Purse-string skin closure versus linear skin closure in people undergoing stoma reversal.

BACKGROUND: Stoma reversal is associated with a relatively high risk of surgical site infection (SSI), occurring in up to 40% of cases. This may be explained by the presence of microorganisms around the stoma site, and possible contamination with the intestinal contents during the open-end manipulation of the bowel, making the stoma closure site a clean-contaminated wound. The conventional technique for stoma reversal is linear skin closure (LSC). The purse-string skin closure (PSSC) technique (circumferential skin approximation) creates a small opening in the centre of the wound, enabling free drainage of contaminants and serous fluid. This could decrease the risk of SSI compared with LSC. OBJECTIVES: To assess the effects of purse-string skin closure compared with linear skin closure in people undergoing stoma reversal. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, two other databases, and three trials registers on 21 December 2022. We also checked references, searched for citations, and contacted study authors to identify additional studies. SELECTION CRITERIA: We included all randomised controlled trials (RCTs) comparing PSSC and LSC techniques in people undergoing closure of stoma (loop ileostomy, end ileostomy, loop colostomy, or end colostomy) created for any indication. DATA COLLECTION AND ANALYSIS: Two review authors independently selected eligible studies, extracted data, evaluated the methodological quality of the included studies, and conducted the analyses. The most clinically relevant outcomes were SSI, participant satisfaction, incisional hernia, and operative time. We calculated odds ratios (ORs) for dichotomous data and mean differences (MDs) for continuous data, each with its corresponding 95% confidence interval (CI). We used the GRADE approach to rate the certainty of the evidence. MAIN RESULTS: Nine RCTs involving 757 participants were eligible for inclusion. Eight studies recruited only adults (aged 18 years and older), and one study included people aged 12 years and older. The participants underwent elective reversal of either ileostomy (82%) or colostomy (18%). We considered all studies at high risk of performance and detection bias (lack of blinding) and four studies at unclear risk of selection bias related to random sequence generation. PSSC compared with LSC likely reduces the risk of SSI (OR 0.17, 95% CI 0.09 to 0.29; I2 = 0%; 9 studies, 757 participants; moderate-certainty evidence). The anticipated absolute risk of SSI is 52 per 1000 people who have PSSC and 243 per 1000 people who have LSC. The likelihood of being very satisfied or satisfied with stoma closure may be higher amongst people who have PSSC compared with people who have LSC (100% vs 89%; OR 20.11, 95% CI 1.09 to 369.88; 2 studies, 122 participants; low-certainty evidence). The results of the analysis suggest that PSSC compared with LSC may have little or no effect on the risk of incisional hernia (OR 0.51, 95% CI 0.07 to 3.70; I2 = 49%; 4 studies, 297 participants; very low-certainty evidence) and operative time (MD -2.67 minutes, 95% CI -8.56 to 3.22; I2 = 65%; 6 studies, 460 participants; very low-certainty evidence). AUTHORS' CONCLUSIONS: PSSC compared with LSC likely reduces the risk of SSI in people undergoing reversal of stoma. People who have PSSC may be more satisfied with the result compared with people who have LSC. There may be little or no difference between the skin closure techniques in terms of incisional hernia and operative time, though the evidence for these two outcomes is very uncertain.

Predictive value of Hajibandeh index in determining peritoneal contamination in acute abdomen: A cohort study and meta-analysis.

