Intra-abdominal Abscess Rate Research Articles

Postoperative Adverse Events Following Neoadjuvant Therapy and Surgery for Borderline Resectable Pancreatic Cancer in a Phase 2 Clinical Trial (Alliance A021501).

Postoperative adverse events (AEs) in patients with borderline resectable pancreatic ductal adenocarcinoma (BR-PC) treated with neoadjuvant therapy and pancreatectomy in the national cooperative group setting have not been previously characterized. We conducted a preplanned secondary analysis of patients enrolled on the Alliance A021501 clinical trial to quantify perioperative AE rates. The A021501 phase 2 trial randomized patients with BR-PC to receive 8 doses of mFOLFIRINOX (Arm 1) or 7 doses of mFOLFIRINOX and hypofractionated radiotherapy (Arm 2), followed by pancreatectomy (December 31, 2016 to May 31, 2019). Adverse events were assessed 90 days after pancreatectomy. Of 126 enrolled patients, 51 (40%) underwent pancreatectomy (n = 32, Arm 1; n = 19, Arm 2) at 28 institutions. Five (10%) patients required reoperation within 90 days; 56% of patients (n = 27/48) experienced at least one grade 3 or higher AE (50% vs. 67%, p = 0.37). Ninety-day mortality was 2.0%. Readmission was less frequent in Arm 1 (16% vs. 42%, p = 0.05), but there were no differences between study arms in rates of reoperation (13% vs. 5%), pancreatic fistula or intra-abdominal abscess requiring drainage (9% vs. 16%), or wound infection (6% vs. 16%). Pancreatic fistula or intra-abdominal abscess requiring drainage was associated with receipt of adjuvant therapy (p = 0.012). No difference in overall survival was observed based on occurrence of postoperative AEs (hazard ratio = 1.1; 95% confidence interval 0.5-2.6). In this multicenter study, rates of postoperative AEs were consistent with those previously reported. Multimodality trials of preoperative therapy for BR-PC may be performed in the cooperative group setting with careful quality assurance and safety monitoring. Clinicaltrials.gov identifier: NCT02839343.

Impact of Concomitant Traumatic Pancreatic and Colon Injuries on Outcomes.

Colon and pancreatic injuries have both long been independently associated with intraabdominal infectious complications in trauma patients. The goal of this study was to evaluate the impact of concomitant pancreatic injury on outcomes in patients with traumatic colon injuries. Consecutive patients over a 3-year period who underwent operative management of colon injuries were identified. Patient characteristics, severity of injury and shock, presence and grade of pancreatic injury, and intraoperative packed red blood cell (PRBC) transfusions were recorded. Outcomes including intraabdominal abscess formation and suture line failure were collected and compared. Multivariable logistic regression analysis was then performed to determine the impact of concomitant pancreatic injury on intraabdominal abscess formation. 243 patients with traumatic colon injuries were identified. 17 of these also had pancreatic injuries. Patients with combined colon and pancreatic injuries were clinically similar to those with isolated colon injuries with respect to age, gender, penetrating mechanism of injury, admission lactate, ISS, suture line failure, and admission systolic blood pressure. Both intraabdominal abscess rates (88.2% vs 29.6%, P < .001) and intraoperative PRBC transfusions (8 vs 1 units, P = .004) were higher in the combined pancreatic and colon injury group. Multivariable logistic regression identified both intraoperative PRBC transfusions (odds ratio, 1.09; 95% confidence interval, 1.04-1.15; P < .001) and concomitant pancreatic injury (odds ratio, 14.8; 95% confidence interval, 3.92-96.87; P < .001) as independent predictors of intraabdominal abscess formation. Both intraoperative PRBC transfusions and presence of concomitant pancreatic injury are independent predictors of intraabdominal abscess formation in patients with traumatic colon injuries.

Laparoscopic Appendectomy in Complicated Appendicitis: A Narrative Review

The treatment of complicated appendicitis has moved from conservative treatment to immediate appendectomy and laparoscopic appendectomy has become the treatment of choice for this condition. Laparoscopic appendectomy is safe and associated with reduced morbidity, but it was initially associated with increased intra-abdominal abscess rates. With time there seems to be a reduction in this complication rate and hence we have conducted this review article to look at the use of laparoscopic appendectomy in the management of complicated appendicitis, with regards to complications and morbidity.

