Impact of penicillin allergy labels on surgical site infections in a large UK cohort of gastrointestinal surgery patients.

Objectives: Studies in the USA, Canada and France have reported higher surgical site infection (SSI) risk in patients with a penicillin allergy label (PAL). Here, we investigate the association between PALs and SSI in the UK, a country with distinct epidemiology of infecting pathogens and range of antimicrobial regimens in routine use. Methods: Electronic health records and national SSI surveillance data were collated for a retrospective cohort of gastrointestinal surgery patients at Cambridge University Hospitals NHS Foundation Trust from 1 January 2015 to 31 December 2021. Univariable and multivariable logistic regression were used to examine the effects of PALs and the use of non-ß-lactam-based prophylaxis on likelihood of SSI, 30 day post-operative mortality, 7 day post-operative acute kidney injury and 60 day post-operative infection/colonization with antimicrobial-resistant bacteria or Clostridioides difficile. Results: Our data comprised 3644 patients and 4085 operations; 461 were undertaken in the presence of PALs (11.3%). SSI was detected after 435/4085 (10.7%) operations. Neither the presence of PALs, nor the use of non-ß-lactam-based prophylaxis were found to be associated with SSI: adjusted OR (aOR) 0.90 (95% CI 0.65-1.25) and 1.20 (0.88-1.62), respectively. PALs were independently associated with increased odds of newly identified MRSA infection/colonization in the 60 days after surgery: aOR 2.71 (95% CI 1.13-6.49). Negative association was observed for newly identified infection/colonization with third-generation cephalosporin-resistant Gram-negative bacteria: aOR 0.38 (95% CI 0.16-0.89). Conclusions: No evidence was found for an association between PALs and the likelihood of SSI in this large UK cohort, suggesting significant international variation in the impact of PALs on surgical patients.

Systematic review and meta-analysis comparing perioperative outcomes of emergency appendectomy performed by trainee vs trained surgeon.

BACKGROUND: Appendectomy is a benchmark operation for trainee progression, but this should be weighed against patient safety and perioperative outcomes. METHODS: Systematic literature review and meta-analysis comparing outcomes of appendectomy performed by trainees versus trained surgeons. RESULTS: Of 2086 articles screened, 29 studies reporting on 135,358 participants were analyzed. There was no difference in mortality (Odds ratio [OR] 1.08, P = 0.830), overall complications (OR 0.93, P = 0.51), or major complications (OR 0.56, P = 0.16). There was no difference in conversion from laparoscopic to open surgery (OR 0.81, P = 0.12) and in intraoperative blood loss (Mean Difference [MD] 5.58 mL, P = 0.25). Trainees had longer operating time (MD 7.61 min, P < 0.0001). Appendectomy by trainees resulted in shorter duration of hospital stay (MD 0.16 days, P = 0.005) and decreased reoperation rate (OR 0.78, P = 0.05). CONCLUSIONS: Appendectomy performed by trainees does not compromise patient safety. Due to statistical heterogeneity, further randomized controlled trials, with standardized reported outcomes, are required.

Systematic review and meta-analysis comparing perioperative outcomes of pediatric emergency appendicectomy performed by trainee vs trained surgeon.