BACKGROUND: Hajibandeh index (HI), derived from combined levels of C-reactive protein, lactate, neutrophils, lymphocytes and albumin, is a modern predictor of peritoneal contamination and mortality in patients with acute abdominal pathology. AIM: To validate the performance of HI in predicting the presence and nature of peritoneal contamination in patients with acute abdominal pathology in a larger cohort study and to synthesis evidence in a systematic review and meta-analysis. METHODS: The STROBE guidelines and the PRISMA statement standards were followed to conduct a cohort study (ChiCTR2200056183) and a meta-analysis (CRD42022306018), respectively. All adult patients undergoing emergency laparotomy for acute abdominal pathology were eligible. The accuracy of the HI was evaluated using receiver operating characteristic (ROC) curve analysis in the cohort study and using weighted summary area under the curve (AUC) under the fixed and random effects modelling in the meta-analysis. The Quality Assessment of Diagnostic Accuracy Studies 2 criteria were used for methodological quality assessment of the included studies. RESULTS: A total of 1437 patients were included (700 from the cohort study and 737 from the literature search). ROC curve analysis of the cohort study showed that the AUC of HI for presence of contamination, purulent contamination and feculent contamination were 0.79 [95% confidence interval (CI): 0.76-0.82, P < 0.0001], 0.76 (95%CI: 0.72-0.80, P < 0.0001), and 0.83 (95%CI: 0.79-0.86, P < 0.0001), respectively. The meta-analysis showed that the pooled AUC of HI for presence of contamination, purulent contamination and feculent contamination were 0.79 (95%CI: 0.75-0.83), 0.78 (95%CI: 0.74-0.81), and 0.80 (95%CI: 0.77-0.83), respectively. CONCLUSION: The HI is a strong and accurate predictor of intraperitoneal contamination. Although the available evidence is robust, it is limited to the studies conducted by our evidence synthesis group. We encourage other researchers to validate performance of HI in predicting the presence of intraperitoneal contamination and more importantly in predicting mortality following emergency laparotomy.

Hajibandeh Index versus NELA score in predicting mortality following emergency laparotomy: A retrospective Cohort Study.

OBJECTIVES: To compare performance of the Hajibandeh Index (HI) and National Emergency Laparotomy Audit (NELA) score in predicting postoperative mortality in patients undergoing emergency laparotomy. METHODS: In compliance with STROCSS guidelines for observational studies a cohort study was conducted. All patients aged over 18 who underwent emergency laparotomy between January 2014 and January 2021 in our centre were considered eligible for inclusion. The HI and NELA indices in predicting 30-day and 90-day postoperative mortality were compared. The discrimination of each test was evaluated using Receiver Operating Characteristic (ROC) curve analysis, classification using the classification table and calibration using a plotted diagram of the expected versus observed mortality rates. RESULTS: Analysis of 700 patients showed that the predictive performance of the HI and NELA models were comparable (30-day mortality: AUC: 0.86 vs 0.87, P = 0.557; 90-day mortality: AUC: 0.81 vs 0.84, P = 0.0607). In terms of 30-day mortality, HI was significantly better than the NELA model in predicting postoperative mortality in patients aged over 80 (AUC: 0.85 vs 0.72, P = 0.0174); however, the performances of both tools were comparable in patients with ASA status above 3 (AUC: 0.82 vs 0.82, P = 0.9775), patients with intraperitoneal contamination (AUC: 0.77 vs 0.85, P = 0.0728) and patients who needed a bowel resection (AUC: 0.85 vs 0.88, P = 0.2749). In terms of 90-day mortality, HI was significantly better than the NELA model in predicting mortality in patients aged over 80 (AUC: 0.82 vs 0.71, P = 0.0214); however, NELA had better predictive value in patients with intraperitoneal contamination (AUC: 0.76 vs 0.85, P = 0.0268); the performances of both tools were comparable in patients with ASA status above 3 (AUC: 0.77 vs 0.80, P = 0.2582), and patients who needed a bowel resection (AUC: 0.81 vs 0.86, P = 0.05). Both tools were comparable in terms of classification and calibration. CONCLUSIONS: Hajibandeh index was better than the NELA score in predicting postoperative 30-day and 90-day mortality in patients aged over 80 undergoing emergency laparotomy. Its performance in predicting 30-day and 90-day mortality was comparable with NELA score in other subgroups except 90-day mortality in patients with intraperitoneal contamination where the performance of NELA was better. We encourage other researchers to validate HI in predicting mortality following emergency laparotomy.

The risk and predictors of mortality in octogenarians undergoing emergency laparotomy: a multicentre retrospective cohort study.

