceptions of colorectal surgeons in South Korea regarding intracorporeal ileocolic anastomosis (IIA) in minimally invasive right hemicolectomy (RHC). Members of the Korean Society of Coloproctology (KSCP) participated in an online survey encompassing demographic information, surgical experiences, methods for IIA, and advantages, barriers, and perceptions of IIA. We performed a statistical analysis of survey results. Among the 1,074 KSCP members contacted, 178 responded to the survey. Most respondents were males aged 40-49 years with >10 years of experience who were affiliated with a tertiary healthcare facility. One hundred fifty-six respondents had performed <100 colorectal cancer surgeries annually. Fifty-nine respondents reported experiences of the IIA technique in minimally invasive RHC. Most respondents favored the isoperistaltic side-to-side (S-S) anastomosis and stapled S-S anastomosis, hand-sewn closure for the common channel, and the periumbilical area for primary specimen extraction. Respondents with IIA experience emphasized the reduction in postoperative complications as the primary reason for performing IIA, whereas respondents without IIA experience cited the lack of benefits as the main deterrent. Respondents commonly cited concerns regarding anastomotic leakage and intraabdominal contamination as the primary reasons for not performing IIA. Respondents with IIA experience demonstrated a more positive response towards attempting or transitioning to IIA than those without. Respondents with IIA experience prioritized self-sufficiency, whereas respondents without IIA experience prioritized proctorship and discussions of the initial cases. Measures to standardize the IIA technique and appropriate training programs must be implemented to enhance its use in minimally invasive RHC.

Evisceration due to full thickness injury to the abdominal wall, with intestinal involvement, plus trauma to the chest wall, extremities and genitals due to high voltage electrical burn; case report and review of the literature

Electrical burns are one of the most drastic traumas to which an individual can be exposed; being able to directly or indirectly compromise almost all tissues of the human body. They cause more than 3,000 admissions to specialized burn units in the United States. Up to 40% of serious electrical injuries are fatal, resulting in approximately 1000 deaths per year.Its incidence depends on the type of exposure to electricity: low voltage, due to contact with electrical cables or plugs. High voltage, due to occupational exposures and power lines while climbing trees or poles. These voltages are more likely to cause injuries to deep tissues and internal organs compared to low voltage injuries and also the degree of body surface area burned.Its approach constitutes a challenge, since the risks of visceral involvement are added to the morbidity and mortality inherent to the burn. Early treatment of intra-abdominal complications allows a more conservative approach, reducing ostomies and their associated comorbidity. It is preferable to manage the abdominal defect by preserving the tissues themselves and restoring the midline. In our case, it was feasible to perform a primary closure of the abdominal wall. Your treatment will depend on factors such as: the amount of tissue lost, intra-abdominal contamination, general condition, and factors such as: physical resources and experience of the hospital. Mortality from burns ranges between 3 and 55%, those with the highest risk of death are those at extreme ages, higher degrees of burns, injuries associated with inhalation, and injuries in patients with comorbidities.

Comparing extracorporeal, semi-extracorporeal, and intracorporeal anastomosis in laparoscopic right hemicolectomy: introducing a bridging technique for colorectal surgeons.

Intracorporeal anastomosis (IA) in laparoscopic right hemicolectomy has been associated with faster recovery in bowel function compared to extracorporeal anastomosis (EA). However, the technical difficulty of laparoscopic suturing technique and intraabdominal fecal contamination hinder many surgeons from implementing such a procedure. We introduce and compare a bridging technique designated as "semi-extracorporeal" anastomosis (SEA), which embraces the advantages and amends the drawbacks of IA and EA. Between May 2016 and October 2022, 100 patients who underwent laparoscopic right hemicolectomy were analyzed. All patients who received laparoscopic right hemicolectomy underwent one of the 3 anastomosis methods (EA, SEA, and IA) by a single colorectal surgeon at a single tertiary care hospital. Data including perioperative parameters and postoperative outcomes were analyzed by each group. A total of 100 patients were reviewed. Thirty patients underwent EA; 50 and 20 patients underwent SEA and IA, respectively. Operation time (minute) was 170 (range, 100-285), 170 (range, 110-280), and 147.5 (range, 80-235) in EA, SEA, and IA, respectively (P = 0.010). Wound size was smaller in SEA and IA compared to EA (P < 0.001). IA was associated with a shorter time (day) to first flatus compared to SEA and EA (4 [range, 2-13] vs. 4 [range, 2-7] vs. 2.5 [range, 1-4], P < 0.001). Postoperative complication showed no statistical significance between the 3 groups. Semi-extracorporeal was an attractive bridging option for colorectal surgeons worrisome of the technical difficulty of IA while maintaining faster bowel recovery and smaller wound incisions compared to EA.

