Does perioperative biological therapy increase 30-day post-operative complication rates in inflammatory bowel disease patients undergoing intra-abdominal surgery? A systematic review.

BACKGROUND: Biopharmaceuticals revolutionised inflammatory bowel disease (IBD) treatment. However, it is postulated they compromise immunity, collagen production and angiogenesis resulting in infective post-operative complications and altered wound/anastomotic healing. Research has failed to agree on risks associated with perioperative biologics therefore it was anticipated that a systematic review may provide a consensus and contribute recommendations for clinical practice. METHODS: A systematic review conducted as per PRISMA guidelines included a methodical search of PubMed, Google Scholar, EMBASE/Ovid and Cochrane Library using MeSH and/or keywords for papers published between 01/01/1998 and 04/02/2019.The population analysed included adult ulcerative colitis, Crohn's disease, Indeterminate Colitis or IBD unclassified patients. The intervention was intra-abdominal surgery in patients treated with biological therapy in the preceding 12 weeks compared to patients who had intra-abdominal surgery without biological therapy within the defined timeframe. The primary outcome was surgical site infection (SSI) with secondary outcomes including wound dehiscence, intra-abdominal sepsis/abscess, systemic infection and anastomotic breakdown within 30 days post-procedure. Papers were evaluated by two independent reviewers and those included were assessed for quality/bias using the Newcastle-Ottowa scale. RESULTS: 2064 UC, Crohn's and IC patients were analysed across 8 included studies. Several studies' multivariate analyses demonstrated corticosteroids to be independent predictors of morbidity. There are no increased complications associated with anti-TNFα exposure while vedolizumab increased SSI and small bowel obstruction. CONCLUSION: Prospective studies and randomised control trials are required to clarify study outcomes and recommendations published to date. Presently, biologics should continue to be used and considered beneficial in this population.

Laparoscopic versus Open surgery for small bowel Crohn's disease.

BACKGROUND: Crohn's disease (CD) is a chronic inflammatory bowel disease that most commonly involves the terminal ileum and colon (55 percent). Surgical treatment is required in approximately 70 percent of patients. Multiple procedures and repeat operations are required in 30 - 70 percent of all patients (Duepree 2002) but the disease remains incurable.Laparoscopy has gained wide acceptance in gastrointestinal surgery with potential advantages of faster return to normal activity and diet, reduced hospital stay, reduced postoperative pain, better cosmesis (Duepree 2002, Dunker 1998, Milsom 2001, Reissman 1996), improved social and sexual interaction (Albaz 2000) and its use is accepted in benign and malignant colorectal diseases. Laparoscopic surgery offers additional advantage of smaller abdominal fascial wounds, low incidence of hernias, and decreased rate of adhesive small-bowel obstruction (Albaz 2000) compared with conventional surgery reducing the need for non-disease-related surgical procedures in CD population.There are concerns about missing occult segments of disease and critical proximal strictures due to limited tactile ability, earlier recurrence due to possible reduced immune response induced by laparoscopy, technical difficulty due to fragile inflamed bowel and mesentery and the existence of adhesions, fistulas, and abscesses (Uchikoshi 2004). It is therefore important to evaluate the potential benefits and risks of laparoscopic surgery versus open surgery in patients with small bowel CD (Lowney 2005). OBJECTIVES: To determine if there is a difference in the perioperative outcomes and re-operation rates for disease recurrence following laparoscopic surgery compared to open surgery in small bowel CD. SEARCH STRATEGY: Published and unpublished randomised controlled trials were searched for in the following electronic databases: The Cochrane Central Register of Controlled Trials (CENTRAL) 2010 issue 2 The Cochrane Database of Systematic Reviews, and Database of Abstracts of Reviews of Effects (DARE) 2010 issue 2 The Cochrane Colorectal Cancer Group Controlled Trials Register Ovid MEDLINE (1990 to 2010) EMBASE (1990 to 2010) Health Technology Assessment (HTA) Database (1990 to 2010) SELECTION CRITERIA: Randomised controlled trials (RCT) comparing laparoscopic and open surgery for small bowel CD were included. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed the studies and extracted data. RevMan 5.0 was used for statistical analysis. MAIN RESULTS: Two RCTs comparing laparoscopic and open surgery for small bowel CD were identified. Long term outcomes of the patients in both the trials were published separately and these were included in the review.Laparoscopic surgery appeared to be associated with reduced number of wound infections (1/61 vs 9/59), reoperation rates for non disease related complications (3/57 vs 7/54 ) but the difference was not statistically significant [p values were 0.23 and 0.19 respectively]. There was no statistically significant difference between any of the compared outcomes between laparoscopic and open surgery in the management of small bowel CD. AUTHORS' CONCLUSIONS: Laparoscopic surgery for small bowel CD may be as safe as the open operation. There was no significant difference in the perioperative outcomes and the long term reoperation rates for disease-related or non-disease related complications of CD.