Appendicectomy is a common pediatric surgical procedure performed by trainees and surgeons with varying reported outcomes. It is a benchmark procedure for trainee progression and training benefits should be weighed against patient safety and perioperative outcomes. This systematic review and meta-analysis investigated any differential perioperative outcomes dependent on the grade of the operating surgeon. A systematic literature review and meta-analysis were performed comparing outcomes of pediatric appendicectomy performed by trainees versus trained surgeons. Of 2,086 articles screened, 5 retrospective non-randomized comparative studies reporting on 10,019 participants were analyzed. There was no difference in overall complications (OR 0.92; 95% CI 0.76, 1.12; P = 0.42), major complications [Clavien-Dindo (CD) III/IV] (OR 1.18; 95% CI 0.71, 1.97; P = 0.52), minor complications (CD I/II) (OR 1.13; 95% CI 0.57, 2.27; P = 0.72), post-op ileus (OR 0.74; 95% CI 0.10, 5.26; P = 0.76), wound infections (OR 0.87; 95% CI 0.62, 1.21; P = 0.41), abscess formation (OR 0.58; 95% CI 0.28, 1.22; P = 0.15), operation times [Mean Difference (MD) 2.31 min; 95% CI - 4.94, 9.56; P = 0.53] and reoperation rate (OR 1.22; 95% CI 0.23, 6.42; P = 0.81). Trainees had fewer conversions to open appendicectomy (OR 0.14; 95% CI 0.02, 0.88; P = 0.04). Appendicectomy performed on pediatric patients by trainees did not compromise patient safety. LEVEL OF EVIDENCE: III.

Compliance with evidence-based clinical guidelines in the management of acute biliary pancreatitis: the MANCTRA-1 study protocol.

Despite existing evidence-based practice guidelines for the management of biliary acute pancreatitis (AP), the clinical compliance with recommendations is overall poor. Studies in this field have identified significant discrepancies between evidence-based recommendations and daily clinical practice. The most commonly reported gaps between clinical practice and AP guidelines include the indications for CT scan, need and timing of artificial nutritional support, indications for antibiotics, and surgical/endoscopic management of biliary AP. The MANCTRA-1 (coMpliAnce with evideNce-based cliniCal guidelines in the managemenT of acute biliaRy pancreAtitis) study is aiming to identify the areas for quality improvement that will require new implementation strategies. The study primary objective is to evaluate which items of the current AP guidelines are commonly disregarded and if they correlate with negative clinical outcomes according to the different clinical presentations of the disease. We attempt to summarize the main areas of sub-optimal care due to the lack of compliance with current guidelines to provide the basis for introducing a number of bundles in AP patients' management to be implemented during the next years. The MANCTRA-1 study is an international multicenter, retrospective cohort study with the purpose to assess the outcomes of patients admitted to hospital with a diagnosis of biliary AP and the compliance of surgeons worldwide to the most up-to-dated international guidelines on biliary AP. ClinicalTrials.Gov ID Number: NCT04747990, Date: February 23, 2021. Protocol Version V2.2.

Re-exploring the pelvic neuroanatomy from a new perspective and a potential guidance for TaTME: a "bottom-up" approach.

Neuro-anatomy of the perineum has gained renewed attention due to its significance in the transanal procedures for rectal cancer (eg TaTME). Surgeons embarking on this technique must have sophisticated knowledge and a precise anatomical understanding of the perineum before proceeding with this reversed rectal approach. We report anatomical observations deriving from a relevant experience in the colorectal surgery field. The collective multicenter experience of the present study is clinically relevant and based on the rectal and transanal resections performed in colorectal centers of excellence from Greece, UK, and Italy over the last 10 years (2011-2020). From the original anatomical and intraoperative observations derived from collective cases operated by this multicenter group of colorectal surgical centers in three European countries, data were retrieved and analyzed in collaboration with specialist researchers of human anatomy and interpreted for their clinical significance and potential use for preoperative planning and intraoperative guidance during TaTME. This descriptive article demonstrates in detail the neurogenic pathways encountered in the perineum and pelvic cavity during transanal procedures. Specific anatomical and topographic implications are also included serving as a guide for colorectal surgeons to perform a nerve-sparing procedure. transanal approach for rectal excision offers new insights into the complex pelvic and perineal neuroanatomy while the procedure itself remains a challenge for surgeons. Preoperative anatomical planning and 3D reconstruction may help in anticipating technical difficulties, resulting in more precise surgical dissections and decreased postoperative complications.

Fishbone perforation of the small bowel mimicking internal herniation and obstruction in a patient with previous gastric bypass surgery.