Povidone-iodine intra-abdominal irrigation versus no irrigation in pediatric perforated appendicitis: A secondary economic analysis of a Bayesian randomized controlled trial

BackgroundA pilot randomized controlled trial (RCT) conducted in children (2–17 ​y) with perforated appendicitis demonstrated an 89% probability of reduced intra-abdominal abscess (IAA) rate with povidone-iodine (PVI) irrigation, compared with no irrigation (NI). We hypothesized that PVI also reduced 30-day hospital costs. MethodsWe conducted a retrospective economic analysis of a pilot RCT. Hospital costs, inflated to 2019 U.S. dollars, were obtained for index admissions and 30-day emergency visits and readmissions. Cost differences between groups were assessed using frequentist and Bayesian generalized linear models. ResultsWe observed a 95% Bayesian probability that PVI reduced 30-day mean total hospital costs ($16,555 [PVI] versus $18,509 [NI]; Bayesian cost ratio: 0.90, 95% CrI, 0.78–1.03). The mean absolute difference per patient was $1,954 less with PVI (95% CI, -$4,288 to $379). ConclusionsPVI likely reduced the IAA rate and 30-day hospital costs, suggesting the intervention is both clinically superior and cost saving.

Early surgery for perforated appendicitis: Are we moving the needle on postoperative abscess?

BackgroundPerforated appendicitis is often managed nonoperatively though upfront surgery is becoming more common. We describe postoperative outcomes for patients undergoing surgery at their index hospitalization for perforated appendicitis. MethodsWe used the 2016–2020 National Surgical Quality Improvement Program database to identify patients with appendicitis who underwent appendectomy or partial colectomy. The primary outcome was surgical site infection (SSI). Results132,443 patients with appendicitis underwent immediate surgery. Of 14.1% patients with perforated appendicitis, 84.3% underwent laparoscopic appendectomy. Intra-abdominal abscess rates were lowest after laparoscopic appendectomy (9.4%). Open appendectomy (OR 5.14, 95% CI 4.06–6.51) and laparoscopic partial colectomy (OR 4.60, 95% CI 2.38–8.89) were associated with higher likelihoods of SSIs. ConclusionsUpfront surgical management of perforated appendicitis is now predominantly approached by laparoscopy, often without bowel resection. Postoperative complications occurred less frequently with laparoscopic appendectomy compared to other approaches. Laparoscopic appendectomy during the index hospitalization is an effective approach to perforated appendicitis.

Effect of endoscopic loop ties in acute appendicitis on wound infection rate: A meta-analysis.

A meta-analysis study to measure the consequence of endoscopic loop ties (ELT) in acute appendicitis (AA) on wound infection rate. A comprehensive literature inspection till February 2023 was applied and 2765 interrelated studies were reviewed. The 27 chosen studies enclosed 15 093 subjects with AA in the chosen studies' starting point, 7141 of them were ELT, and 7952 were open surgery. Odds ratio (OR) in addition to 95% confidence intervals (CIs) were used to compute the value of the effect of ELT in AA on wound infection rate by the dichotomous and continuous styles and a fixed or random model. Open surgery had a significantly higher postoperative surgical site wound infection (SSWI). (OR, 1.41; 95% CI, 1.09-1.83, P = 0.009) with low heterogeneity (I2 = 34%) compared to ELT in AA subjects. Although no significant difference was detected between open surgery and ELT in intra-abdominal abscess rate (OR, 0.88; 95% CI, 0.56-1.40, P = 0.59) with moderate heterogeneity (I2 = 51%) in AA subjects. Open surgery had a significantly higher postoperative SSWI, however, no significant difference was found in intra-abdominal abscess rate compared to ELT in AA subjects. However, caused by the small sample sizes of several chosen studies for this meta-analysis, care must be exercised when dealing with its values.