OBJECTIVES: This study aims to evaluate the risk of postoperative mortality in octogenarians undergoing emergency laparotomy. METHODS: In compliance with STROCSS guideline for observational studies, we conducted a multicentre retrospective cohort study. All consecutive patients aged over 80 with acute abdominal pathology requiring emergency laparotomy between April 2014 and August 2019 were considered eligible for inclusion. The primary outcome measure was 30-day postoperative mortality, and the secondary outcome measures were in-hospital mortality and 1-year mortality. Statistical analyses included simple descriptive statistics, binary logistic regression analyses, and Kaplan-Meier survival statistics. RESULTS: A total of 523 octogenarians were eligible for inclusion. Emergency laparotomy in octogenarians was associated with 21.8% (95% CI 18.3-25.6%) 30-day postoperative mortality, 22.6% (95% CI 19.0-26.4%) in-hospital mortality, and 40.2% (95% CI 35.9-44.5%) 1-year mortality. Binary logistic regression analysis identified ASA status (OR, 2.49; 95% CI 1.82-3.38, P < 0.0001) and peritoneal contamination (OR, 2.00; 95% CI 1.30-3.08, P = 0.002) as predictors of 30-day postoperative mortality. The ASA status (OR, 1.92; 95% CI 1.50-2.46, P < 0.0001), peritoneal contamination (OR, 1.57; 95% CI 1.07-2.48, P = 0.020), and presence of malignancy (OR, 2.06; 95% CI 1.36-3.10, P = 0.001) were predictors of 1-year mortality. Log-rank test showed significant difference in postoperative survival rates among patients with different ASA status (P < 0.0001) and between patients with and without peritoneal contamination (P = 0.0011). CONCLUSIONS: Emergency laparotomies in patients older than 80 years with ASA status more than 3 in the presence of peritoneal contamination carry a high risk of immediate postoperative and 1-year mortality. This should be taken into account in communications with patients and their relatives, consent process, and multidisciplinary decision-making process for operative or non-operative management of such patients.

Meta-analysis of survival and functional outcomes after total mesorectal excision with or without lateral pelvic lymph node dissection in rectal cancer surgery.

BACKGROUND: To compare outcomes of total mesorectal excision with or without lateral pelvic lymph node dissection for the treatment of rectal cancer. METHODS: The electronic data sources were explored to capture all studies comparing total mesorectal excision with and without lateral pelvic lymph node dissection in patients undergoing operation for rectal cancer. Random effects modelling was utilized for the analyses. The uncertainties associated with varying follow-up periods among the included studies were resolved by analysis of time-to-event outcomes. RESULTS: Eighteen comparative studies enrolling 6,133 patients were eligible. No difference was found between the 2 groups in terms of overall survival (hazard ratio: 0.92, 95% confidence interval 0.77-1.10, P = .36, I2 = 67%), overall survival at maximum follow-up (odds ratio: 1.02, 95% confidence interval 0.83-1.25, P = .86, I2 = 22%), 5-year overall survival (odds ratio: 1.01, 95% confidence interval 0.78-1.30, P = .94, I2 = 50%), disease-free survival (hazard ratio: 1.25, 95% confidence interval 0.87-1.82, P = .23, I2 = 74%), disease-free survival at maximum follow-up (odds ratio 1.07, 95% confidence interval 0.88-1.31, P = .50, I2 = 0%), 5-year disease-free survival (odds ratio: 1.07, 95% confidence interval 0.86-1.32, P = .54, I2 = 0%), local recurrence (odds ratio: 1.01, 95% confidence interval 0.72-1.42, P = .97, I2 = 34%), distant recurrence (odds ratio: 0.96, 95% confidence interval 0.62-1.46, P = .84, I2 = 18%), and total recurrence (odds ratio: 0.97, 95% confidence interval 0.72-1.29, P = .82, I2 = 0%). Total mesorectal excision with lateral pelvic lymph node dissection resulted in longer operative time (mean difference: 116.02, 95% confidence interval 89.20-142.83, P < .00001, I2 = 68%) and higher risks of postoperative complications (odds ratio: 1.59, 95% confidence interval 1.14-2.24, P = .007, I2 = 0%), urinary dysfunction (odds ratio: 6.66, 95% confidence interval 3.31-13.39, P < .00001, I2 = 23%), and sexual dysfunction (odds ratio: 9.67, 95% confidence interval 2.38-39.26, P = .002; I2 = 51%). The results remained consistent through separate analyses for randomized trials, observational studies, and patients with or without neoadjuvant chemoradiotherapy. CONCLUSION: The available evidence suggests that lateral pelvic lymph node dissection results in greater postoperative morbidity, urinary dysfunction, and sexual dysfunction without improving recurrence and survival. Further evidence is needed from randomized controlled trials to enable experts in the nerve-sparing surgical experiences and neoadjuvant therapy experience to advise on the best treatment strategies for the management of rectal cancer patients including those with possible positive nodes on pretreatment imaging.