Intestinal perforation following the ingestion of fishbone is unusual and rarely diagnosed preoperatively, as clinical and radiological findings are non-specific. We report a case of a female patient post Roux-en-Y gastric bypass (RYGBP) for obesity, who presented with severe abdominal pain and guarding in left iliac fossa. Computed tomography (CT) suggested internal herniation with compromised vascular supply to the bowel. Exploratory laparotomy identified a perforation site in the blind loop of the RYGBP due to a protruding fishbone. After extraction, primary suture repair was performed. In retrospect, the fishbone was identified on CT but misinterpreted as suture line at the enteroenterostomy site. This case emphasizes that although rare, the ingestion of fishbone can lead to severe complications and should therefore be included in the differential for an acute abdomen. On CT, it should be noted that fishbone may simulate suture line within the bowel if the patient has history of previous surgery.

Diaphragm disease of the terminal ileum presenting as acute small bowel obstruction.

Diaphragm disease (DD) of the small bowel is a rarely reported complication of non-steroidal anti-inflammatory drug (NSAID) use, characterised by diaphragm-like strictures, most commonly in the ileum, causing varying degrees of obstruction. It typically presents in the elderly, over many years with non-specific symptoms. Diagnosis is challenging, the majority of cases relying on histopathology for confirmation. Treatment involves NSAID cessation and surgery through a combination of stricturoplasties and/or segmental resection. Very rarely DD presents as a surgical emergency. A case presenting as acute small bowel obstruction (SBO) is described, initially diagnosed as adhesions, later confirmed to be DD of the terminal ileum following histopathological examination. Given the widespread use of NSAIDs and an ageing population, it is likely the incidence of DD will increase. It is, therefore, important that surgeons are aware of this disease entity and consider it as a potential diagnosis in patients presenting with acute SBO.

Spontaneous bowel perforation in the setting of colonic involvement with scleroderma.

Here we present a rare case of spontaneous colonic perforation in a middle-aged woman affected by systemic sclerosis (SSc). In spite of maximal medical support and prompt emergency laparotomy for source control the patient died due to multiorgan failure within 48 hours of admission. This case emphasises that although rarely, patients with scleroderma can present with colonic perforation which unfortunately due to their decreased physiological reserve, can lead to rapid and irreversible deterioration and subsequent death. It is therefore essential that clinicians faced with abdominal symptoms and signs in patients affected by SSc are able to quickly differentiate acute visceral perforation from benign causes.

Rare Case of Hepatic Endometriosis as an Incidental Finding: Difficult Diagnosis of a Diagnostic Dilemma.

Endometriosis is the abnormal existence of functional uterine mucosal tissue outside the uterus. It is a usual disorder of women in reproductive age which is mainly located in the female genital tract. Hepatic endometriosis is one of the rarest disorders characterized by the presence of ectopic endometrium in the liver. It is often described as cystic mass with or without solid component. Preoperative diagnosis is difficult via cross-sectional imaging and histopathologic evaluation remains the gold standard for diagnosis. We report an asymptomatic 40-year-old female with a large cystic mass involving the left hepatic lobe. She underwent laparoscopic removal of the cyst. The diagnosis of hepatic endometriosis was established by the histopathological analysis of the surgical specimen.

Assessing the clinical utility of Wnt pathway markers in colorectal cancer.

PURPOSE: ß-catenin and AXIN2 play an important role in the Wnt signaling pathway. The aim of this study was to investigate ß-catenin and AXIN2 expression in colorectal cancer (CRC) and relate these findings with patients' clinicopathological features and prognosis. METHODS: 57 consecutive patients with surgically treated CRC were included in this study. Quantitative PCR and immunohistochemistry (IHC) analyses were performed to characterize the expression of the aforementioned markers in CRC tissues. RESULTS: ß-catenin overexpression in the nucleus was associated with advanced N stage CRCs (p=0.04). Multivariate Cox regression analysis showed that ß-catenin overexpression is an independent prognostic factor for overall survival (OS). A positive correlation between ß-catenin location and AXIN2 mRNA was observed. CONCLUSIONS: Nuclear ß-catenin is a valuable prognostic factor. AXIN2 is a component of the "Destruction Complex" and also a Wnt target gene. However, the clinical importance of AXIN2 expression in CRC remains unclear.

