Intraperitoneal contamination index (Hajibandeh index) predicts nature of peritoneal contamination and risk of postoperative mortality in patients with acute abdominal pathology: a prospective multicentre cohort study.

OBJECTIVES: To assess whether intraperitoneal contamination index (ICI) (Hajibandeh index) derived from combined levels of CRP, lactate, neutrophils, lymphocytes, and albumin can predict the nature of intraperitoneal contamination in patients with acute abdominal pathology and to assess whether ICI can predict postoperative mortality in patients undergoing emergency laparotomy. METHODS: In order to prospectively validate the ICI, developed and validated retrospectively in our previous study, a multicentre prospective cohort study was conducted between January 2019 and June 2020 including all adult patients who presented with acute abdominal pathology requiring emergency laparotomy. ROC curve analysis was performed to determine discrimination and cut-off values of preoperative ICI that could predict the nature of intraperitoneal contamination and postoperative mortality. RESULTS: Overall, 269 patients were included in the prospective validation cohort which were compared with 234 patients in the primary cohort and 234 patients in the retrospective validation cohort. The analyses identified ICI of 24.76 as cut-off value for purulent contamination (AUC: 0.78, P < 0.0001; sensitivity: 82.4%, specificity: 60.9%); ICI of 33.84 as cut-off value for feculent contamination (AUC: 0.78, P < 0.0001; sensitivity: 82%, specificity: 67.8%), and ICI of 33.47 as cut-off value for postoperative mortality (AUC: 0.70, P < 0.0001; sensitivity: 72.7%, specificity: 58.47%). The results of the prospective validation cohort were comparable with the results of the primary and retrospective validation cohorts. CONCLUSIONS: Hajibandeh index predicts the presence of purulent and feculent intraperitoneal contamination in patients with acute abdominal pathology and postoperative mortality in patients undergoing emergency laparotomy. Future studies should investigate the effect of ICI use on the accuracy of preoperative prognostic scoring tools and on patient selection for operative or non-operative management of underlying abdominal pathology.

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.

Routine versus selective computed tomography in non-traumatic acute abdominal pain: meta-analysis of randomised trials.

PURPOSE: To compare the routine vs. selective use of computed tomography (CT) in patients presenting with non-traumatic acute abdominal pain (AAP) to a surgical service. METHODS: We conducted a systematic review of literature and meta-analysis of outcomes according to PRISMA statement standards to compare the routine vs. selective use of CT in adult patients presenting with non-traumatic AAP. RESULTS: Analysis of 722 patients from 4 randomised controlled trials showed no difference between the routine CT and selective CT groups in terms of proportion of correct diagnoses (OR 1.36,95% CI 0.89, 2.07, P = 0.15), mortality (RD 0.03, 95% CI - 0.08, 0.02, P = 0.27] and length of hospital stay (LOS) [MD - 0.26, 95% CI - 2.07, 1.55, P = 0.78). CONCLUSIONS: The routine use of CT does not improve the proportion of correct diagnoses and mortality compared to selective use of CT in adult patients with non-traumatic AAP. The available evidence regarding the influence of routine CT on LOS may be subject to type 2 error. These findings, however, may not apply to the elderly patient with AAP and further studies are required.

Irrigation Versus Suction Alone in Laparoscopic Appendectomy: Is Dilution the Solution to Pollution? A Systematic Review and Meta-Analysis.

OBJECTIVES: To investigate outcomes of peritoneal irrigation versus suction without irrigation in patients undergoing emergency laparoscopic appendectomy. METHODS: We performed a systematic review and conducted a search of electronic information sources to identify all randomized controlled trials (RCTs) and observational studies investigating outcomes of irrigation versus suction alone in patients undergoing emergency laparoscopic appendectomy. We used the Cochrane risk of bias tool and the Newcastle-Ottawa scale to assess the risk of bias of RCTs and observational studies, respectively. Random-effects models were applied to calculate pooled outcome data. RESULTS: We identified 3 RCTs and 2 retrospective observational studies, enrolling 2511 patients. Our results suggested that there was no difference between peritoneal irrigation and suction alone in terms of intraabdominal abscess rate (odds ratio = 2.39, 95% confidence interval [CI] = 0.49-11.74, P = .28), wound infection (risk difference = 0.00, 95% CI = -0.04 to 0.05, P = .85), and length of stay (mean difference = -1.02, 95% CI = -3.10 to 1.07, P = .34); however, peritoneal irrigation was associated with longer operative time (mean difference = 7.12, 95% CI = 4.33 to 9.92, P < .00001). Our results remained consistent when randomized trials, adult patients, and pediatric patients were analyzed separately. CONCLUSIONS: The best available evidence suggests that the peritoneal irrigation with normal saline during laparoscopic appendectomy does not provide additional benefits compared with suction alone in terms of intraabdominal abscess, wound infection, and length of stay but it may prolong the operative time. The quality of the best available evidence is moderate; therefore, high-quality RCTs, which are adequately powered, are required to provide more robust basis for definite conclusions.

Impact of Toupet Versus Nissen Fundoplication on Dysphagia in Patients With Gastroesophageal Reflux Disease and Associated Preoperative Esophageal Dysmotility: A Systematic Review and Meta-Analysis.

