Primary omental torsion with clinical masquerading as acute appendicitis and radiological key for diagnosis.

Omental torsion is a medical condition characterized by the twisting of the omentum along its longitudinal axis, which leads to compromised blood flow. This condition is rarely diagnosed before surgery and can present symptoms similar to other causes of acute surgical abdomen. This report details a case of primary omental torsion initially suspected to be acute appendicitis. The patient was admitted to the hospital with symptoms of lower right quadrant abdominal pain and mild fever. Computed tomography imaging revealed a twisted mass of fatty tissue with surrounding fat stranding changes, but no signs of appendicitis were found, indicating omental torsion. The patient underwent surgery to remove the twisted and necrotic omentum, leading to an improvement in symptoms. This case highlights the challenges in diagnosis and the crucial role of computed tomography imaging in managing this rare condition.

Frailty and Long-Term Mortality Following Emergency Laparotomy: A Comparison Between the 11-Item and 5-Item Modified Frailty Indices.

INTRODUCTION: Emergency laparotomy (EL) is a high-risk operation which is increasingly performed on an aging patient population. Objective frailty assessment using a validated index has the potential to improve preoperative risk stratification. This study aimed to assess the correlation between frailty and long-term mortality and morbidity outcomes for older EL patients. Secondary aims were to compare the 11-item and shortened five-item modified frailty indices (mFIs) in terms of value and predictive validity. METHODS: A prospective multicenter observational study of patients aged ≥55 y undergoing EL was conducted across five hospitals in New Zealand between 2017 and 2022. Frailty was measured using the 11-item and abbreviated five-item mFIs. Multivariable logistic regression was used to determine whether frailty was independently associated with one-year postoperative mortality and other morbidity outcomes. Correlation between the two frailty indices were assessed with the Spearman's correlation coefficient (P). RESULTS: Frailty assessments were performed in 861 participants, with the prevalence being 18.7% and 29.8% using the 11-item and five-item mFIs, respectively. Both frailty indices demonstrated similar associations with one-year mortality (two-fold increased risk), major complications, admission to intensive care unit, rehabilitation, and 30-d readmission. The 11-item mFI demonstrated a greater association with early mortality (four-fold increased risk), reoperations, and increased length of stay compared with the five-item frailty index. Spearman P was 0.6 (P < 0.001). CONCLUSIONS: Frailty, as identified by the 11-item and five-item mFIs, was associated with one-year mortality and other important morbidity outcomes for older EL patients. These forms of frailty assessment provide important information that may aid in risk assessment and patient-centered decision-making.

Wound infection rate after skin closure of damage control laparotomy with wicks or incisional negative wound therapy: An EAST multi-center trial.

Damage control laparotomy (DCL) has a high risk of SSI and as an attempt to mitigate this, surgeons often leave the skin open to heal by secondary intention. A recent retrospective study showed that DCL wounds could be closed with the addition of wicks or incisional wound vacs with acceptable rates of wound infection. The aim of this prospective trial was to corroborate these results. This is a prospective multicenter observational trial performed by 7 institutions from July 2020 to April 2022. Adult patients who underwent DCL and fascia/skin closure with the addition of wicks or an incisional wound vac were included. Patients who died within seven days of DCL were excluded. Demographics, mechanism of initial presentation, wound classification, antibiotics given, surgical site infections, procedures performed, and mortality data was collected. Fisher's Exact test was used for categorical data and Wilcoxon Rank Sum test for continuous data. Mean days to closure was assessed using Student's t-test for independent groups. P-values <0.05 were considered indicative of statistical significance. Over the 21-month period, a total of 119 patients analyzed. Most patients were male (n = 66, 63 %), and the average age was 51 years. The average number of days the abdomen was kept open was 2.6. A majority of the DCLs were performed on acute care patients (n = 76, 63.8 %) and 92 patients (77.3 %) had a wound classification of contaminated or dirty. Most of the patients' skin was closed with wicks in place (68.9 %). There was a 9.8 % infection rate in patient's skin closed with wicks versus 16.2 % closed with an incisional wound vac (p = 0.361). Although the wick group had a higher proportion of class III and IV wound types, patients primarily treated with wicks had a lower risk of wound infection compared to those treated with incisional wound VACs; however, this difference was not statistically significant.

Incidental gallbladder cancer detected during laparoscopic cholecystectomy: conversion to extensive resection is a feasible choice.