The Diagnostic Dilemma of Primary Epiploic Appendagitis and How to Establish a Diagnosis.

Primary epiploic appendagitis (PEA) is a relatively uncommon, non-surgical situation that clinically mimics other conditions requiring surgery. In PEA, torsion and inflammation of an epiploic appendix results in localized abdominal pain. This condition may be clinically misdiagnosed, resulting in unnecessary surgical intervention. We report the unusual case of a healthy 44-year-old man, who presented to the 417 NIMTS Military Veterans' Fund Hospital of Athens with non-migratory left lower quadrant abdominal pain, which had started 24 hours before admission. The patient described a constant, sharp, non-radiating pain. He had no symptoms of nausea, vomiting, constipation, diarrhea, or fever. Abdominal examination showed focal abdominal tenderness with slight rebound tenderness. The diagnosis of PEA of the sigmoid colon was made based on the findings of an abdominal contrast computed tomography (CT). The key findings of CT were an oval lesion with a maximum diameter of 2.4 cm, with fat attenuation, and a circumferential hyperdense ring located adjacent to the sigmoid colon. This case is presented to highlight the clinical characteristics of PEA, which may help clinicians to overcome this diagnostic dilemma and reach the correct diagnosis.

Sigmoid carcinoma localized in the sac of a right inguinoscrotal hernia.

The inguinoscrotal hernia with colonic malignancy in the sac presents rare but severe consequence. The most common side of this type of hernia is the left one while the most common part of the large bowel is the sigmoid colon. The clinical picture can be easily confused with simple inguinoscrotal hernia unless the clinician is alert to the presence of certain sinister symptoms and signs. We report an extremely rare case of a 91-year-old man presented with anemia who had a right inguinoscrotal hernia containing a sigmoid colon carcinoma.

Persistent Coughing as the First Symptom of Primary Mucinous Appendiceal Adenocarcinoma.

Primary appendiceal adenocarcinomas are extremely rare entities. Preoperative diagnosis is very difficult and is mainly based on computed tomography (CT) scan findings. Furthermore, in many cases, difficulties in establishing an accurate intraoperative diagnosis have resulted in a two-stage surgical intervention. We herein report a case of a primary appendiceal mucinous adenocarcinoma in a 67-year-old Caucasian man who presented with atypical symptoms of persistent coughing and weight loss. The chest CT showed lesions with features favorable of malignancy. Further investigation with abdominal CT and colonoscopy revealed a large tumor of the cecum expanding to the ascending colon. Typical right hemicolectomy was performed and the histopathological examination confirmed mucinous adenocarcinoma of the appendix. As some cases are accidentally discovered, the presented case describes an extremely rare first presentation of this tumor and emphasizes that the preoperative diagnosis of appendiceal cancer is challenging due to the lack of specific symptoms and signs.

Scalp metastasis as the first sign of small-cell lung cancer: management and literature review.

Cutaneous metastasis from primary visceral malignancy is a relatively uncommon clinical entity, with a reported incidence ranging from 0.22% to 10% among various series. However, the presence of cutaneous metastasis as the first sign of a clinically silent visceral cancer is exceedingly rare. We describe here a case of an asymptomatic male patient who presented with a solitary scalp metastasis as the initial manifestation of an underlying small-cell lung cancer. Diagnostic evaluation revealed advanced disease. We conclude that the possibility of metastatic skin disease should always be considered in the differential diagnosis in patients with a history of smoking or lung cancer presenting with cutaneous nodules. Physicians should be aware of this rare clinical entity, and appropriate investigation should be arranged for early diagnosis and initiation of the appropriate treatment. The prognosis for most patients remains poor.