The incidence of right-sided colon cancer in patients aged over 40 years with acute appendicitis: A systematic review and meta-analysis.

OBJECTIVES: To determine the incidence of right-sided colon cancer in patients aged over 40 years with acute appendicitis. METHODS: We performed a systematic review in accordance with PRISMA statement standards. A search of electronic information sources was conducted to identify all studies reporting the incidence of right-sided colon cancer in patients aged over 40 years with acute appendicitis. The ROBINS-I tool was used to assess the risk of bias of the included studies. Fixed-effect and random-effects models were applied to calculate pooled outcome data. RESULTS: A total of 8 studies, enrolling 4328 patients, were included. The mean age of patients was 59 (95% CI 53-65); 54% were male (2330 out of 4328). The diagnosis of appendicitis and colon cancer were based on histological assessment only. In patients aged over 40 years the pooled incidence of right-sided colon cancer was 1.043% (95% CI 0.762-1.367); the level of between-study heterogeneity was low (I2 = 0%, P = 0.45). The risk of right-sided colon cancer in patients aged over 40 with acute appendicitis was significantly higher than the risk in general population [standardised risk ratio (SRR): 10.65 95% CI 3.83-29.66, P < 0.0001]. The number needed to treat (NNT) was calculated as 112 patients (95% CI 83-171). The quality of available evidence was moderate. CONCLUSIONS: The risk of right-sided colon cancer in patients aged over 40 years with acute appendicitis is 10 times higher than the risk in general population. This suggests a need for routine preoperative CT scans and postoperative colonic assessment in all patients aged over 40 years presenting with acute appendicitis.

Meta-analysis and Trial Sequential Analysis of Randomized Controlled Trials Comparing High and Low Ligation of the Inferior Mesenteric Artery in Rectal Cancer Surgery.

BACKGROUND: Despite ongoing debates, there is still no consensus regarding where to divide the inferior mesenteric artery for oncological reasons in rectal cancer: at its origin from the aorta (high ligation) or distal to the origin of the left colic artery (low ligation). OBJECTIVES: The purpose of this study was to compare the outcomes of high and low ligation of the inferior mesenteric artery in rectal cancer surgery. DATA SOURCES: MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, World Health Organization International Clinical Trials Registry, ClinicalTrials.gov, and ISRCTN Register were searched. STUDY SELECTION: andomized controlled trials investigating outcomes of curative anterior resection in patients with cancer of the rectum were included. INTERVENTIONS: High ligation of the inferior mesenteric artery was compared with low ligation technique. MAIN OUTCOME MEASURES: We measured the total number of lymph nodes harvested, anastomotic leak, postoperative complications, postoperative mortality, operative time, intraoperative blood loss, conversion to open surgery, overall survival, and disease-free survival. RESULTS: Analysis of 1102 patients from 8 trials suggested no difference between high and low ligation of the inferior mesenteric artery in terms of total number of lymph nodes harvested (mean difference = -0.87; p = 0.26), anastomotic leak (OR = 1.39; p = 0.15), postoperative complications (OR = 1.39; p = 0.78), postoperative mortality (risk difference = -0.00; p = 0.48), operative time (mean difference = -1.99; p = 0.79), intraoperative blood loss (mean difference = -2.28; p = 0.77), conversion to open surgery (risk difference = 0.01; p = 0.48), 5-year overall survival (OR = 0.76; p = 0.32), 5-year disease-free survival (OR = 0.88; p = 0.58), overall survival at maximum follow up (OR = 0.80; p = 0.43), and disease-free survival at maximum follow-up (OR = 0.83; p = 0.35). LIMITATIONS: Limited data were available on functional and long-term survival outcomes. CONCLUSIONS: There is no difference between high and low ligation of the inferior mesenteric artery in terms of oncological outcomes or postoperative morbidity and mortality. The available evidence is subject to potential confounding by the use of neoadjuvant therapy, adjuvant therapy, disease stage, location of tumor, and use of protective stoma. Functional outcomes including postoperative bowel, urinary and sexual function, and long-term survival outcomes should be the outcome of study in future trials. PROSPERO registration number: CRD42019148626.

Diathermy versus scalpel for skin incision in patients undergoing open inguinal hernia repair: A systematic review and meta-analysis.