Background: Re-resection is recommended for patients with incidental gallbladder carcinoma (iGBC) at T1b stage and above. It is unclear whether continuation of laparoscopic re-resection (CLR) for patients with intraoperatively detected iGBC (IDiGBC) is more beneficial to short- and long-term clinical outcomes than with conversion to radical extensive-resection (RER). Methods: This single-centre, retrospective cohort study of patients with iGBC was conducted between June 2006 and August 2021. Patients who underwent immediate reresection for T1b or higher ID-iGBC were enrolled. Propensity score matching (PSM) was used to match the two groups (CLR and RER) of patients, and differences in clinical outcomes before and after matching were analyzed. Result: A total of 102 patients with ID-iGBC were included in this study. 58 patients underwent CLR, and 44 underwent RER. After 1:1 propensity score matching, 56 patients were matched to all baselines. Patients in the RER group had a lower total postoperative complication rate, lower pulmonary infection rate, and shorter operation time than those in the CLR group did. Kaplan-Meier analysis showed that the overall survival rate of patients who underwent CLR was significantly lower than that of patients who underwent RER. Multivariate analysis showed that CLR, advanced T stage, lymph node positivity, and the occurrence of postoperative ascites were adverse prognostic factors for the overall survival of patients. Conclusion: Patients with ID-iGBC who underwent RER had fewer perioperative complications and a better prognosis than those who underwent CLR. For patients with ID-iGBC, conversion to radical extensive-resection appears to be a better choice.

Diathermy Versus Scalpel in Midline Abdominal Incision: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

INTRODUCTION: Our study aimed to compare the midline abdominal incision with scalpel and diathermy. METHODS: PubMed, EMBASE, and Cochrane were searched through January 2024 following PRISMA guidelines (PROSPERO, ID: CRD42024516771), and only randomized controlled trials were included. Heterogeneity was assessed using Cochran's Q test and the I2 heterogeneity index. Statistical analysis was performed using Review Manager 5.4 software. RESULTS: Six randomized controlled trials were included, from which 469 patients (51.5%) received diathermy incision and 442 patients (48.5%) underwent the scalpel technique. Patients treated with the electrocautery approach had less incision blood loss (MD -17.57 mL; P < .01). No statistically significant differences were found between groups regarding wound infection incidence, incision time, incision area or first-day postoperative pain. CONCLUSION: Diathermy use in midline abdominal incision may be advocated as it demonstrated a significant reduction in incision-related blood loss, with no differences in wound infection or early postoperative pain incidences compared to the scalpel.

A Rare Case of Gastric Trichobezoar Managed by Laparotomy.

Trichobezoars, rare gastrointestinal foreign bodies composed of ingested hair, typically affect females with psychiatric disorders such as trichotillomania and pica. This case report highlights the diagnostic and treatment challenges in an 18-year-old female presenting with a left upper quadrant mass and pain, who was found to have a large gastric trichobezoar. After diagnostic imaging confirmed the bezoar, it was surgically removed, and the patient had an uneventful recovery. Psychiatric follow-up was arranged to address the underlying disorders and prevent recurrence. This case underscores the importance of early recognition and management of trichobezoars to avoid serious complications.

Evaluation of Negative Pressure Dressings for Closed Surgical Incisions in Decreasing Surgical Site Infections After Emergency Laparotomy: A Randomized Controlled Study.

Objectives The aim of this study is to compare the effectiveness of negative pressure dressings (NPDs) versus conventional dressings for closed surgical incisions after emergency midline laparotomy, focusing on their impact on surgical site infection (SSI) rates, wound dehiscence, hospital stay duration, and cosmetic outcomes. Methods The randomized controlled study was conducted over 24 months, involving 80 patients aged 18-65 years who had peritonitis and underwent emergency midline laparotomies. Patients with diabetes mellitus, a BMI >35 kg/m², immunocompromised conditions, or those requiring re-exploration within 30 days of surgery were excluded. The participants were randomly assigned into two groups using a computer-generated randomization table: Group A, the case group, consisted of 40 patients who received NPDs, while Group B, the control group, included 40 patients who received conventional dressings. Data were recorded in Microsoft Excel (Microsoft Corporation, Redmond, WA, USA) and analyzed using IBM SPSS Statistics for Windows, Version 25.0 (Released 2017; IBM Corp., Armonk, NY, USA), with a p-value of <0.05 considered statistically significant. Results The overall occurrence of SSIs within the 30-day follow-up period was significantly lower in the NPD group compared to the conventional dressing group (30% vs. 70%, p < 0.05). The mean duration of hospital stay was 14.85 ± 10.43 days for the NPD group and 15.4 ± 9.75 days for the control group, with no statistically significant difference (p = 0.712). The mean Vancouver Scar Scale score was 5.3 ± 2.47 in the NPD group and 6.5 ± 2.14 in the control group, also showing no statistically significant difference (p = 0.11). Conclusions NPDs significantly reduced the incidence of SSIs compared to conventional dressings, but they did not have a significant impact on scar cosmesis or the duration of hospital stay.