BACKGROUND: Controversy exists regarding the best surgical approach for the management of gastroesophageal reflux disease (GORD) and associated preoperative esophageal dysmotility. Our aim was to conduct a systematic review and meta-analysis to compare the outcomes of Toupet fundoplication (TF) and Nissen fundoplication (NF) in patients with GORD and coexistent preoperative esophageal dysmotility. METHODS: We conducted a systematic search of electronic information sources, including MEDLINE, EMBASE, CINAHL, CENTRAL, ClinicalTrials.gov , and bibliographic reference lists. We applied a combination of free text search and controlled vocabulary search adapted to thesaurus headings, search operators, and limits in each of the above-mentioned databases. Postoperative dysphagia and improvement in dysphagia were primary outcome parameters. RESULTS: We identified 3 randomized controlled trials and 1 observational study reporting a total of 220 patients, of whom 126 underwent TF and the remaining 94 patients had NF. Despite the existence of significantly higher preoperative dysphagia in the TF group (29.3% vs 4.2%, P = .05), TF was associated with significantly lower postoperative dysphagia (odds ratio [OR] = 0.31, P = .002) with low between-study heterogeneity ( I2 = 11%, P = .34), and significantly higher improved dysphagia (OR = 10.32, P < .0001) with moderate between-study heterogeneity ( I2 = 31%, P = .23) compared with NF. CONCLUSION: TF may be associated with significantly lower postoperative dysphagia than NF in patients with GORD and associated preoperative esophageal dysmotility. However, no definite conclusions can be drawn as the best available evidence comes mainly from a limited number of heterogeneous randomized controlled trials. Future studies are encouraged to include patients with similar preoperative dysphagia status and report the outcomes with respect to recurrence of acid reflux symptoms.

Meningioangiomatosis with Skull Erosion.

Meningioangiomatosis (MA) is a rare, poorly studied brain hamartomatous lesion, the etiology of which is not fully elucidated. It typically involves the leptomeninges, extending to the underlying cortex, characterized by small vessel proliferation, perivascular cuffing, and scattered calcifications. Given its close proximity to, or direct involvement of, the cerebral cortex, MA lesions typically manifest in younger patients as recurrent episodes of refractory seizures, comprising approximately 0.6% of operated-on intractable epileptic lesions. Due to the absence of characteristic radiological features, MA lesions constitute a significant radiological challenge, making them easy to miss or misinterpret. Although MA lesions are rarely reported with still-unknown etiology, it is prudent to be aware of these lesions for prompt diagnosis and management to avoid morbidity and mortality associated with delayed diagnosis and treatment. We present a case of a young patient with a first-time seizure caused by a right parieto-occipital MA lesion that was successfully excised via an awake craniotomy, achieving 100% seizure control.

Neurocysticercosis presenting as a locked-in lateral ventricle: A case report and evidence-based review.

Human neurocysticercosis is one of the most prevalent parasitic infestations of the central nervous system. It is considered the most frequent underlying etiology of acquired epilepsy in endemic areas in Central and South America, East Europe, Africa, and Asia, with over 50 million people affected globally. Ventricular involvement is a severe form of neurocysticercosis commonly manifests as arachnoiditis, raised intracranial pressure, or hydrocephalus, secondary to CSF flow obstruction of the ventricular system by cysts of Taenia solium, hence requiring prompt, aggressive intervention to alleviate the increased intracranial pressure to prevent imminent lethal complications. Ventricular neurocysticercosis can involve any brain ventricle but with a paramount preference for the fourth ventricle, causing non-communicating hydrocephalus and symmetric ventriculomegaly. However, in this clinical report, we present an uncommon case of trapped (locked-in) lateral ventricle caused by an isolated cysticercus trapped at the ipsilateral foramen of Monro, which is an atypical location for neurocysticercosis, adding more challenges to diagnosis and during the process of surgical extraction. We additionally provide a comprehensive, evidence-based review of the clinical course and management options relevant to the entity of ventricular neurocysticercosis, besides recent relevant clinical updates.

Glioblastoma masquerading as a cystic brain lesion: A case report and evidence-based review.

INTRODUCTION AND IMPORTANCE: In adults, glioblastomas account for approximately 12-15 % of primary intracranial neoplasms. In current standard-of-care treatment, glioblastomas have a 5-year survival rate of ~7.5 % and a median survival of ~15 months. Glioblastoma exhibits a highly variable imaging appearance, but the thick and irregular ring enhancement surrounding a necrotic core with infiltrative growth is the most prevalent imaging pattern. Glioblastoma with a cystic component (also known as cystic glioblastoma) is a rare presentation that can be misleading and often mistaken for other cystic brain lesions. CASE PRESENTATION: In this report, we present a case of a 43-year-old woman who presented to the emergency department with a 2-month history of progressive neurologic manifestations that was attributed to a right-sided cystic brain lesion detected on routine imaging studies, which was later characterized as a cystic glioblastoma based on specific imaging and molecular studies. CLINICAL DISCUSSION: We highlight the importance of combining radiological and molecular modalities with clinical suspicion for a better characterization of cystic brain lesions and including glioblastoma in the list of potential diagnoses. Furthermore, we provide a comprehensive, evidence-based review of the entity of cystic glioblastoma and how the existence of the cystic component might affect the management and the overall prognosis. CONCLUSION: Several characteristics make cystic glioblastoma unique. However, it is also capable of mimicking other benign cystic brain lesions, delaying definitive diagnosis and hence the most appropriate management plan.

Beta-propeller protein-associated neurodegeneration: A clinical update with a case report.

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