Implementing protocol-based relaparoscopy for severe complications in laparoscopic colorectal surgery.

Although laparoscopy has demonstrated growing applications for either primary colorectal resections or reoperations, no standardized criteria for implementing laparoscopy in revisional surgery have been reported. This study analyzes a single-center series of major complications after laparoscopic colorectal surgery, undergoing laparoscopic (LR), or open reoperations in compliance with a hemodynamics-based institutional management. This study retrospectively analyzes a series of consecutive patients who primarily underwent either laparoscopic left colectomy or low anterior resection in a tertiary referral center between 2016 and 2021. Major complications requiring reoperation (MCR) were managed through an interdisciplinary protocol and submitted to reoperation according to patient hemodynamics and intra-abdominal contamination. A cohort analysis primarily assessed treatment failure rates (i.e., 90-day mortality and need for further surgery), while postoperative morbidity was secondarily examined. Out of 1137 laparoscopic colorectal resections, 497 patients met eligibility criteria, while 45 (9.1%) developed MCRs were managed according to the standardized interdisciplinary protocol. Revisional surgery was performed through either LR (66.7%) or (33.3%). Treatment failure was 13.3% overall, including additional surgery (11.1%) and 90-day mortality (6.6%) after reoperation. In both overall and anastomotic leak-specific MCRs, relaparoscopy resulted in minimized length of hospital stay, postoperative morbidity, and intensity of care. Relaparoscopy for MCR preserves clinical benefits related to minimally invasive colorectal surgery. Further studies should investigate applicative determinants and impediments related to the center volume.

Plastic Wound Protector vs Surgical Gauze for Surgical Site Infection Reduction in Open GI Surgery

Surgical site infections (SSIs) are prevalent hospital-acquired infections with significant patient impacts and global health care burdens. The World Health Organization recommends using wound protector devices in abdominal surgery as a preventive measure to lower the risk of SSIs despite limited evidence. To examine the efficacy of a dual-ring, plastic wound protector in lowering the SSI rate in open gastrointestinal (GI) surgery irrespective of intra-abdominal contamination levels. This multicenter, patient-blinded, parallel-arm randomized clinical trial was conducted from August 2017 to October 2022 at 13 hospitals in an academic setting. Patients undergoing open abdominal bowel surgery (eg, for bowel perforation) were eligible for inclusion. Patients were randomized 1:1 to a dual-ring, plastic wound protector to protect the incision site of the abdominal wall (experimental group) or a conventional surgical gauze (control group). The primary end point was the rate of SSI within 30 days of open GI surgery. A total of 458 patients were randomized; after 1 was excluded from the control group, 457 were included in the intention-to-treat analysis (mean [SD] age, 58.4 [12.1] years; 256 [56.0%] male; 341 [74.6%] with a clean-contaminated wound): 229 in the wound protector group and 228 in the surgical gauze group. The overall SSI rate in the intention-to-treat analysis was 15.7% (72 of 458 patients). The SSI rate for the wound protector was 10.9% (25 of 229 patients) compared with 20.5% (47 of 229 patients) with surgical gauze. The wound protector significantly reduced the risk of SSI, with a relative risk reduction (RRR) of 46.81% (95% CI, 16.64%-66.06%). The wound protector significantly decreased the SSI rate for clean-contaminated wounds (RRR, 43.75%; 95% CI, 3.75%-67.13%), particularly for superficial SSIs (RRR, 42.50%; 95% CI, 7.16%-64.39%). Length of hospital stay was similar in both groups (mean [SD], 15.2 [10.5] vs 15.3 [10.2] days), as were the overall postoperative complication rates (20.1% vs 18.8%). This randomized clinical trial found a significant reduction in SSI rates when a plastic wound protector was used during open GI surgery compared with surgical gaze, supporting the World Health Organization recommendation for use of wound protector devices in abdominal surgery. ClinicalTrials.gov Identifier: NCT03170843.