OBJECTIVES: To compare outcomes of diathermy and scalpel for skin incision in patients undergoing open inguinal hernia repair. METHODS: We performed a systematic review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement standards. We conducted a search of electronic information sources to identify all randomised controlled trials (RCTs) and observational studies comparing use of diathermy and scalpel for skin incision in patients undergoing inguinal hernia repair. Surgical site infection (SSI) was the primary outcome measure. Secondary outcome measures included haematoma, seroma, visual analogue scale (VAS) pain score at 6 h, 12 h, and 24 h, and incision time. We used Cochrane risk of bias tool and ROBINS-I tool to assess the risk of bias of randomised and non-randomised studies. Fixed-effect model was applied to calculate pooled outcome data. RESULTS: We identified 9 studies, 4 randomised controlled trials and 5 prospective cohort studies, enrolling a total of 830 patients. Meta-analysis of RCTs showed no difference between the diathermy and scalpel groups in terms of surgical site infection (OR: 0.77, 95% CI 0.34, 1.75, P = 0.53), seroma (OR: 0.86, 95% CI 0.29, 2.55, P = 0.78), VAS pain score at 6 h (MD: -0.10, 95% CI -0.31, 0.11, P = 0.34), 12 h (MD: -0.10, 95% CI -0.13, 0.33, P = 0.40), and 24 h (MD: 0.03, 95% CI -0.16, 0.21, P = 0.79). Use of diathermy for skin incision was associated with shorter incision time (MD: -36.00, 95% CI -47.92, -24.08, P < 0.00001) and lower risk of haematoma (OR: 0.14, 95% CI 0.03, 0.65, P = 0.01). Meta-analysis of observational studies showed no difference between the diathermy and scalpel groups in terms of surgical site infection (OR: 0.87, 95% CI 0.54, 1.39, P = 0.55), haematoma (OR 0.14, 95% CI 0.02-1.23, P = 0.08), seroma (OR: 0.86, 95% CI 0.29, 2.55, P = 0.78), VAS pain score at 6 h (MD: -0.10, 95% CI -0.44, 0.24, P = 0.56), 12 h (MD: -0.10, 95% CI -0.26, 0.46, P = 0.58), and 24 h (MD: 0.10, 95% CI -0.27, 0.47, P = 0.59). Use of diathermy for skin incision was associated with shorter incision time (MD: -39.40, 95% CI -41.02, -37.78, P < 0.00001). The results remained consistent through sensitivity analyses. The between-study heterogeneity was low and the quality of the available evidence was moderate. CONCLUSIONS: There is no difference between use of diathermy and scalpel for skin incision in patients undergoing open inguinal hernia repair in terms of surgical site infection, seroma and postoperative pain. Use of diathermy for skin incision may be associated with shorter incision time and may reduce the risk of haematoma formation.

Watch-and-wait approach versus surgical resection after chemoradiotherapy for patients with rectal cancer (the OnCoRe project): a propensity-score matched cohort analysis.

