Level 1a Evidence Comparing Use of Antibiotics Versus No Antibiotics in Management of Acute Left-Sided Uncomplicated Diverticulitis.

BACKGROUND: Acute uncomplicated diverticulitis (AUD) is a common cause of acute abdominal pain. Recent guidelines advise selective use of antibiotics in AUD patients. This meta-analysis aimed to compare the effectiveness of no antibiotics vs antibiotics in AUD patients. METHODS: This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses to identify randomized controlled trials (RCTs) involving AUD patients which compared the use of antibiotics with no antibiotics. Pooled outcome data was calculated using random effects modeling with 95% confidence intervals (CIs). RESULTS: 5 RCTs with 1934 AUD patients were included. 979 patients were managed without antibiotics (50.6%). Patients in the no antibiotic and antibiotic groups had comparable demographics (age, sex, and body mass index) and presenting features (temperature, pain score, and C-reactive protein levels). There was no significant difference in rates of complicated diverticulitis (OR: .61, 95% CI: 0.27-1.36, P = .23), abscess (OR: .51, 95% CI: .08-3.25, P = .47) or fistula (OR: .33, 95% CI: .03-3.15, P = .33) formation, perforation (OR: .98, 95% CI: .32-3.07, P = .98), recurrence (OR: .96, 95% CI: .66-1.41, P = .85), need for surgery (OR: 1.36, 95% CI: .47-3.95, P = .37), mortality (OR: 1.27, 95% CI: .14-11.76, P = .82), or length of stay (MD: .215, 95% CI: -.43-.73, P = .61) between the 2 groups. However, the likelihood of readmission was higher in the antibiotics group (OR: 2.13, 95% CI: 1.43-3.18, P = .0002). CONCLUSION: There is no significant difference in baseline characteristics, clinical presentation, and adverse health outcomes between AUD patients treated without antibiotics compared to with antibiotics.

Role of Omega-3 Fatty Acid Infusion in Surgical Outcomes of Perforation Peritonitis Patients: A Randomized Controlled Trial.

Background Perforation peritonitis is associated with a high rate of morbidity and mortality in spite of advances in antibiotics and surgical techniques. The Omega-3 fatty acid is an immune-enhancing essential fatty acid that has been found to have anti-inflammatory properties, which help in quicker recovery. The present study examined the role of Omega-3 fatty acid infusion in the surgical outcome of perforation peritonitis. Methods Three hundred consecutive patients in the age group of 18-70 years operated for perforation peritonitis were included in this study. Patients in the study group received Omega-3 fatty acid emulsion postoperatively while those in the control group received a placebo. The groups were compared with respect to clinical and biochemical parameters. Results The Omega-3 fatty acid helped in reducing postoperative complications. The incidence of postoperative pyrexia (22.67% versus 82.67%), chest infection (6% versus 31.33%), and complete wound dehiscence (12% versus 34%) was significantly less in the study group compared to the control group. There was a 4.5-day difference in overall length of stay, favoring the study group who were on Omega-3 fatty acids (LOS 8.06 vs. 12.65 days). There was no mortality in the study group compared with 17 deaths (11.3%) in the control group. Conclusion Postoperative perforation peritonitis patients receiving Omega-3 fatty acids are at a lower risk of developing postoperative complications, have a shorter duration of hospital stay, and have lower morbidity and mortality.

Effect of Octreotide on Lymphorrhea in Patients After Modified Radical Mastectomy for Carcinoma Breast: A Randomized Controlled Trial.