Outcomes and associated factors of open abdomen after urgent laparotomy at a University Hospital in Southern Brazil: a retrospective study.

The technique of open abdomen refers to a surgical procedure that intentionally involves leaving an opening in the abdominal wall. This study aimed to evaluate the clinical outcomes, mortality, and morbidity of patients undergoing open abdomen in a public hospital in Brazil and investigate associated risk factors associated with the outcome. Data from electronic medical records were collected from 2017 to 2022. The variables were used for descriptive analyses, association analysis, and survival analysis using the Kaplan-Meier curve. The sample included 104 patients, with 84 presenting with acute abdomen and 20 with trauma, having highly variable ages and comorbidities. Peritonitis and the need for early reoperation were the most common indication for the procedure, each accounting for 34%, and negative pressure wound therapy was the most commonly used technique. Fistula was the most frequent complication, with the majority forming in the early days after the surgery. The number of interventions and open abdomen time obtained statistical significance in comparison with the outcome. The overall mortality rate was 62,5%. Despite open abdomen being a technique that can have benefits in controlling intraabdominal contamination and preventing abdominal compartment syndrome, its implementation is associated with complications. The mortality and complication rates were high in this sample. The decision to use the technique should be individualized and based on several factors, including the indications and the patient's clinical status.

Exfoliate cancer cell analysis in rectal cancer surgery: comparison of laparoscopic and transanal total mesorectal excision, a pilot study.

Minimally invasive surgery (MIS) is currently the standard treatment for rectal cancer. However, its limitations include complications and incomplete total mesorectal resection (TME) due to anatomical features and technical difficulties. Transanal TME (TaTME) has been practiced since 2010 to improve this, but there is a risk of local recurrence and intra-abdominal contamination. We aimed to analyze samples obtained through lavage to compare laparoscopic TME (LapTME) and TaTME. From June 2020 to January 2021, 20 patients with rectal cancer undergoing MIS were consecutively and prospectively recruited. Samples were collected at the start of surgery, immediately after TME, and after irrigation. The samples were analyzed for carcinoembryonic antigen (CEA) and cytokeratin 20 (CK20) through a quantitative real-time polymerase chain reaction. The primary outcome was to compare the detected amounts of CEA and CK20 immediately after TME between the surgical methods. Among the 20 patients, 13 underwent LapTME and 7 underwent TaTME. Tumor location was lower in TaTME (7.3 cm vs. 4.6 cm, P=0.012), and negative mesorectal fascia (MRF) was more in LapTME (76.9% vs. 28.6%, P=0.044). CEA and CK20 levels were high in 3 patients (42.9%) only in TaTME. There was 1 case of T4 with incomplete purse-string suture and 1 case of positive MRF with dissection failure. All patients were followed up for an average of 32.5 months without local recurrence. CEA and CK20 levels were high only in TaTME and were related to tumor factors or intraoperative events. However, whether the detection amount is clinically related to local recurrence remains unclear.

An Iatrogenic Hepato-Peritoneal Hydatidosis Revealed at the Stage of Abdominal Cutaneous Fistula: A Case Report

Hydatidosis is a parasitic disease caused by the development of the larval form of Echinococcus granulosus, it is a significant public health problem in Morocco due to its frequency and the severity of some of its complications. Hepato-peritoneal hydatidosis is a rare serious condition, with a high risk of recurrence and significant morbidity and mortality. The peritoneal localization is most frequently iatrogenic caused by a previous hydatidosis surgery; the revelation by external abdomino-parietal fistulization makes it more uncommon. The large laparotomy surgery excision is the chosen treatment. Furthermore, to prevent possible recurrence a long-term antiparasitic therapy should be implemented. In our case, it was an intra-abdominal hydatid contamination due to the iatrogenic intraperitoneal rupture of the hepatic hydatidosis. This condition was revealed at the stage of cutaneious abdominal fistulization. The abdominal CT scan showed both positive and topographic diagnosis. our therapeutic strategy associated a large laparotomy surgery and antiparasitic medical treatment. The secondary peritoneal hydatidosis caused by iatrogenic trauma is rare but constitute a serious problem with short free recurrence disease and a high risk of morbi-mortality. This case illustrates the potential complication of hydatid cyst surgery, and the latency of the peritoneal localization.