Is There an Increased Risk of Intra-Abdominal Abscesses After Laparoscopic Appendectomy? Laparoscopic Versus Open Appendectomy: A Single-Institution Experience

Background: Acute appendicitis is the most common cause of acute abdomen. Currently, larger numbers of appendectomies are being performed laparoscopically. The aim of this study was to compare laparoscopic appendectomies to open surgery in terms of intra- and post-operative complications, including the risk of intra-abdominal abscess formation, operative time, time of initiating oral diet, and the length of hospital stay in our institution.&#x0D; Methods: The study group of 283 patients having undergone appendectomies between January 2013 and Jan 2016 was divided into two subgroups as ‘open’ and ‘laparoscopic’. The data regarding the surgical outcomes of these groups were evaluated retrospectively and statistically analyzed.&#x0D; Results: In terms of postoperative complications, intra-abdominal abscesses were found to be higher in the laparoscopic group (p=.045). On the other hand, surgical site infection (SSI) rates were found to be higher in the open group (but did not reach statistical significance). Operative time was affected by the surgeon’s expertise and was found to be shorter in the laparoscopic group (p&lt;0.05). The time of initiating oral diet was sooner in the laparoscopic group compared to the open group (p=0.043), and the overall length of hospital stay was shorter in the laparoscopic group (p=0.0001).&#x0D; Conclusions: Laparoscopic appendectomy is associated with early return to a normal diet, fewer wound complications, and a shorter hospital stay, but also with a slightly higher rate of intra-abdominal abscesses. Notably, it is now the standard method of acute appendicitis management in some centers.

Postoperative Antibiotics for Complicated Appendicitis in Children: Piperacillin/Tazobactam Versus Ceftriaxone with Metronidazole

Recent studies are discordant regarding postoperative use of piperacillin/tazobactam (PT) versus ceftriaxone/metronidazole (CM) for pediatric complicated appendicitis. Some argue that the broader spectrum PT decreases intraabdominal abscess formation; however, antibiotic stewardship, and once-a-day dosing favor CM. We aim to compare outcomes of postoperative antibiotic utilization using a large administrative database. We queried the Pediatric Health Information System for patients 2-18 years old who underwent laparoscopic appendectomy for complicated appendicitis between 2016 and 2021. Patients were grouped into PT, CM, or other using the first postoperative day antibiotics. Adverse events and antibiotic use trends were evaluated. We included 29,015 children from 45 hospitals. CM was used in 51.9% and 31.3% received PT. Wide variation was seen among hospitals with PT use decreasing over the years. Overall rate of abscess was 9.2%. On multivariable regression, PT was associated with higher risk for abscess formation (RR 1.35, 99% CI 1.04-1.75) and readmission (RR 1.38, 99% CI 1.13-1.68) compared to the CM group. However, following adjustment for hospitals with high CM prevalence, these associations were no longer significant. Postoperative use of PT for complicated appendicitis is associated with higher rates of readmissions and intraabdominal abscess when compared to CM. However, this effect is mitigated when adjusting for common practice patterns. Level III. Retrospective Comparative Study.

S2792 A Tale of Three Stomas: A Challenging Case of Inflammatory Bowel Disease

Introduction: Inflammatory bowel disease (IBD) and diverticular disease have many overlapping sequelae. It can be difficult to distinguish between them in an acute presentation. Here, we report a challenging case of IBD that originally presented as complicated diverticular disease. We highlight the diagnostic and management considerations. Case Description/Methods: A 75-year-old female without personal or family history of IBD presented in June 2021 with abdominal pain and fever, was diagnosed with uncomplicated diverticulitis and treated with a course of antibiotics. She recovered clinically but presented in July 2021 with worsening abdominal pain and bloody diarrhea. She was found on imaging to have a colonic perforation and abscess. She was taken for a Hartmann procedure with sigmoidectomy and colostomy formation, with surgical pathology suggestive of acute diverticulitis. Abdominal pain and bloody ostomy output continued. She presented to our medical center in September 2021. Evaluation showed deep ulcerations and spontaneous friability, concerning for IBD. She was started on steroids but she proved refractory. We then offered rescue infliximab, after which she clinically improved. She was maintained on infliximab as an outpatient. Before repeat endoscopic evaluation, she presented again to the hospital with abdominal pain and was found to have another colonic perforation. She underwent a completion subtotal colectomy, extensive lysis of adhesions and received an end ileostomy. Pathology showed severely active chronic pancolitis with ulceration. She currently is in clinical remission, not currently on any IBD therapy. Discussion: The diagnosis for this patient has proved difficult, given her initial acute presentation. Complicated diverticulitis has overlapping features with IBD, and is more prevalent than IBD. It is less prevalent in the IBD population, with one study showing prevalence in ulcerative colitis (UC) of 10.8% compared to 27.8% in healthy controls. Endoscopic evaluation was important in understanding the presence of IBD, though it has been challenging to define a distinct entity of UC versus Crohn’s disease given her history of abscess and colonic perforation. The rate of intra-abdominal abscess in UC is low but has been described. In one single center analysis, the rate of intra-abdominal abscess in UC vs Crohn’s disease with 0.8% vs 2.4%, respectively. After surgical recovery, we plan for small bowel evaluation to further delineate the extent of inflammation.Figure 1.: Image from colonoscopy from 9/21/21 showing erythema, ulceration, friability.

