Enhanced recovery after surgery programs improve short-term outcomes after liver transplantation-A systematic review and meta-analysis.

This systematic review aimed to investigate the available quality of evidence (QOE) of enhanced recovery after surgery (ERAS) for liver transplantation (LT) on short-term outcomes, grade recommendations, and identify relevant components for ERAS protocols. A systematic review and meta-analysis were conducted on short-term outcomes after LT when applying comprehensive ERAS protocols (> 1 ERAS component) versus control groups (CRD42021210374), following the GRADE approach for grading QOE and strength of recommendations. Endpoints were morbidity, mortality, length of stay, and readmission rates after ERAS for LT. Of 858 screened articles, two randomized controlled trials, two prospective, and one retrospective cohort studies were included (2002-2020). Frequent ERAS components were early extubation and postoperative antibiotic, fluid, and nutrition management. Overall complications were reduced in ERAS versus control cohorts (OR .4 (CI .2, .7), with no significant differences in mortality and hospital readmission rates. Intensive care unit and hospital length of stay were shorter in ERAS groups (percentage decrease, 55% and 29%, respectively). QOE for individual outcomes was rated moderate to low. ERAS protocols in LT are related to improved short-term outcomes after LT (QOE; Moderate to low | Grade of Recommendation; Strong), but currently lack standardization.

Out of the Loop: The Value of a Preoperative Loopogram for Colostomy Reversal in Trauma.

BACKGROUND: Stoma is occasionally fashioned during trauma surgery. A loopogram is routinely conducted in the surgical planning for stoma reversal. This is associated with medical and cost implications. A study was undertaken to evaluate the influence of loopograms on the management of trauma patients at a Johannesburg hospital. METHODS: A retrospective analysis of records in the stoma database (January 2013 to December 2018) was conducted. The patient demographics, method of injury, stoma-type, loopogram findings and post-operative courses were analysed. RESULTS: 112 records were obtained. 9 (8%) patients were excluded for pending investigations or surgery. 13 (11.6%) patients were excluded for incomplete data. The remaining 90 (80.3%) patients, with a mean age of 32.9 had non-contributory loopograms and underwent a reversal procedure. 43 (47.8%) had a loop colostomy while 47 (52.2%) had undergone a Hartmann's procedure. Mechanism of injury was stab wounds (81.4%L; 61.7%H); gunshot wounds (13.9%L; 29.7%H) and blunt trauma (L5% and 9%H). The post-operative complication rate was 30% for the loop group (2.3% ≥ Clavien-Dindo 3) and 25.5% for the Hartmann's group (4% ≥ Clavien-Dindo 3). The average timing to reversal was 38 weeks (range 12-60) in the Hartmann's group and 22 weeks (range 12-32) the loop colostomy group. CONCLUSION: Significant findings are infrequent on loopogram for trauma patients. When these findings are detected, the effect on management is questionable. They are not without complications and have cost and time implications. Loopograms are helpful in selective cases rather than as a routine investigation, particularly in resource-limited settings.

Xanthogranulomatous cholecystitis complicated by a cholecysto-colonic fistula and liver abscesses.

A 57-year-old male presented to the emergency department with right upper quadrant pain and constitutional symptoms. Initial investigation revealed biliary sepsis with features of chronic cholecystitis, multiple liver abscesses and a fistulous connection between the gallbladder and colon. He was subsequently diagnosed with a cholecysto-colonic fistula, an unusual complication of biliary pathology, with an incidence of 0.06-0.14% at cholecystectomy. It is the second most common form of cholecystoenteric fistula, the first of which is cholecystoduodenal. A preoperative diagnosis was suggested using computed tomography and sinogram imaging. The associated liver abscesses together with the xanthogranulomatous inflammation found on histopathology, makes the case particularly exceptional.

Unusual case of a migrating spinal bullet: An opportunity for reflection.

The following case report documents the presentation of a 28 year old male who presented to the Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) trauma unit following a single gunshot wound to the spine. He presented walking, with no neurological dysfunction. On further investigation he was found to have a retained bullet at the L3 level of the spinal canal, which migrated within the canal from its initial point of entry. He was subsequently taken for a laminectomy and bullet removal under fluoroscopic guidance. Post operatively he was noted to have reduced proprioception bilaterally.

Post-traumatic arteriovenous malformation of the superficial temporal artery.