Should Preventive Antifungal Treatment Be Given to Patients With Abdominal Contamination in the Intensive Care Unit?

Background Intra-abdominal contamination is a critical risk factor for candidemia. Because of the high mortality of candidemia and delayed results of cultures, preventive antifungal (AF) treatment can be administered. Especially in the intensive care unit (ICU), it may be necessary to determine the preventive AF approach due to the poor clinical condition of the patients. However, this practice is not standard among clinicians, and it is controversial whether it is beneficial or not. This study aimed to evaluate the effects of different AF treatment approaches (prophylactic, empirical, and culture-directed) on mortality, development of candidemia, and length of hospital stay in these patients. The primary outcome of the study was mortality, and the secondary outcomes were the development of candidemia and length of hospital stay. Methodology This is a retrospective, single-center, cohort study. Adult patients who were hospitalized in the ICU with the diagnosis of intra-abdominal contamination between January 1, 2017, and December 31, 2020, were reviewed retrospectively from electronic hospital records and Infectious Diseases ICU patient follow-up forms. Age, gender, comorbid diseases, the reason for hospitalization, history of surgical operation, surgical procedure type, length of hospital stay, culture results of blood and intraoperative intra-abdominal samples (pus, peritoneal fluid, abscess), type of AF agents, and mortality status of the patients were recorded. Furthermore, white blood cell (WBC) count, platelet count, C-reactive protein (CRP) level, procalcitonin (PCT) level, and serum albumin levels in blood samples taken on three different days (the day of diagnosis, the day of operation, and the day of candidemia) were examined. The patients were grouped as without AF, receiving prophylactic AF, receiving empirical AF, and receiving culture-directed AF. Additionally, the study population was evaluated by dividing it into two groups, namely, those who developed candidemia and those who did not. The patients were evaluated regarding the development of candidemia, AF treatment approach, length of hospital stay, and mortality. Results A total of 196 patients were included in the study. Candidemia was determined in 31.6% of the patients. Candidemia was more common in patients with a history of previous surgery and presenting with acute abdominal pain than other causes. It was determined that 70% of the patients who developed candidemia had perforation, with the most common being colonic perforation. The hospital stay was longer in patients with candidemia than without candidemia (47.9 vs. 22.4 days; p < 0.001). When empirical and prophylactic AF recipients were compared, there was no difference in mortality and length of hospital stay. Prolongation of the time to empirical treatment after perforation/leak was associated with increased candidemia (p = 0.004). Furthermore, patients with a waiting time of ≥4.5 days until surgical operation were at a higher risk of developing candidemia. Conclusions Although the study did not demonstrate a difference in terms of reducing mortality, it was concluded that preventive AF therapy can be administered to reduce the risk of candidemia and hospitalization duration, especially in patients with a history of previous surgical operations and abdominal contamination with a prolonged waiting period until the surgical operation.

Intracorporeal anastomosis for minimally invasive right colectomy - is it time for wider uptake?