Standardized perioperative care reduces colorectal surgical site infection in children: A Western Pediatric Surgery Research Consortium multicenter analysis

PurposeSurgical site infection (SSI) remains a significant source of patient morbidity and resource utilization in children undergoing colorectal surgery. We examined the utility of a protocolized perioperative care bundle in reducing SSI in pediatric patients undergoing colorectal surgery. MethodsWe conducted a prospective cohort study of patients ≤18 years of age undergoing colorectal surgery at ten United States children's hospitals. Using a perioperative care protocol comprising eight elements, or “colon bundle”, we divided patients into low (1–4 elements) or high (5–8 elements) compliance cohorts. Procedures involving colorectal repair or anastomosis with abdominal closure were included. Demographics and clinical outcomes were compared between low and high compliance cohorts. Compliance was compared with a retrospective cohort. The primary outcome was superficial SSI incidence at 30 days. ResultsThree hundred and thirty-six patients were included in our analysis: 138 from the low compliance cohort and 198 from the high compliance cohort. Age and gender were similar between groups. Preoperative diagnosis was similar except for more patients in the high compliance cohort having inflammatory bowel disease (18.2% versus 5.8%, p<0.01). The most common procedure performed was small bowel to colorectal anastomosis. Wound classification and procedure acuity were similar between groups. Superficial SSI at 30 days occurred less frequently among the high compliance compared to the low compliance cohort (4% versus 9.7%, p = 0.036). Median postoperative length of stay and 30-day rates of readmission, reoperation, intra-abdominal abscess and anastomotic leak requiring operation were not significantly different between groups. None of the individual colon bundle elements were independently protective against superficial SSI. ConclusionStandardization of perioperative care is associated with a reduction in superficial SSI in pediatric colorectal surgery. Expansion of standardized protocols for children undergoing colorectal surgery may improve outcomes and decrease perioperative morbidity. Type of StudyClinical Research Paper Level of EvidenceLevel II

Impact of postoperative NSAIDs (IV-PCA) use on short-term outcomes after laparoscopic gastrectomy for the patients of gastric cancer.

Further data are necessary to evaluate the risk of complications associated with the use of non-steroidal anti-inflammatory drugs (NSAIDs) postoperatively. This study aimed to determine the correlation between the use of NSAIDs in intravenous patient-controlled analgesia (IV-PCA) and postoperative complications after laparoscopic gastrectomy in patients with gastric cancer. This retrospective, single-center study was conducted. The study population comprised 2150 patients who underwent laparoscopic gastrectomy for gastric cancer treatment. They were divided into two groups: non-NSAIDs (n = 1215) and NSAIDs (n = 935) according to their use of the drugs. Clinicopathologic characteristics, operative details, postoperative complications within 30days, risk factors for complications, and survival were analyzed. Of the 2150 patients, 935 (43.49%) used NSAIDs. The overall complication rate showed no significant difference between the NSAIDs and non-NSAIDs groups (22.7% vs. 20.7%, p = 0.280), while the rates of anastomotic leakage and duodenal leakage were higher in the NSAID group (2.4% vs. 0.7%, p = 0.002 and 1.8% vs. 0.6%, p = 0.007, respectively). The rates of intra-abdominal bleeding and intra-abdominal abscess were significantly higher in the NSAID group (2.1% vs. 0.7%, p = 0.005 and 1.5% vs. 0.4%, p = 0.008, respectively). However, postoperative ileus occurred more frequently in the non-NSAID group (3.0% vs. 1.4%, p = 0.015). On multivariate analysis, NSAID use was an independent risk factor for early postoperative complications (1.303 [1.042-1.629], p = 0.020). Meanwhile, the NSAID group showed no differences in overall survival at each pathological stage. Postoperative NSAID use by IV-PCA is associated with anastomotic leakage, duodenal stump leakage, intra-abdominal bleeding, and intra-abdominal abscess in patients who underwent laparoscopic gastrectomy for gastric cancer. Caution is advised when NSAIDs are used peri-operatively.

