A meta-analysis on continuous versus interrupted skin closure following appendicectomy.

BACKGROUND: The aim of this review was to analyse RCTs comparing wound-related outcomes between continuous subcuticular and interrupted transdermal wound closures for open appendicectomies in all age groups. METHODS: A systematic literature search was conducted in April 2020 (MEDLINE, Embase, CENTRAL, Web of Science, PROSPERO, Google Scholar, WHO International Clinical Trials Registry Platform). RCTs without restrictions on study language, year, status of publication, and patient age were included. The risk of bias was assessed using the risk-of-bias tool for RCTs. Pooled risk ratios (RRs) and mean differences (MDs) for binary and continuous variables were calculated using random-effects models. A summary-of-findings table was generated to assess the level of evidence. RESULTS: Eleven trials were included (1781 patients analysed, 891 in continuous and 890 in interrupted groups). The overall rate of wound infection was 7.1 per cent. There was no significant difference in the risk of wound infection (11 trials, 1781 patients; RR 1.13, 95 per cent c.i. 0.77 to 1.66; P = 0.530) or wound exploration (7 trials, 1129 patients; RR 0.74, 0.41 to 1.34, P = 0.320) between the two groups. Continuous wound closure had a significantly reduced risk of wound dehiscence (6 trials, 865 patients; RR 0.16, 0.05 to 0.50; P = 0.002) and smaller wound scar (3 trials, 417 patients; MD -2.11 (95 per cent c.i. -2.57 to -1.66) mm; P < 0.001). The absolute risk reduction and number needed to treat for wound dehiscence were 6.1 per cent and 16 respectively. There was no significant statistical heterogeneity for all outcomes (I2 0-15 per cent, χ2 P > 0.100). Most RCTs had a high risk of bias. CONCLUSION: Continuous subcuticular open appendicectomy wound closure is not associated with an increased risk of wound infection and exploration. This method of closure has a reduced risk of wound dehiscence and better cosmetic outcomes.

Wound infection after open appendicectomy remains a significant problem around the world. As such, wounds with infection frequently require exploration, leading to poor cosmetic outcomes. This study investigated whether the method of skin closure (continuous versus interrupted) used after this surgery has any bearing on wound-related outcomes, including wound infection. Patient satisfaction, quality of life, cost, and length of hospital stay were also compared between the two common methods of skin closure. Evidence from a multitude of published works in all languages from around the world was analysed. The evidence suggests that continuous skin closure is not associated with an increased risk of infection and wound opening, but has better wound integrity, cosmetic outcome, and patient satisfaction. The length of hospital stay is no different between these two types of wound closure.

Appendiceal Duplication: A Comprehensive Review of Published Cases and Clinical Recommendations.

BACKGROUND: Duplex appendix is very rare (incidence 0.004%) but has clinical relevance given the frequency of appendicectomies performed. Failure to recognise duplication can result in failure of treatment and medico-legal consequences. A review of published cases was undertaken to identify factors that may help in managing this rare condition. METHODS: All English and non-English publications were identified in PubMed, Embase and Cochrane databases. Patient demographics, intraoperative findings, anatomical details and histopathology were analysed. RESULTS: A total of 141 cases were identified [male/female ratio 1.4:1, median age 20 years (range foetus to 69 years)]. Duplication of the appendix ranges from branching of the appendix trunk to a fully matured appendix located elsewhere along the colon. Most can be categorised by the Cave-Wallbridge classification. There were 22 Type A, 8 Type B1, 46 Type B2 and 10 Type C cases (Cave-Wallbridge). There were six cases of horseshoe and two cases of triple appendix. Six reports gave anatomical descriptions that could not be classified by Cave-Wallbridge categories and in 11 cases there were no anatomical descriptions. CONCLUSIONS: An anteriorly placed appendix, away from the convergence of the taenia, or a normal appendix in the presence of convincing clinical or radiological signs of appendicitis should instigate a careful examination of the caecal pole and possible exploration of the retrocaecal space for appendiceal duplication. If the patient had previous surgery for congenital abnormalities, Type B1 or Type C duplication should be considered.

Mortality for emergency laparotomy is not affected by the weekend effect: a multicentre study.

INTRODUCTION: The 'weekend effect' describes variation in outcomes of patients treated over the weekend compared with those treated during weekdays. This study examines whether a weekend effect exists for patients who undergo emergency laparotomy. MATERIALS AND METHODS: Data entered into the National Emergency Laparotomy Audit between 2014 and 2017 at four NHS trusts in England and Wales were analysed. Patients were grouped into those admitted on weekdays and those on weekends (Friday 5pm to Monday 8am). Patient factors, markers of quality of care and patient outcomes were compared. Secondary analysis was performed according to the day of surgery. RESULTS: After exclusion of patients who underwent laparotomy more than one week after admission to hospital, a total of 1717 patients (1138 patients admitted on weekdays and 579 admitted on weekends) were analysed. Age, preoperative lactate and P-POSSUM scores were not significantly different between the two groups. Time from admission to consultant review, decision to operate, commencement of antibiotics and theatre were not significantly different. Grades of operating surgeon were also similar in both groups. Inpatient 60-day mortality was 12.5% on weekdays and 12.8% on weekends (P = 0.878). Median length of postoperative stay was 12 days in both groups. When analysed according to day of surgery, only number of hours from admission to antibiotics (12.8 weekday vs 9.4 weekend, P = 0.046) and number of hours to theatre (26.5 weekday vs 24.1 hours weekend, P = 0.020) were significantly different. DISCUSSION: Quality of care and clinical outcomes for patients undergoing emergency laparotomy during the weekend are not significantly different to those carried out during weekdays.