In 2023, minimally invasive surgery has become the default operative platform for colorectal procedures in the majority of specialist colorectal units, across Eastern and Western countries.1-3 However, there exist differing opinions and varying levels of evidence to support the indications for, and extent to which, minimally invasive surgery is utilized.4, 5 Wide surgical uptake of minimally invasive colonic surgery did not always follow compelling evidence; one could argue, it was encouraged by commercial and industry pressures. This reality is neither unique to colonic surgery nor the uptake of minimally invasive surgery. Fortunately, the advantages of minimally invasive colonic surgery in terms of short-term recovery outcomes, and its oncological equivalence, are now well supported in the literature.6-8 One aspect of minimally invasive colonic surgery, which has not been taken up with the enthusiasm applied to mobilization of the colon, is the intracorporeal anastomosis (ICA) after right hemicolectomy. ICA is more technically demanding, and given the need for an extraction site, ICA may seem like an unnecessary step that exposes patients to potential intra-abdominal contamination. Nonetheless, some units took up this challenge – perhaps driven by the cosmetic advantage of smaller incisions, the flexibility of extraction site (Pfannenstiel or natural orifice), or the response to a technical challenge. In auditing their results, and then backed up by formal trials, these groups observed improvements in gastrointestinal recovery, with lower rates of ileus, earlier return to bowel function, and reduced length of stay.9-12 Consider the typical body habitus of patients we care for in Australia and New Zealand. In patients with central adiposity and a fatty shortened mesentery, the extracorporeal anastomosis necessitates a wider extent of dissection to ensure there is sufficient mobilization to deliver the colon through a fatty abdominal wall to the wound surface. The extraction site must be larger to minimize trauma to the stretched mesentery when it is delivered, and accommodate the resultant bulky anastomosis when it is returned to the abdomen. Despite these steps, an extracorporeal anastomosis may sometimes result in a degree of tension and trauma to the join and the mesentery. Of course, all patients stand to benefit from an anastomotic technique that reduces anastomotic and mesenteric stress. During an ICA, the mesentery is not stretched for the purposes of extraction, and the potential to manually traumatize the anastomosis when it is returned to the abdomen through a fascial incision is eliminated. These could only add to the benefits ascribed to placing a smaller extraction wound in an anatomical location with improved cosmesis and lower risk of incisional hernia.12, 13 In fact, the argument to embrace the ICA is more compelling in the western world, given the higher BMI in our patient demographic. Interestingly, this is in direct contrast to the arguments which dominate most East versus West operative oncology discussions, for example in complete mesocolic excision and central vascular ligation during right hemicolectomy, where the marginal benefits from extended lymphadenectomy techniques may be outweighed by the higher potential morbidity in patients with a higher BMI.14-18 Although ICA may be more technically demanding, laparoscopy has dominated colorectal surgical training for the last 10 years, spawning computer-based simulation to expedite the acquisition and mastery of minimally invasive skills. Furthermore, developments by industry have complemented and encouraged this drive, with fit-for-purpose instruments to facilitate various steps and surgical manoeuvres; there is no need to attempt complex steps with existing basic equipment.19 Some argue the robot may provide the ultimate answer to new, more complex technical challenges. Regardless, in 2023, the surgical community should be well equipped to learn, teach and disseminate this skill set with low risk to the patient.20 Currently, there may not be clear evidence to support universal uptake of ICA after right hemicolectomy. However, it seems to the authors that there are potential benefits for the standard western patient cohort, which deserve to be explored. Open access publishing facilitated by University of New South Wales, as part of the Wiley - University of New South Wales agreement via the Council of Australian University Librarians. Edward A. Cooper: Conceptualization; writing – review and editing. David Z. Lubowski: Conceptualization; writing – review and editing. Kim-Chi Phan-Thien: Conceptualization; writing – original draft; writing – review and editing.

Validation of appendiceal stump invagination in laparoscopic appendectomy.

There are various methods for appendiceal stump dissection, but the necessity for stump invagination remains unclear. This study aimed to assess the efficacy of appendiceal stump invagination in patients with acute appendicitis after laparoscopic appendectomy (LA). We enrolled 327 patients with acute appendicitis who underwent LA between 2012 and 2020. Perioperative variables and surgical outcomes were analyzed between the invagination of the appendiceal stump and noninvagination groups. Propensity score-matched analysis (PSM) was performed. More patients experienced severe inflammation and severe intra-abdominal contamination in the noninvagination group than in the invagination group. Patients in the noninvagination group had an older age, higher body mass index, and poorer American Society of Anesthesiologists physical status than the invagination group. Severe inflammation in the noninvagination group was associated with longer hospital stays and poorer postoperative complications than in the invagination group. PSM analysis was performed to minimize bias in the two groups. After PSM analysis, there were no significant differences in surgical site infection, postoperative intra-abdominal abscess, Clavien-Dindo class ≥IIIa, or postoperative stay between the two groups. During the follow-up period, the postoperative adhesive ileus was not significantly different between the invagination and noninvagination groups. Invagination of the appendiceal stump during LA is not necessary to prevent short- and long-term complications. Even in cases dissected using a laparoscopic endostapler, the appendiceal stump per se is not related to postoperative adhesive ileus.