Antibiotic bowel preparation prior to epithelial ovarian cancer surgery does not impact infectious or oncologic outcomes (494)

<b>Objectives:</b> Antibiotic therapy has been associated with worse oncologic outcomes in women with epithelial ovarian cancer (EOC) receiving platinum chemotherapy. The objective of this study was to identify whether antibiotic bowel preparation impacts progressionfree survival (PFS) and overall survival (OS) in women with epithelial ovarian cancer (EOC). <b>Methods:</b> An IRB-approved, retrospective single-institution cohort study was performed in women who underwent cytoreductive surgery (CRS) for EOC from 2008 to 2017. Type of bowel preparation was defined as <i>1)</i> none, <i>2)</i> mechanical bowel preparation alone, or <i>3)</i> antibiotic with or without mechanical bowel preparation. Infectious wound outcomes were defined using Centers for Disease Control definitions: superficial incisional SSI, deep incisional SSI, and organ/ space infections. The impact of bowel preparation type upon incidence of SSI was assessed using univariate models. Cox regression was used to determine the impact of bowel preparation on progression-free survival (PFS) and overall survival (OS). <b>Results:</b> Of 560 women, 174 (31.1%) received no bowel preparation, 354 (63.2%) received mechanical bowel preparation, and 32 (5.7%) received antibiotic bowel preparation, either alone or in combination with mechanical bowel preparation. The superficial SSI rate was 12.6% (<i>n</i>=22), 10.2% (<i>n</i>=36), and 6.3% (<i>n</i>=2) for patients with no bowel preparation, mechanical bowel preparation and antibiotic bowel preparation, respectively (p=0.48). Similarly, there was no difference in pelvic or intra-abdominal abscess rate between the groups: 8.6% (<i>n</i>=15), 4.0% (<i>n</i>=14), and 3.1 % (<i>n</i>=1), respectively (p=0.069). On univariate analysis, there was no difference in PFS between no bowel preparation versus mechanical bowel preparation (17.5 vs 20.5 months, HR: 0.98, 95% CI: 0.79-1.20, p=0.82) or no bowel preparation versus antibiotics bowel preparation (17.5 vs 14.9 months; HR: 1.09, 95% CI: 0.70-1.69, p=0.70). Similarly, there was no statistically significant difference in OS between the three groups (60.9 months vs 54.3 months vs 48.0 months, p=0.30 and p=0.49, respectively). <b>Conclusions:</b> In women with EOC undergoing CRS, the type of bowel preparation does not impact infectious or oncologic outcomes. Given recent studies showing negative impacts of antibiotics on chemotherapy response in EOC, further investigation is needed to understand how timing and delivery of antibiotics may impact outcomes.

Inhalation anaesthesia compared with total intravenous anaesthesia and postoperative complications in colorectal cancer surgery: an observational registry-based study†