Centralisation for resection of the pancreatic head: A comparison of operative factors and early outcomes during the evolving unit and tertiary unit phases at a UK institution.

AIMS: To assess impact of centralisation on patients undergoing pancreatic head resections at a tertiary hepatobiliary (HPB) centre in the UK. METHODS: Data were analysed from a prospectively maintained database from 1998 to 2014 on all patients undergoing pancreatic head resections. Two specific time periods were defined; these were the evolving unit phase (EU) from 1998 to 2009 and finally the established tertiary unit phase (TU) from 2010 to 2014. Peri-operative factors and post-operative outcomes were analysed. RESULTS: 395 resections were undertaken during the study period. Following establishment of our tertiary HPB unit, the volume of resections undertaken increased greater than three-fold with an associated increase in case-complexity (p = 0.004). Operating time was found to increase in the TU phase compared with EU phase (p=>0.0005) whilst there was no significant difference in the rate of peri-operative transfusion, or in post-operative morbidity rates. There was a significant reduction in the post-operative length of stay in the TU phase (p = 0.003) with a significantly higher proportion of patients being discharged within 9 days of their procedure (p=<0.0005). There was also a significant reduction in 30-day post-operative mortality in the TU phase (0.5%) compared with the EU phase (3%) (p = 0.029). CONCLUSIONS: Data from our series of 395 cases suggests that centralisation of pancreatic cancer services to a tertiary centre does result in improved patient outcomes. The benefits of a multi-disciplinary and specialist HPB service results in a high volume, high quality unit with improved patient outcomes.

Acute afferent loop syndrome in the early postoperative period following pancreaticoduodenectomy.

INTRODUCTION: Afferent loop syndrome (ALS) is a recognised complication of foregut surgery caused by mechanical obstruction at the gastrojejunostomy anastomosis itself or at a point nearby. Acute ALS has only been reported following pancreaticoduodenectomy (PD) after several years due to recurrence of malignancy at the anastomotic site. We report five cases of acute ALS in the first postoperative week. METHODS: The presentation, clinical findings and successful management of the 5 patients with ALS were obtained from a prospectively collected database of 300 PDs. All five patients with early acute ALS presented with signs and symptoms of a bile leak. Since the fifth patient, the surgical technique has been modified with the creation of a larger window in the transverse mesocolon and a Braun enteroenterostomy. RESULTS: There have been no further incidents of ALS since the adoption of these modifications to the standard technique of PD and there has also been a reduction in postoperative bile leaks (6.4% vs 3.6%, p=0.416). CONCLUSIONS: Acute ALS is a rare but important complication in the immediate postoperative period following PD and causes disruption to adjacent anastomoses, resulting in a bile leak. A prophylactic Braun anastomosis and wide mesocolic window may prevent this complication and subsequent deterioration.

The two-port laparoscopic retroperitoneal approach for minimal access pancreatic necrosectomy.

INTRODUCTION: Despite advances in surgery and critical care, severe pancreatitis continues to be associated with a high rate of mortality, which is increased significantly in the presence of infected pancreatic necrosis. Controversy persists around the optimal treatment for such cases, with specialist units variously advocating open necrosectomy, simple percutaneous drainage or one of several minimal access approaches. We describe our technique and outcomes with a two-port laparoscopic retroperitoneal necrosectomy (2P-LRN). METHODS: Thirteen consecutive patients with proven infected pancreatic necrosis were treated by 2P-LRN over a three-year period in the setting of a specialist hepatopancreatobiliary unit. The median patient age was 46 years (range: 28-87 years) and 10 of the patients were male. RESULTS: The median number of procedures required to clear the necrosis was 2 (range: 1-5), with a median time to discharge following the procedure of 44 days (range: 10-135 days). There was no 90-day mortality and the morbidity rate was 38%, consisting of pancreatic fistula (31%) and bleeding (23%). CONCLUSIONS: Two-port laparoscopic retroperitoneal necrosectomy has been demonstrated to confer similar or better outcomes to other techniques for necrosectomy. It carries the additional advantages of better visualisation, leading to fewer procedures and the opportunity to deploy simple laparoscopic instruments such as diathermy or haemostatic clips.

Acute abdominal pain following fracture of a heterotopically formed bone incorporating a prolene mesh.

A case is presented of severe abdominal pain around a healed scar following fracture of a heterotopically formed bone. This should be considered an unusual differential diagnosis in patients with acute pain of unknown origin who had open abdominal surgery in the past. To our knowledge, we have also reported the first case of hetertopic bone formation incorporating a prolene mesh.