Risk factors for leak after omentopexy for duodenal ulcer perforations.

Duodenal ulcer perforations are frequently encountered but there is limited literature regarding risk factors for leak after omentopexy. The record of 100 patients of duodenal ulcer perforation undergoing omentopexy by open approach was prospectively maintained to identify any significant factors contributing towards leak. Out of 100 patients undergoing omentopexy, 9 (9%) developed leak; when leak occurred, the mortality was very high (44.4%). Patients who developed leak (09) were compared against those who did not (91), and it was seen that seen that duration of symptoms before surgery (> 3days), amount of intra-abdominal contamination (> 2L), low body mass index (BMI < 19.35kg/m2), serum creatinine (> 1.5mg/dl), and deranged International Normalized Ratio (INR) were found to be significant on univariate analysis; however, multivariate analysis revealed only low BMI and high creatinine to be contributory towards leak. Leak after omentopexy carries a high morbidity and mortality. Identification of risk factors may help in optimizing patients at risk and reduce the incidence of leak and its sequelae. CTRI/2020/03/023798.

Laparoscopic appendectomy for complicated appendicitis in children: does the post-operative peritoneal drain make any difference? A pilot prospective randomised controlled trial

PurposeThis was a pilot randomised, prospective study, which aimed to determine and compare the post-operative complications of paediatric patients undergoing laparoscopic appendectomy (LA) for complicated appendicitis, with and without a peritoneal drain.MethodsPatients younger than 13 years, undergoing LA for complicated appendicitis at the Dr George Mukhari Academic Hospital (DGMAH), over a 15-month period during 2019–2020 were enrolled. Randomisation was achieved by a blocked randomisation plan. Patients were randomised in a 1:1 ratio into the “drain” (D) and “no drain” (ND) groups.ResultsThirty-four patients were included in this study; seventeen in each group. The complication rate was 26%. Intra-abdominal collection accounted for 89% of the complications. The complication rate in the “D” group was 18% and 35% in the “ND” group, with no statistically significant difference. Complication rates were higher (38%) in patients with generalised pus when compared to localised pus (7%), although not statistically significant. The mean theatre time, hospital stay, and duration of antibiotic use did not differ significantly between the groups.ConclusionFrom our study, the post-operative peritoneal drain did not make any statistically significant difference in patient outcome. The amount of intra-abdominal contamination is more likely to contribute in the development of complications.Trial registration numberSMUREC/M/15/2019: PG.

Protected Laparoscopic Large Ovarian Cyst Aspiration: A 5-Step Alternative to Laparotomy

In this video, we describe a 5-step surgical technique that allows us to safely incise and aspirate the content of large ovarian cysts through a single-port laparoscopic incision. This allows performing laparoscopic oophorectomies instead of large xipho-pubic laparotomies. A stepwise demonstration of the technique with narrated video footage. Ovarian masses, especially cysts, are common gynecologic conditions [1]. However, depending on their size, large adnexal cysts are usually managed with transverse or midline laparotomies [2]. This is to prevent cyst ruptures and abdominal contamination and ensure oncological safety of the procedure [3-5]. Different leak-proof aspiration techniques have been described in the literature allowing for safe large cyst aspiration and adnexectomy through a mini-laparotomy incision or via laparoscopy [2,3,6-10]. We describe a 5-step surgical technique allowing for closed aspiration of ovarian intracystic fluid and adnexectomy while respecting oncological safety. Step 1: Perform diagnostic laparoscopy to rule out peritoneal carcinomatosis contraindicating this procedure and then after cyst exposition, thoroughly dry the cyst wall. Step 1 Bis: Cut the cuff of a sterile glove to prepare a square piece of membrane. Step 2: Place a protective gauze and then apply the surgical glue to the ovarian cyst wall followed by the glove/membrane application. Perform a purse suture through the glove/membrane and the ovarian wall superficially to ensure further adhesion and prevent ovarian fluid spillage. Step 3: Incise the ovarian wall, introduce the aspiration cannula and tighten the purse suture to aspirate the cystic fluid. Step 4: After aspiration is complete, tighten the suture and close the glove to guarantee a closed space and prevent abdominal contamination. Step 5: Perform laparoscopic oophorectomy or cystectomy. Safely remove the specimen in an endoscopic retrieval bag through the trocar incision. This technique allows safe laparoscopic large ovarian cysts resections while respecting oncologic safety and preventing intra-abdominal spillage and contamination.