BackgroundPostoperative complications are common after colorectal surgery, and possibly related to the type of anaesthesia. We aimed to determine associations between the type of anaesthesia and complications after colorectal cancer surgery using Danish registries. MethodsPatients undergoing colorectal cancer surgery (2004–18) were identified in the Danish Colorectal Cancer Group Database. The cohort was enriched with the Danish Anaesthesia Database and Danish National Prescription Registry data linked by Danish Central Person Registration number. Patients were classified according to type of general anaesthesia: inhalation or TIVA. Confounders were adjusted by propensity score matching. The primary outcome was complications within 30 days postoperatively. Secondarily, we assessed specific medical and surgical complications. ResultsWe identified 22 179 individuals undergoing colorectal cancer surgery with accompanying anaesthesia data. Propensity score matching yielded 8722 individuals per group. After propensity score matching, postoperative complications were seen in 1933 (22.2%) patients undergoing inhalation anaesthesia and in 2199 (25.2%) undergoing TIVA (odds ratio [OR]=0.84; 95% confidence interval [CI], 0.79–0.91). Although no difference was observed for medical complications, 1369 (15.7%) undergoing inhalation anaesthesia had surgical complications compared with 1708 (19.6%) undergoing TIVA (OR=0.76; 95% CI, 0.71–0.83). Rates of wound dehiscence, anastomotic leak, ileus, wound abscess, intra-abdominal abscess, and sepsis were statistically significantly lower in the inhalation anaesthesia group. ConclusionIn this propensity score-matched registry study, use of inhalation anaesthesia was associated with fewer postoperative complications after colorectal cancer surgery than use of TIVA. Inhalation anaesthesia was associated with fewer complications related to wound healing and surgical infections.

Costs associated with postoperative intra-abdominal abscess in pediatric perforated appendicitis: A retrospective cohort study

BackgroundIntra-abdominal abscess, the most common complication after perforated appendicitis, is associated with considerable economic burden. However, costs of intra-abdominal abscesses in children are unknown. We aimed to evaluate resource utilization and costs attributable to intra-abdominal abscess in pediatric perforated appendicitis. MethodsA single-center retrospective analysis was performed of children (<18 years) who underwent appendectomy for perforated appendicitis (2013–2019). Hospital costs incurred during the index admission and within 30 postoperative days were obtained from the hospital accounting system and inflated to 2019 USD. Generalized linear models were used to determine excess resource utilization and costs attributable to intra-abdominal abscess after adjusting for confounders. ResultsOf 763 patients, 153 (20%) developed intra-abdominal abscesses. Eighty-one patients with intra-abdominal abscesses (53%) underwent percutaneous abscess drainage. Intra-abdominal abscess was independently associated with a nearly 8-fold increased risk of 30-day readmission (adjusted risk ratio, 7.8 [95% confidence interval, 4.7–13.0]). Patients who developed an intra-abdominal abscess required 6.1 excess hospital bed days compared to patients without intra-abdominal abscess (95% confidence interval, 5.3–7.0). Adjusted mean hospital costs for patients with intra-abdominal abscess totaled $27,394 (95% confidence interval, $25,688–$29,101) versus $15,586 (95% confidence interval, $15,102–$16,069) for patients without intra-abdominal abscess. Intra-abdominal abscess was associated with an incremental cost of $11,809 (95% confidence interval, $10,029–$13,588). Hospital room costs accounted for 66% of excess costs. ConclusionPostoperative intra-abdominal abscess nearly doubled pediatric perforated appendicitis costs, primarily due to more hospital bed days and associated room costs. Intra-abdominal abscesses resulted in estimated excess costs of $1.8 million during the study period. Even small reductions in intra-abdominal abscess rates or hospital bed days could yield substantial health care savings.

Is laparoscopy a reliable alternative to laparotomy in Hartmann's reversal? An updated meta-analysis.

The aim of this study was to perform a systematic review of the literature on and updated meta-analysis of surgical postoperative complications after laparoscopic Hartmann's reversal (LHR) and open Hartmann's reversal (OHR). Studies comparing LHR versus OHR published from inception until June 2020 were selected and submitted to a systematic review and meta-analysis. Articles were searched in the MEDLINE and Cochrane Trials Register databases. Meta-analysis was performed with Review Manager 5.0. Twenty-three retrospective comparative studies (including 5 case-controlled studies) with a total of 3139 patients with LHR and a total of 10,325 patients with OHR were included. Meta-analysis showed that LHR was significantly associated with a decreased rate of revision surgery (OR = 0.73, 95% CI = 0.60-0.89, p < 0.001), anastomotic leakage (OR = 0.61, 95% CI = 0.49-0.75, p < 0.00001), postoperative morbidity (OR = 0.53, 95% CI = 0.47-0.58, p < 0.00001), intra-abdominal abscess (OR = 0.67 [0.52-0.87], 95% CI = , p = 0.003), wound abscess (OR = 0.53 [0.46-0.61], 95% CI = , p < 0.00001), and postoperative ileus (OR = 0.46, 95% CI = 0.29-0.72, p = 0.0008), respectively. Conversely, mortality was comparable between LHR and OHR. These results suggest that LHR significantly improved surgical postoperative outcomes. However, considering the low level of evidence, further randomized trials are required to validate these findings.