An arteriovenous malformation is a rare vascular anomaly composed of a complex network of interconnected arteries and veins of the scalp. It is usually congenital, but infrequently occurs after trauma. Over the years, several terms have been used to describe these lesions, such as cirsoid/rasemose/arteriovenous aneurysm, plexiform angioma and aneurysma serpentinum, or arteriovenous fistula when a single connection exists. Head and neck malformations occur in 0.1% of the population. Involvement of the superficial temporal artery is rare, occurring in about 0.5% to 2.0% of cases. They are diagnosed by angiography and can be managed by endovascular or open resection. The case of a 23-year-old man who presented with a pulsatile head mass after blunt trauma 5 years prior is presented. This entity was diagnosed as an arteriovenous malformation supplied by the superficial temporal arteries. He subsequently underwent successful open exploration and resection. The information is presented with the patient's consent.

Incidental gastric diverticulum in a young female with chronic gastritis: A case report.

INTRODUCTION: Gastrointestinal upset is a common presentation to surgical departments, often requiring investigation with endoscopy. Pathologies such as gastritis or ulcers are common culprits. Occasionally, rare or unusual pathologies, such as gastric diverticula as was seen in the case presented, are found. CASE PRESENTATION: A 26 year old female, with no known co-morbid conditions presented with a two week history of abdominal pain associated with nausea and vomiting. On further inquiry, she had one episode of blood stained vomiting, prompting investigation with an oesophagogastroduodenoscopy (OGD). Findings included diffuse haemorrhagic gastritis with a single outpouching measuring 1-2 cm in the gastric fundus. A gastric diverticulum was confirmed on barium swallow. Investigation with sonar and a Computed Tomography (CT) scan reported the stomach as normal. CONCLUSION: The patient was successfully treated non-operatively with proton pump inhibitor therapy for her concomitant gastritis. Gastric Diverticula are often associated with other gastric findings and their individual contribution varies from case to case. DISCUSSION: Gastric Diverticula are the manifestation of a common condition in an unusual location. Their clinical implications vary from being insignificant to life threatening when complicated by haemorrhage, perforation or malignant transformation. The associated symptoms are non-specific and diagnosis may be challenging. The case highlights the importance of selecting appropriate imaging modalities for luminal structures, being only diagnosed in 2 (OGD, Swallow) of the four modalities (incl. ultrasound and CT scan) used. Treatment may be conservative or surgical and is patient dependent. Written consent and ethical approval was obtained. The work is reported in line with the SCARE criteria.

Splenic artery aneurysm as a rare cause of an upper GIT bleed.

Upper gastrointestinal bleeding (UGIB) is a common life-threatening presentation in the emergency department. Causes are typically divided into variceal and non-variceal bleeds. Non-variceal pathologies typically include bleeding peptic ulcers, haemorrhagic gastritis and Mallory Weiss Tears. Occassionally, less common pathologies are encountered such as Dieulafoy's lesions, haemosuccus pancreas, haemobilia or aorto-enteric fistula. The following report documents the case of a 49-year-old man who presented with an UGIB. His risk factors included a history of nonsteroidal anti-inflammatory drug, smoking and ethanol abuse. Despite his typical presentation and risk factors, investigation revealed an unusual and rare pathology. He was found to have a giant splenic artery aneurysm, abutting and eroding the gastric mucosa. Diagnosis was made using a combination of gastro-oesophagoscopy and CT scan. Successful treatment consisted of angio-embolisation of the aneurysm.

Oesophageal tuberculosis with concomitant candidiasis: a rare cause of dysphagia.

We present a case of a 23-year-old woman with dysphagia. She was reportedly newly diagnosed with HIV and had been initiated on antiretroviral treatment and tuberculosis (TB) prophylaxis. Oesophagogastroduodenoscopy revealed an irregular, ulcerative oesophageal lesion. Subsequent histopathology revealed M ycobacterium tuberculosis as well as C andida albicans A CT scan demonstrated widespread disease with miliary TB. She was subsequently initiated on antituberculous and antifungal medications. TB is one of the most common and deadly infectious diseases in the world, with the highest rates seen in the developing countries. It commonly occurs as an opportunistic infection of HIV. Despite its potential for systemic infection, infection of the oesophagus is incredibly rare, more so as a co-infection with candida. This case highlights the need to have a high index of suspicion in high risk groups, as early treatment is crucial in addressing this global health crisis.