Management of Crohn's Disease and Its Complexities: A Case Report and Literature Review.

This case report and literature review explore Crohn's disease (CD), a chronic inflammatory disorder of the gastrointestinal tract characterized by unpredictable flare-ups and remissions. The study highlights the diverse clinical manifestations, including abdominal pain, diarrhea, and weight loss, which significantly affect quality of life. It examines the interplay of genetic, environmental, and immune factors in CD's pathogenesis and the complexities in managing the disease. Through a case study of a 20-year-old male, the report addresses various treatment strategies, including medications and surgery, and emphasizes the challenges, particularly post-surgical complications like small bowel leaks. The findings underscore the need for vigilant postoperative care to enhance patient outcomes in this complex condition.

Obturator Hernia: Report of a Rare Case.

Obturator hernia, an uncommon type of abdominal wall hernia, predominantly occurs in elderly, multiparous women and often presents with nonspecific symptoms. The preoperative diagnosis of obturator hernia is particularly challenging due to its vague clinical manifestations. The clinical picture consists of intestinal blockage, abdominal pain, nausea, and vomiting. The treatment is only surgical. Delayed diagnosis can result in intestinal necrosis, thereby increasing the risk of mortality. This report discusses the case of a 73-year-old woman who experienced abdominal pain and restricted extension of her right leg. Computed tomography confirmed the presence of a right obturator hernia. The hernia was successfully repaired without necessitating resection of the small intestine. Postoperatively, the patient recovered well and experienced no complications.

Trichobezoars in children - A psychological perspective.

Trichobezoars or hairballs in the gastrointestinal tract occur as a complication of trichotillomania or compulsive hair pulling, and trichophagia, or compulsive eating of hair. The DSM-5 classifies trichotillomania as an obsessive-compulsive spectrum disorder. In this case series of four children with trichobezoar, we present the varied psychopathology that led to the same and discuss the current literature on complex issues underlying trichotillomania.

Demographic, Clinical, Radiological, and Surgical Outcome of Patients with Intestinal Tuberculosis: A Single-Center Retrospective Study.

Background: Intestinal tuberculosis (iTB) represents a potentially underrecognized clinical entity with limited clinical and radiological differentiating features. This study aims to assess the patterns of iTB clinical and radiological findings, along with the treatment approaches and the overall outcome. Methods: This retrospective cross-sectional study included patients with histopathologically confirmed iTB who presented with acute abdomen and were surgically managed between September 2005 and October 2023. Clinical and sociodemographic variables, imaging features, surgical treatments, and overall outcomes were retrospectively analyzed. Results: 96 patients with iTB were included, with a mean age of 36.1 ± 11.5 years and a relatively proportionate gender distribution. Abdominal pain was the most common presenting symptom (45.8%). The radiological features varied by the modality. Plain imaging showed non-specific findings, while ultrasonography showed loculated ascites (25%), and lymphadenopathy (22%). In computed tomography scans, multi-segmental symmetric intestinal thickening (53.1%) was the most prevalent finding. The most commonly performed surgical procedure was adhesiolysis (29.2%), with the ileocecal junction being the most commonly involved structure (39.6%). Histopathological examination of all the tissue biopsies revealed epithelioid granulomas. Postoperative complications occurred in 19 patients (19.8%), with surgical site infection being the most common complication (10.4%). Conclusion: Intestinal obstruction is an underrecognized manifestation of tuberculosis, particularly in endemic regions. The non-specific clinical presentation, coupled with the limited utility of laboratory and radiological tests, often leads to delayed recognition and treatment. Maintaining a high index of suspicion is essential, especially in younger patients, inhabitants of endemic areas, or those with laboratory findings indicative of chronic inflammation. Prompt recognition is crucial to ensure the timely initiation of anti-tuberculosis therapy and to optimize patient outcomes through appropriate follow-up.

Pseudotumoral pelviperitoneal tuberculosis mimicking ovarian cancer: A case report.