Primary colorectal anastomosis, no preparation, no stoma needed

Background: Mechanical bowel preparation was regarded for a long time as a vital prerequisite for successful colorectal surgery; this is now being questioned. The distressful effect of bowel preparation, alongside the safety of primary colorectal anastomosis in emergency cases, has led to a considerable change in the surgical protocol, making primary repair and anastomosis after colon resection safer without bowel preparation, and the role of colostomy has changed from mandatory to optional. Aim: To assess whether colorectal surgery can be performed safely without mechanical bowel preparation or colostomy. Method: A series of 130 patients, who underwent elective and emergency colorectal surgery, were followed prospectively over a three-year period in Al Bashir Teaching Hospital, Amman, Jordan. The patients were randomized into two groups. In one group (preparation group) 66 elective patients were selected from the outpatient department; the bowel was prepared using Fortran’s solution. In the second group (non-preparation group), 64 patients were selected from the emergency and outpatient departments, no bowel preparation was used. Colostomy was omitted in both groups. The main outcomes regarding operative time, hospital stay, rate of postoperative wound infection, anastomotic leak and intra-abdominal abscess were compared between the two groups. Results: Malignancy was the most prevalent pathology in both the preparation and non-preparation groups, 75.7% and 62.5% respectively, while benign diseases were present in up to 24.2% of the preparation group and in 1.5% of the non-preparation group. Anastomosis was ileo-colic in 33.3% and 37.5%, colo-colic or colo-rectal in 66.6% and 62.5% of the preparation and non-preparation groups respectively. There was no significant statistical difference in the overall postoperative complication rates between the two groups, 16.6% in the preparation group and 14% in the non-preparation group. Postoperative wound infection, wound dehiscence, intra-abdominal abscess and anastomotic leak occurred in 9.09%, 1.5%, 1.5% and 4.5% in the preparation group, as compared to 7.8%, 3.1%, 0% and 3.1% in the non-preparation group respectively. The mortality rate was nil in both groups. Conclusion: Resection of colorectal pathology followed by primary anastomosis, without stoma, can be performed safely with the omission of preoperative mechanical bowel preparation.

Diagnostic Value of Serum Cytokines in Predicting a Complicated Acute Appendicitis.

The diagnostic role of serum cytokines depends on the etiology and pathogenesis of acute appendicitis but the clinical significance of these cytokines in the differential diagnosis of complicated acute appendicitis remains unclear. To investigate the prediction of progression and diagnostic values of interleukin-6, interleukin-1 beta, and tumor necrosis factor-alpha in complicated acute appendicitis. This study was conducted in 100 patients with a definitive diagnosis of acute appendicitis and 20 individuals assigned for the control group. Venous blood was collected to assess biochemical tests, as well as interleukin-6, interleukin-1β, and tumor necrosis factor-α levels. Serum levels of all parameters were dramatically higher in the complicated group compared with uncomplicated. Duration of hospitalization, rates of postoperative infection, intraabdominal abscess, and re-hospitalization were higher in complicated group. Cut-off points of WBC, CRP, NLR, interleukin-6, interleukin-1β and tumor necrosis factor-α were 13.5x103/µL, 1.92 mg/dL, 6.09, 23.4 pg/mL, 5.6 pg/mL and 24 pg/mL (p=0.0014, p<0.001, p=0.009, respectively and p<0.001 for the rest). AUC of interleukin-6 was larger than AUCs of all other parameters, suggesting the highest predicting power of interleukin-6 among other parameters. Serum interleukin-6, interleukin-1β, and tumor necrosis factor-α levels are valuable diagnostic parameters to predict a complicated acute appendicitis.