BACKGROUND: Induction of a clinical complete response with chemoradiotherapy, followed by observation via a watch-and-wait approach, has emerged as a management option for patients with rectal cancer. We aimed to address the shortage of evidence regarding the safety of the watch-and-wait approach by comparing oncological outcomes between patients managed by watch and wait who achieved a clinical complete response and those who had surgical resection (standard care). METHODS: Oncological Outcomes after Clinical Complete Response in Patients with Rectal Cancer (OnCoRe) was a propensity-score matched cohort analysis study, that included patients of all ages diagnosed with rectal adenocarcinoma without distant metastases who had received preoperative chemoradiotherapy (45 Gy in 25 daily fractions with concurrent fluoropyrimidine-based chemotherapy) at a tertiary cancer centre in Manchester, UK, between Jan 14, 2011, and April 15, 2013. Patients who had a clinical complete response were offered management with the watch-and-wait approach, and patients who did not have a complete clinical response were offered surgical resection if eligible. We also included patients with a clinical complete response managed by watch and wait between March 10, 2005, and Jan 21, 2015, across three neighbouring UK regional cancer centres, whose details were obtained through a registry. For comparative analyses, we derived one-to-one paired cohorts of watch and wait versus surgical resection using propensity-score matching (including T stage, age, and performance status). The primary endpoint was non-regrowth disease-free survival from the date that chemoradiotherapy was started, and secondary endpoints were overall survival, and colostomy-free survival. We used a conservative p value of less than 0·01 to indicate statistical significance in the comparative analyses. FINDINGS: 259 patients were included in our Manchester tertiary cancer centre cohort, 228 of whom underwent surgical resection at referring hospitals and 31 of whom had a clinical complete response, managed by watch and wait. A further 98 patients were added to the watch-and-wait group via the registry. Of the 129 patients managed by watch and wait (median follow-up 33 months [IQR 19-43]), 44 (34%) had local regrowths (3-year actuarial rate 38% [95% CI 30-48]); 36 (88%) of 41 patients with non-metastatic local regrowths were salvaged. In the matched analyses (109 patients in each treatment group), no differences in 3-year non-regrowth disease-free survival were noted between watch and wait and surgical resection (88% [95% CI 75-94] with watch and wait vs 78% [63-87] with surgical resection; time-varying p=0·043). Similarly, no difference in 3-year overall survival was noted (96% [88-98] vs 87% [77-93]; time-varying p=0·024). By contrast, patients managed by watch and wait had significantly better 3-year colostomy-free survival than did those who had surgical resection (74% [95% CI 64-82] vs 47% [37-57]; hazard ratio 0·445 [95% CI 0·31-0·63; p<0·0001), with a 26% (95% CI 13-39) absolute difference in patients who avoided permanent colostomy at 3 years between treatment groups. INTERPRETATION: A substantial proportion of patients with rectal cancer managed by watch and wait avoided major surgery and averted permanent colostomy without loss of oncological safety at 3 years. These findings should inform decision making at the outset of chemoradiotherapy. FUNDING: Bowel Disease Research Foundation.

Neonatal extravasation injury: prevention and management in Australia and New Zealand-a survey of current practice.

BACKGROUND: Extravasation injury remains an important cause of iatrogenic injury in neonatal intensive care. This study aims to describe the current approach to extravasation injury (EI) prevention and management in Neonatal Intensive Care Units (NICUs) in Australia and New Zealand. METHODS: A literature review regarding extravasation injury in the newborn was carried out to inform questionnaire design. An internet-based survey was then conducted with the clinical directors of the 27 tertiary NICUs in Australia and New Zealand. RESULTS: The survey received a 96% response rate. Approximately two thirds of Australian and New Zealand NICUs have written protocols for prevention and management of extravasation injury. Considerable practice variation was seen for both prevention and treatment of EI. 92% of units had experienced cases of significant EI. CONCLUSIONS: Australian and New Zealand tertiary neonatal units clearly recognise EI as an important cause of iatrogenic morbidity and mortality. Significant variation still exists among units with regards to guidelines for both prevention and management of EI. We recommend that neonatal staff should remain vigilant, ensuring that guidelines for the prevention and treatment of EI are available, and rigorously followed.

Does pre-operative chemoradiotherapy cause wound complications after abdominoperineal excision for rectal cancer? An observational study.

INTRODUCTION: Neo-adjuvant chemoradiotherapy is commonly used before surgery for rectal cancer. Very low rectal cancers are still treated by abdominoperineal excision of the rectum (APER). Perineal wound complications are common after APER. There is evidence that radiotherapy increases wound complications. We wished to examine the effect of preoperative radiotherapy (SCPRT) and long course chemoradiotherapy (LCCRT) on perineal wound complications. METHODS: We undertook a review of all patients undergoing APER at one institution between 2000 and 2010. Details of SCPRT, LCCRT and both minor and major wound complications were identified by retrospective notes review. RESULTS: Of 74 patients suitable for analysis, 38 (51%) had recorded wound complications, with 23 (31%) having major wound complications. 43 patients (58%) underwent LCCRT and 11 (15%) SCPRT. Overall wound complications were more common in the LCCRT group than those receiving no treatment (58% vs 30%, p = 0.03), and major wound complications more common after SCPRT than LCCRT (45% vs 35%, p = 0.04) or no treatment (45% vs 10%, p = 0.04). Use of mesh led to more wound complications (71% vs 41%), but almost all of these patients received LCCRT. CONCLUSIONS: Pre-operative LCCRT and SCPRT are both associated with increased perineal wound complications after APER.

Changing management of suspected appendicitis in the laparoscopic era.