Tuberculosis is a rare but treatable infectious disease that continues to pose a significant health issue in regions with high prevalence. Its abdominopelvic localization can mimic advanced ovarian cancer, leading to diagnostic challenges. This report describes the case of a 33-year-old woman who was admitted to the gastroenterology unit with ascites, peritoneal thickening, and an ovarian mass on imaging. The diagnosis of abdominopelvic and peritoneal tuberculosis was confirmed after laparoscopy. The patient underwent antitubercular chemotherapy and showed clinical improvement.

Abdomen (A Pandora's Box): A Delayed Presentation of Blunt Abdominal Injury With a Mesenteric Tear Leading to Gangrenous Bowel.

In the emergency department, blunt trauma to the abdomen is frequently seen following a blunt injury. Road traffic accidents are the leading cause of this type of injury. This is a case presentation of a young adult male who presented to the emergency medicine department one week after he had a road traffic accident. After the initial assessment, an ileal perforation with peritonitis was suspected, and the patient was taken up for surgery. Intraoperative findings led to the patient being diagnosed with a case of gangrenous ileum secondary to a complete mesenteric tear. This case report highlights how a high level of suspicion and prompt intervention in a timely manner can play an important role in reducing morbidity and case fatality.

Left Para-Duodenal Hernia Presenting With Recurrent Abdominal Pain: A Diagnostic Challenge.

Paraduodenal hernias (PDH) are a type of internal hernia that results from errors in midgut rotation and failure of mesenteric fusion. Internal hernias themselves are a rare presentation that accounts for less than 1% of total hernias, and paraduodenal hernias contribute more than half of internal hernias. Left paraduodenal hernias (LPDH) occur more frequently as compared to right paraduodenal hernias. Left paraduodenal hernias happen when the small intestine bulges out in the left paraduodenal space, which is also called the space of Landzert. This can cause vague abdominal pain and signs of intestinal blockage, which makes diagnosis difficult. We present a case of a 28-year-old male with recurrent abdominal pain for 7 years, diagnosed with LPDH via laparotomy after inconclusive imaging studies, such as the whirlpool sign on USG. Intraoperatively, jejunal loops were found in Landzert's fossa, hindering hernia repair and adhesiolysis. Clinicians must maintain a high index of suspicion for PDH when assessing nonspecific abdominal symptoms to ensure timely diagnosis and management, optimising patient outcomes.

Diagnostic Laparoscopy in Trauma Patients: Do We Need to Open and See if We Can See Without Opening?

BACKGROUND: Diagnostic laparoscopy (DL) has been advocated to reduce the incidence of nontherapeutic laparotomies (NL) among stable trauma patients. This study aimed to compare the outcomes of hemodynamically stable trauma patients undergoing DL versus NL. METHODS: This is a retrospective analysis of the American College of Surgeons Trauma Quality Improvement Program database over 4 y (2017-2020). Hemodynamically stable (systolic blood pressure >90 & heart rate < 120) adult (≥18 y) trauma patients undergoing DL or NL were included. Patients were stratified into DL and NL and substratified based on the mechanism of injury (blunt versus penetrating) and compared. RESULTS: Over 4 y, 3801 patients were identified, of which, 997 (26.2%) underwent DL. Overall, 25.6% sustained blunt injuries. The mean (SD) age was 39 (16) and 79.5% were male. The median injury severity score and abdominal abbreviated injury scale were 4 [4-9] and 1 [1-2], with no difference among study groups (P ≥ 0.05). The overall mortality and major complication rates were 2.8% and 13.2%, respectively. After controlling for potential confounding factors, DL was independently associated with lower odds of mortality (adjusted odds ratio: 0.10, 95% CI [0.04-0.29], P < 0.001) and major complications (adjusted odds ratio: 0.38, 95% CI [0.29-0.50], P < 0.001) and shorter hospital length of stay (ß: -1.22, 95% CI [-1.78 to -0.67], P < 0.001). The trends toward improved outcomes in the DL group remained the same in the subanalysis of patients with penetrating and blunt injuries. CONCLUSIONS: With advances in minimally invasive surgery, unnecessary exploratory laparotomy can be avoided in many trauma patients. Our study shows that hemodynamically stable patients undergoing DL had superior outcomes compared to those with NL.

Comparative analysis between outcomes of minimally invasive gynaecological surgeries and traditional abdominal surgeries for benign gynaecological conditions.