Inappropriate manipulation and drainage exacerbate post-operative pain and prolong the hospital stay after laparoscopic appendectomy for pediatric complicated appendicitis

BackgroundThis study examined whether drain placement or not is associated with the postoperative outcomes of pediatric patients following trans-umbilical single-port laparoscopic appendectomy (TUSPLA) for complicated appendicitis.Methods The medical records of pediatric patients undergoing TUSPLA for acute complicated appendicitis from January 2012 to September 2018 in Kaohsiung Chang Gung Memorial Hospital were reviewed retrospectively. They were classified according to whether they received passive drainage with a Penrose drain (Penrose group) (19), active drainage with a Jackson-Pratt drain with a vacuum bulb (JP group) (16), or no drain (non-drain group) (86). The postoperative outcomes of the three groups were compared.ResultsPostoperative visual analog scale pain score was significantly higher in the non-drain group than in either the JP group or Penrose group. Patients in the Penrose group had a significantly longer postoperative hospital stay than those in the non-drain group and a higher rate of intra-abdominal abscess, while patients in the JP group had a significantly shorter postoperative hospital stay; moreover, no patient in JP group developed a postoperative intra-abdominal abscess.ConclusionsCompared to passive drainage with a Penrose drain or no drain, active drainage with a JP drain shorter the postoperative hospital stay and decreased the risk of postoperative intra-abdominal abscess.

A dual-institutional study on first-year practice outcomes of pediatric surgeons who trained in the era of work hour restrictions.

In July 2003, an 80-h work week restriction for residencies was mandated. This was met with skepticism regarding its potential impact on operative training. We hypothesized no difference in outcomes for pediatric surgeons who trained under duty hour restrictions compared to historical complication rates. Dual-institutional review of pediatric patients who underwent five of the most common operations (2013-2018) by first-year pediatric surgeons who trained under duty hour restrictions was performed. Tests of proportions were used to compare complication rates to published rates on data collected prior to 2003. Patient mean age was 10.1years. No significant differences (p values > 0.05) were found in laparoscopic appendectomy rates of infection, bleeding or intra-abdominal abscess compared to previously published rates. Pyloromyotomy rates of infection or duodenal perforation were not different. No differences were detected in rates of infection, recurrence or testicular atrophy for inguinal hernia repair. Umbilical hernia rates of infection, bleeding, and recurrence were also not different. There was no difference in CVC rates of hemopneumothoraces; significantly more bleeding events were detected (1.2% vs. 0.1%; p value = 0.04). In this study, first-year complication rates of pediatric surgeons who trained under duty hour restrictions were not significantly different when compared to published rates.

Re-visiting Drain Use in Operative Liver Trauma: A Retrospective Analysis

Despite the liver being one of the most frequently injured abdominal organs in trauma patients, clinical management strategies differ between trauma surgeons. Few studies have critically evaluated current practice patterns in the operative management of liver trauma. Historical studies recommended against the use of drains but there has not been a modern investigation of this issue. The objective of this study was to analyze outcomes associated with intra-operative drain use for liver trauma. A retrospective chart review of all adult trauma patients presenting to a Level I trauma center from 2012 to 2018 was performed. Patients who underwent operative management of liver trauma were divided into groups based on whether an intra-abdominal drain was utilized and differences in outcomes between the groups were analyzed. The primary endpoint evaluated was post-operative intra-abdominal abscesses. Univariate and multivariate analyses were performed. 184 patients with operative management of liver trauma were included in the study. Closed suction drains were utilized in 26.1% of post-operative patients. Rate of intra-abdominal abscesses was significantly higher in the drain group (35.4% versus 8.8%, P < 0.001). Drains were more commonly used in patients receiving more units of PRBCs (median, 9 units [IQR 4-20] versus median 5.5 units, [IQR 2-14], P=0.03). Drain use was found to be an independent risk factor for post-operative intra-abdominal abscess on multivariate analysis (OR 4.9, 95% CI 1.7-14, P=0.003). The results of this study support previous conclusions that drain placement for operative liver trauma is associated with increased risks of infectious complications. Drains were used in patients with more severe liver injury, intra-operative bile leaks, penetrating trauma, and increased blood transfusion requirements. Future studies should focus on the development of specific guidelines for the use of drains in liver trauma.