Is Natural Orifice Specimen Extraction Surgery Really Safe in Radical Surgery for Colorectal Cancer?

BackgroundThe main feature of natural orifice specimen extraction (NOSE) is its avoidance of an auxiliary abdominal incision. The safety of NOSE remains controversial. This study aimed to investigate the early safety of transanal NOSE in the treatment of sigmoid colon and upper rectal cancer from the follow aspects: clinical and pathological characteristics, inflammatory and immune indicators and postoperative complications.MethodsData from 125 patients diagnosed with sigmoid colon, and upper rectal cancer by gastrointestinal surgery in the First Affiliated Hospital of Wannan Medical College from January 2017 to June 2020 were analyzed. Patients were assigned to two surgical groups: Conventional laparoscopic-assisted radical resection for CRC (CLA, 75cases) and laparoscopic-assisted radical resection for CRC with NOSE (La-NOSE, 50 cases). The following were compared: clinical and pathological characteristics; intraoperative, bacteriological, and oncological results; postoperative inflammation and immune response indexes. Bacteriological results were obtained by aerobic and anaerobic bacterial culture of peritoneal wash fluid and oncology results by cytological analysis of peritoneal wash liquid exudation. Inflammation indicators included postoperative C-reactive protein (CRP) and procalcitonin (PCT) trend reactions. The immune index was the level of postoperative T lymphocytes (CD3, CD4/CD8). All data were analyzed by using SPSS statistical version 18.0 for windows. Measurement data are presented as the means ± standard deviations, and two-group comparisons were performed using the t-test. Comparisons of count data were performed using the chi-square test. p <0.05 indicates that the difference was statistically significant.ResultsThe bacterial culture positive rate was not significant in the La-NOSE group (15/50 vs 19/75) than in the CLA group. The exfoliative cytology (EC) rate of the peritoneal wash fluid was 0 in both groups.The La-NOSE group had a significantly higher postoperative day 2(POD2) CRP and PCT level than the CLA group. The POD2 CD3 and CD4/CD8 levels were higher in the La-NOSE group than in the CLA group. There was no significant difference in the incidence of postoperative complications between the two groups (La-NOSE group vs CLA group: 3/50 vs 6/75) (p>0.05).ConclusionsAlthough the incidence of intra-abdominal contamination is high, it does not develop into a severe infectious disease, and does not lead to the implantation of free tumor cells into the abdominal cavity. Therefore, it is safe for the NOSE to treat colorectal cancer.

RISK FACTOR ANALYSIS OF TYPE COLORECTAL OPERATION AND INTRAABDOMEN CONTAMINATION ON EVENT POST OPERATIVE ADHESION: SYSTEMATIC REVIEW AND METAANALYSIS