Introduction Lymphorrhea or seroma formation after modified radical mastectomy (MRM) is a serious and disabling complication of axillary lymphadenectomy. Octreotide is a hormone with general anti-secretory effects. The potential role of octreotide in the treatment of lymphorrhea after axillary lymph node dissection in patients undergoing MRM is being investigated in this study. The purpose of this research is to study the effect of octreotide on the magnitude and duration of lymphorrhea in patients after MRM for carcinoma breast. Methods This clinical trial was registered in the Clinical Trials Registry India (CTRI/2017/11/010653). It was conducted in the Department of General Surgery, Maulana Azad Medical College and associated Lok Nayak Hospital, New Delhi from September 2015 to March 2017. This study is a parallel randomized controlled trial with a 1:1 allocation ratio. Thirty patients were enrolled and allocated equally into two groups. The intervention group received standard medical care plus injection octreotide 100 micrograms eight hourly intravenously post-operatively for five days and the control group received only standard medical care. The primary outcomes were lymphorrhea volume from 24 hours post-surgery till five days post-operatively and the number of days till the suction drain was removed. Secondary outcomes were surgical site infection, the incidence of seroma formation, complications of octreotide, duration of hospital stay, and the number of lymph nodes isolated. All the patients were followed up twice a week for the first six weeks after discharge followed by three monthly visits. Results A total of 30 patients were included in the study. The mean age was 46.2 years. The mean operative time in the control group was 137.87 ± 23.28 minutes and in the octreotide group was 128.13 ± 12.29 (p = 0.163). The volume of lymphorrhea in the control group was 354.67 ± 346.28 ml and in the octreotide group was 194.00 ± 240.62 ml (p = 0.081). Seroma occurred in 9% of patients in the control group and 2 % of patients in the octreotide group (p = 0.010). The duration of lymphorrhea was 4.93 ± 2.49 days in the control group and 3.13 ± 1.36 days in the octreotide group (p = 0.029). The duration of stay was 7.07 ± 2.40 days in the control group and 5.13 ± 1.06 days in the octreotide and was found to be statistically significant (p = 0.010). No obvious adverse reactions related to injection octreotide, namely, nausea, vomiting, abdominal discomfort, hypotension, bradycardia, and dysglycemia, were seen in any of our patients. Conclusion The duration of lymphorrhea, incidence of seroma formation, and duration of hospital stay were lesser in the octreotide group, and the difference was statistically significant. The wound infection rates were similar in both groups. Thus injection octreotide can be used safely and effectively.

Role of Acute Physiology, Age, and Chronic Health Evaluation (APACHE) II Score in Predicting Outcomes of Peritonitis Due to Hollow Viscous Perforation: A Prospective Observational Study.

Background The Acute Physiology and Chronic Health Evaluation II (APACHE II) is the most commonly used severity-of-disease scoring system in ICUs worldwide. There is a paucity of data describing the role of APACHE II score in predicting outcomes of peritonitis due to hollow viscous perforation. This study aims at identifying the importance of the APACHE II score in predicting outcomes of patients with peritonitis secondary to hollow viscus perforation. Methods The study is a prospective, observational study that included all the patients diagnosed with perforation peritonitis who underwent emergency laparotomy and were admitted to the Department of Surgery from May 2017 to May 2018. APACHE II scores were assigned to all patients in order to calculate their individual risk of mortality before undergoing emergency surgery. The accuracy in outcome prediction of the APACHE II system was assessed by means of receiver operating characteristic (ROC) curve and Pearson correlation coefficient and its significance test. Result A total of 50 patients with perforation peritonitis were included in this study. Peptic ulcer disease was the major etiology leading to perforation in 54% of patients, followed by gangrenous bowel. The mean APACHE II score was 9.54. Out of the 50 patients, seven patients succumbed to the illness. All the seven patients whose APACHE II score > 16 developed systemic complications, and three of them developed a local complication. Conclusion APACHE II score correlated well with the outcome in the current study, and APACHE II score also correlated well with the hospital and ICU stay.

Spontaneous Hepatic Hydatid Cyst Rupture Into the Transverse Colon.

Hydatid disease is a prevalent parasitic infestation caused by the cestode Echinococcus  granulosus in predominantly rural areas of the Mediterranean region, South East Asia, Australia, and South America. This report discusses a unique case of a 32-year-old lady who presented to the Emergency Surgery Department with complaints of abdominal pain, distension, and constipation for five days. Radiological investigations showed air-fluid levels within a large cyst originating from the liver. Surgical exploration revealed a large hepatic hydatid cyst communicating with the transverse colon with the presence of multiple peritoneal hydatid cysts. Evacuation of the cyst contents, lavage, and excision of the rest of the hydatid cysts was done. Dense adhesions were present involving the liver, large bowel, and duodenum. Therefore, a terminal ileum diversion loop ileostomy was made. Ileostomy was reversed after checking the large bowel anatomy with a distal loopogram.

Ingestion of nine metallic nails with corrosive: what happened next?

A 20-year-old woman was brought to the surgery emergency department with the complaint of epigastric pain since 1 day following ingestion of multiple metallic nails with a cup full of toilet cleaner (corrosive acid) with a suicidal intention. Physical examination was essentially unremarkable, and the abdomen showed no signs of perforation peritonitis. X-rays of the abdomen showed multiple 'nail'-like radiopaque shadows in the abdominal cavity with no evidence of free gas under the domes of the diaphragm. A non-operative expectant management was pursued. The patient had passed all the sharps in stools without any complication and was discharged after 12 days. After 3 weeks, the patient presented with non-bilious vomiting. Further investigations revealed pyloric stenosis with no oesophageal luminal stenosis. To bypass the pyloric stenosis, a Billroth II gastrojejunostomy was performed. The postoperative period was uneventful, and the recovery was smooth.