Objective: To compare outcomes of minimally invasive gynaecological surgeries with open gynaecological surgical techniques in a low-resource setting. METHODS: The quasi-experimental study was conducted at a tertiary care public-sector hospital in Rawalpindi, Pakistan, from September 2022 to August 2023, and comprised women with benign gynaecological conditions. The subjects were divided into two groups. Group-I included participants who underwent minimally invasive gynaecological surgeries, while Group- II patients underwent open gynaecological surgical intervention. Outcome variables included pre-discharge pain score, post-operative mobility, operative time, blood-loss during surgery, length of hospital stay and intraoperative as well as postoperative complications. Data was analysed using SPSS 25. RESULTS: Of the 319 women, 146(45.7%) were in Group-I with mean age 30.83±5.47 years, and 173(54.2%) were in group-II with mean age 44.87±10.46 years. Body mass index, length of marriage, history of previous surgery, comorbidities and menopausal status were significantly different between the groups (p<0.05). Duration of surgery and hospital stay were lower in Group-I compared to Group-II (p<0.05). Intra-operative complications were not significantly different between the groups (p<0.05), while the differences in post-operative complications were significant (p<0.05). Conclusion: Better clinical outcomes were observed for minimally invasive gynaecological surgeries than open surgeries among women diagnosed with benign gynaecological diseases.

Prognostic significance of socioeconomic deprivation in patients undergoing emergency laparotomy: A retrospective cohort study.

OBJECTIVES: Deprivation is a complex, multifaceted concept and not synonymous with poverty. The aim of this study was to assess the prognostic influence of the multiple deprivation index on emergency laparotomy (EL) outcome. METHODS: STROCSS statement standards were followed to conduct a retrospective cohort study. Consecutive 1723 adult patients [median age (range): 66 (18-98), 762 M, and 961 F] undergoing EL over eight years (2014-22) at two hospitals [a tertiary teaching center and district general hospital (DGH)] were studied. Deprivation scores and ranks were derived from patients' postcodes using the Welsh Index of Multiple Deprivation and ranks categorized into quartiles. Primary outcome measure was a 30-day operative mortality (OM). RESULTS: OM risk was higher in the most deprived quartile (Q1) compared with the least deprived quartile (Q4) (13.2% vs. 7.9% and p = 0.008). Deprivation was an independent predictor of OM on both univariate (unadjusted OR: 1.75, 95% CI 1.17-2.61, and p = 0.006) and multivariable logistic regression analyses (OR: 1.03, 95% CI 1.01-1.06, and p = 0.023; adjusted for age ≥80 years, American Society of Anesthesiologists grade, need for bowel resection, and peritoneal contamination). Deprivation had poor discriminatory value in predicting OM (AUC: 0.56 and 95% CI 0.54-0.59). Subgroup analysis showed that although the risk of OM was lower in the tertiary center compared with the DGH (7.9% vs. 14.5% and p < 0.001), the predictive significance of deprivation was similar in both hospitals (AUC: 0.54 vs. 0.56 and p = 0.674). CONCLUSION: Deprivation is an independent but modest predictor of OM after EL. The potential prognostic value of incorporating deprivation into preoperative risk assessment algorithms deserves further evaluation.

Emergency laparotomy and endoscopic gastrostomy in patients on extra-corporeal membrane oxygenation (ECMO) support.

INTRODUCTION: An infrequent yet known complication of ECMO is abdominal compartment syndrome requiring emergency laparotomy. Also, the need for prolonged enteral nutrition while on ECMO may require endoscopic gastrostomy to maintain adequate nutritional status. Here we describe our experience with emergency laparotomy and endoscopic gastrostomy in patients on ECMO support. METHODS: We retrieved patient histories from our clinical archives and performed a retrospective description of all patients taken to an emergency laparotomy or endoscopic gastrostomy while on ECMO support at our cardiovascular referral center from July 2019 through June 2024. RESULTS: During the research period of 5 years a total of 401 patients were placed on ECMO support for either cardiogenic shock or respiratory failure. A total of 27 (7%) patients required an abdominal intervention while on ECMO. 14 (3.5%) patients required emergency laparotomy and 13 (3.2%) of patients required endoscopic gastrostomy tube placement. Overall 30-day mortality of all patients requiring a general surgery procedure while on ECMO support was 33%. CONCLUSION: ECMO support can result in many complications despite its many benefits. Patients who require emergency laparotomy while on ECMO have lower survival-to-discharge and higher mortality at 30 days. Endoscopic gastrostomy however, can be safely performed on ECMO with little to no bleeding complications despite anticoagulation.