INTRODUCTION: The aims of this study were to examine the trends in performance of open and laparoscopic appendicectomy at a district general hospital, and to compare the diagnostic outcomes in the two patient groups. PATIENTS AND METHODS: Data were collected prospectively from patients undergoing an open or laparoscopic procedure for suspected appendicitis in an 8-year period between January 2000 and December 2007. RESULTS: A total of 1700 patients (873 women, 827 men) with a median age of 24 years underwent surgery for suspected appendicitis in the study period. There were 1357 patients (group A) who underwent an open procedure for presumed appendicitis (610 women and 747 men [F:M ratio, 1:1.2]). There were 343 patients (group B) who underwent laparoscopy with or without laparoscopic appendicectomy (82 men and 261 women [F:M ratio, 1:0.31]). Over the study period, there was an increasing trend towards the performance of laparoscopic procedures for suspected appendicitis, increasing from 4% to 39% of the total per year. In group A, 1172 (86%) patients had appendicular pathology, while the appendix was normal histologically in 178 (13%). Other pathologies were diagnosed intra-operatively in 1%. In group B, 193 patients (56%) had appendicular pathology while in 150 (44%) the appendix was normal. In the subgroup with a normal appendix, 56 patients (37%) had another cause for their symptoms identified. CONCLUSIONS: Laparoscopic appendicectomy is increasingly being performed. Laparoscopy is often used as a diagnostic tool in general surgical patients, particularly women, with lower abdominal pain. In effect, these patients are undergoing diagnostic laparoscopy, with or without appendicectomy. This has resulted in a lower positive appendicectomy rate, but a higher yield of diagnoses other than appendicitis, in the laparoscopic group. Overall appendicectomy rates, however, have remained unchanged.

Initial experience of laparostomy with immediate vacuum therapy in patients with severe peritonitis.

INTRODUCTION: To report our initial experience of laparostomy and immediate intra-abdominal vacuum therapy in patients with severe peritonitis due to intra-abdominal catastrophes. PATIENTS AND METHODS: Twenty-seven patients underwent emergency laparotomy and laparostomy formation with the application of immediate intra-abdominal TRAC-VAC therapy (male:female ratio, 1:1.2; median age, 73 years; range, 34-84 years). Predicted mortality was assessed using the P-POSSUM score and compared with clinically observed outcomes. RESULTS: Ten patients (37%) with a mean predicted P-POSSUM mortality of 72%, died of sepsis and multi-organ failure. Seventeen patients (mean P-POSSUM 48% expected mortality) survived to discharge. One patient with pancreatitis died from small bowel obstruction 1-year post discharge, two patients developed a small bowel fistula. One patient had an allergic reaction to the VAC dressing. Our patients, treated with laparostomy and TRAC VAC therapy, had a significantly improved observed survival when compared to P-POSSUM expected survival (P = 0.004). CONCLUSIONS: Laparostomy with immediate intraperitoneal VAC therapy is a robust and effective system to manage patients with intra-abdominal catastrophes. There were significantly improved outcomes compared to the mortality predicted by P-POSSUM scores. Damage control surgery with laparostomy formation and intra-abdominal VAC therapy should be considered in patients with severe peritonitis.

Atypical midgut malrotation presenting as chronic bowel obstruction in the eighth decade.

An elderly patient was referred urgently to our rapid access suspected colorectal cancer clinic with symptoms suspicious for malignancy. Despite exhaustive investigations, no cause for his symptomatology could be identified. However, his condition deteriorated and we elected to undertake exploratory surgery, at which time a congenital midgut malrotation, causing chronic small bowel obstruction, was identified. The malrotation was surgical corrected and the patient has made a full recovery.

The "double endoloop" technique--a simple alternative technique for laparoscopic appendectomy.

Diagnostic laparoscopy is now being frequently used in the emergency management of patients with acute lower abdominal pain, particularly where appendicitis is suspected. It is particularly useful in women where other responsible gynecologic causes can be diagnosed and treated thereby decreasing the rate of negative open appendectomy. Recent advances in laparoscopic techniques have resulted in increasing numbers of patients proceeding to laparoscopic appendectomy. Here, we describe a modification of laparoscopic appendectomy using a "double endoloop technique." We have used this method in 53 patients during last 18 months in selected cases. The procedure is simple, quick, effective, and cheap.