BACKGROUND: Colorectal surgery is the highest incidence of adhesion-related problems. The type of surgery might be total coletomy, right hemicolectomy, left hemicolectomy, segmental colectomy, Hartmann procedure, and colostomy. Surgical procedures performed on the colon could be contaminated. The most common contamination is faecal contamination. Various causes of peritoneal irritation result in localized brin production, which results in adhesion to the surfaces in contact. PURPOSE: This study focused on the type of colorectal surgery and intra-abdominal contamination on the incidence of postoperative adhesions. METHOD: Systematic review and meta-analysis. We searched for published journal on types of colorectal surgery and contamination with adhesion events published from 2010-2020 using electronic database : Pubmed, Science Direct and Cochrane. RESULT: Ten journals (8 cohort and 2 case control) were included in the meta-analysis. In the risk factors for colorectal surgery: APR surgery, total colectomy and rectal resection had a signicant risk of postoperative adhesions with a pooled odds ratio of 1.74 (95% CI 1 respectively). ,10-2,78); 2.89 (95% CI 2.44-3.41) and 9.91 (95% CI 8.66-11.35). Intra-abdominal contamination also had a risk of adhesions with a pooled odds ratio of 863.47 (95% CI 177.73-4194.13). CONCLUSION: Types of colorectal surgery : APR, total colectomy, and rectal resection and intra-abdominal contamination had a risk of postoperative adhesions.

SP3.2.3 The open abdomen is associated with increased morbidity and mortality after emergency laparotomy: a retrospective cohort study

Abstract Aims The open abdomen following emergency laparotomy for peritoneal contamination is becoming an increasingly popular method of managing severe intra-abdominal sepsis. However, this approach has been associated with increased morbidity and mortality. The aim of this study is to compare patient populations and post-operative outcomes from patients undergoing primary closure or those managed with an open abdomen after emergency laparotomy. Methods A retrospective case note review was undertaken of all patients recorded on the NELA database over a five-year period at a district general hospital. Patients with no intra-abdominal contamination or who were palliated peri-operatively were excluded. Data collected included P-possum morbidity and mortality, post-operative complications (Clavien-Dindo), length of stay and in-hospital mortality. Results 811 NELA entries were reviewed; 313 were included with 79% (n = 248) undergoing primary closure. Cohorts were similar in age and sex. P-possum morbidity and mortality scores were significantly higher in the open abdomen group (89% vs 79%, p = 0.0003; 38% vs 24%, p = 0.0003, respectively). Of the outcome variables, significant complications (34% vs 11%, p = 0.001), length of stay (31 vs 18 days, p = 0.0001) and mortality (11% vs 4%, p = 0.001) were significantly higher in the open compared to closed abdomen group. Only 10% of patients undergoing primary closure required further surgery. Conclusions This study highlights that the open abdomen is used in higher risk patients, with significantly poorer outcomes. This approach, which confers a significant physiological burden requiring further intervention should be used with caution in selected cases.

Surgical management of Encapsulating Peritoneal Sclerosis (EPS) in children: international case series and literature review

BackgroundEncapsulating Peritoneal Sclerosis (EPS) is a rare phenomenon in paediatric patients with kidney failure treated with peritoneal dialysis (PD). This study highlights clinical challenges in the management of EPS, with particular emphasis on peri-operative considerations and surgical technique.MethodsRetrospective analysis of all paediatric patients with EPS treated at the Manchester Centre for Transplantation.ResultsFour patients were included with a median duration of 78 months on PD. All patients had recurrent peritonitis (> 3 episodes), and all had symptoms within three months of a change of dialysis modality from PD to haemodialysis or transplant. In Manchester, care was delivered by a multi-disciplinary team, including surgeons delivering the adult EPS surgical service with a particular focus on nutritional optimisation, sepsis control, and wound management. The surgery involved laparotomy, lavage, and enterolysis of the small bowel + / − stoma formation, depending on intra-abdominal contamination. Two patients had a formal stoma, which were reversed at three and six months, respectively. Two patients underwent primary closure of the abdomen, whereas two patients had re-look procedures at 48 h with secondary closure. One patient had a post-operative wound infection, which was managed medically. One patient’s stoma became detached, leading to an intra-abdominal collection requiring re-laparotomy. The median length of stay was 25 days, and patients were discharged once enteral feeding was established. All patients remained free of recurrence with normal gut function and currently two out of four have functioning transplants.ConclusionsThis series demonstrates 100% survival and parenteral feed independence following EPS surgery. Post-operative morbidity was common; however, with individualised experience-based decision-making and relevant additional interventions, patients made full recoveries. Health and development post-surgery continued, allowing the potential for transplantation.Graphical abstractA higher resolution version of the Graphical abstract is available as Supplementary information