Fatal cardiac tamponade as the first manifestation of acute myeloid leukemia.

Acute myeloid leukemia is a hemopoietic myeloid stem cell neoplasm. It is the most common acute leukemia affecting adults,and its incidence increases with age. Acute myeloid leukemia is characterized by the rapid growth of abnormal white blood cells that accumulate in the bone marrow and interfere with the production of normal blood cells. As the leukemic cells keep filling the bone marrow, symptoms of the disease started to appear: fatigue, bleeding, increased frequency of infections, and shortness of breath. Cardiac tamponade or pericardial tamponade is an acute medical condition in which the accumulation of pericardial fluid prevents the function of the heart. Signs and symptoms include Beck triad (hypotension, distended neck veins, and muffled heart sounds), paradoxus pulses, tachycardia, tachypnea, and breathlessness. Pericardial effusion and cardiac tamponade are rare and severe complications of leukemia; they often develop during the radiation therapy, chemotherapy, or infections in the course of leukemia. This study sought to assess the fatal cardiac tamponade as the first manifestation of acute myeloid leukemia (AML). We found no reports in the literature linking these 2 clinical entities. Although the patient had no signs or diagnosis of AML previously, this case was remarkable for the rapidly progressive symptoms and the fatal outcome. The pericardial effusion reaccumulated rapidly after its initial drainage; it is a possible explanation that the leukemic cells interfered with cardiac activity or that they decreased their contractility myocytes secreting a toxic essence.

Rectus abdominis muscle malignant fibrous histiocytoma causing a large abdominal wall defect: reconstruction with biological mesh.

Malignant fibrous histiocytoma (MFH) is a common soft tissue sarcoma usually involving limbs and retroperitoneum. MFH of the rectus abdominis muscle is extremely rare. Surgery in similar cases leads to large abdominal wall defects needing reconstruction. Biological and synthetic laminar absorbable prostheses are available for the repair of hernia defects in the abdominal wall. They share the important feature of being gradually degraded in the host, resulting the formation of a neotissue. We herein report the case of an 84-year-old man with MFH of the rectus abdominis muscle which was resected and the large abdominal wall defect was successfully repaired with a biological mesh.

Metaplastic changes in chronic cholecystitis: implications for early diagnosis and surgical intervention to prevent the gallbladder metaplasia-dysplasia-carcinoma sequence.

BACKGROUND: Metaplastic features of the gallbladder epithelium are considered to be the precursors of gallbladder cancer. Considering the possible role of chronic inflammatory changes in the development of these lesions and the rationale for performing an early prophylactic cholecystectomy, we performed a retrospective study to assess the prevalence of gallbladder metaplasia in patients who underwent cholecystectomy due to underlying cholelithiasis. METHODS: We reviewed the routine histopathology reports of 86 patients with chronic cholecystitis, who underwent elective cholecystectomy, to assess the prevalence of gallbladder metaplasia in the course of chronic cholecystitis. We further attempted to evaluate the existence of any correlations between the presence of the gallbladder metaplasia and the type of lithiasis, as well as the gallbladder wall thickness. RESULTS: The overall prevalence of metaplastic features in the resected specimens was 25.6%. Dysplastic changes were more frequent in gallbladder specimens with concurrent metaplasia. Moreover, in presence of metaplastic changes, we observed an increase of the average gallbladder wall thickness. Finally, metaplastic and dysplastic changes were associated with the presence of micro-lithiasis rather than macro-lithiasis. CONCLUSIONS: Gallbladder metaplastic changes appear to be more frequent in cases of micro-lithiasis and seem to be associated with a chronic thickening of the gallbladder wall. Taking into account the usually sub-clinical course of this group of patients, when compared to patients with macro-lithiasis, further studies are needed to evaluate a possible role of prophylactic cholecystectomy in this population to prevent the long term evolution of these early changes to cancerous lesions.