Testicular infarction secondary to protein S deficiency: a case report.

BACKGROUND: Protein S deficiency is an inherited cause of thrombophilia. We present the second reported case in the literature of a man developing testicular infarction secondary to protein S deficiency. CASE PRESENTATION: A 63 year old man presented with sudden onset of pain in his left hemi-scrotum. Despite oral warfarin therapy the plasma INR was only 1.4 at presentation. Doppler ultrasound scan of the scrotum confirmed absent blood flow to the left testis with increased echogenicity. Orchidectomy was performed to remove the necrotic testis. Post-operatively the patient did well and was referred to the Regional Haemophilia and Thrombosis Centre for further management. CONCLUSION: The case highlights a rare but potential complication of protein S deficiency and demonstrates the importance of adequate anticoagulation in these patients.

Laparoscopic cholecystectomy in situs inversus totalis: a case report.

BACKGROUND: Laparoscopic cholecystectomy is one of the commonest surgical procedures carried out in the world today. Occasionally patients present with undiagnosed situs inversus and acute cholecystitis. We discuss one such case and outline how the diagnosis was made and the pitfalls encountered during surgery and how they were overcome. CASE PRESENTATION: A 32 year old female presented to our department with epigastric pain radiating through to the back. A diagnosis of acute cholecystitis in a patient with situs inversus totalis was made following clinical examination and radiological investigation. Laparoscopic cholecystectomy was subsequently performed and the patient made an uneventful recovery. CONCLUSION: Situs inversus presenting with acute cholecystitis is very rare. The surgeon must appreciate that care should be taken to set up the operating theatre in the mirror image of the normal set-up for cholecystectomy, and that right handed surgeons must modify their technique to adapt to the mirror image anatomy.

Pseudo-aneurysm of the anterior tibial artery, a rare cause of ankle swelling following a sports injury.

BACKGROUND: Ankle pain and swelling following sports injuries are common presenting complaints to the accident and emergency department. Frequently these are diagnosed as musculoskeletal injuries, even when no definitive cause is found. Vascular injuries following trauma are uncommon and are an extremely rare cause of ankle swelling and pain. These injuries may however be limb threatening and are important to diagnose early, in order that appropriate treatment can be delivered. We highlight the steps to diagnosis of these injuries, and methods of managing these injuries. It is important for clinicians to be aware of the potential for this injury in patients with seemingly innocuous trauma from sports injuries, who have significant ankle pain and swelling. CASE PRESENTATION: A young, professional sportsman presented with a swollen, painful ankle after an innocuous hyper-plantar flexion injury whilst playing football, which was initially diagnosed as a ligamentous injury after no bony injury was revealed on X-Ray. He returned 2 days later with a large ulcer at the lateral malleolus and further investigation by duplex ultrasound and transfemoral arteriogram revealed a Pseudo-Aneurysm of the Anterior Tibial Artery. This was initially managed with percutaneous injection of thrombin, and later open surgery to ligate the feeding vessel. The patient recovered fully and was able to return to recreational sport. CONCLUSION: Vascular injuries remain a rare cause of ankle pain and swelling following sports injuries, however it is important to consider these injuries when no definite musculo-skeletal cause is found. Ultrasound duplex and Transfemoral arteriogram are appropriate, sensitive modalities for investigation, and may allow novel treatment to be directed percutaneously. Early diagnosis and intervention are essential for the successful outcome in these patients.

Management of cystic tumours of the pancreas.

BACKGROUND: Cystic tumours of the pancreas account for 5% of pancreatic neoplasms and are frequently misdiagnosed as pancreatic pseudocysts. The authors' experience of managing these tumours is presented here, highlighting the clinical presentation, diagnostic difficulties and operative treatment. METHODS: This is a retrospective study of all patients diagnosed to have cystic tumours of the pancreas treated at The Mater Hospital, during a 5-year period from 1997 to 2002. Literature was reviewed and guidelines for the management of these tumours have been outlined. RESULTS: Seven patients with cystic pancreatic tumours were treated over this time-period. All patients were women with a median age of 40. Two of these patients were initially diagnosed as having pseudocysts and were treated elsewhere by cystgastrostomy. The tumour was resected in all patients. All but one was benign. At follow up, ranging from 13 to 66 months, all patients were alive and well. CONCLUSIONS: Cystic tumours of the pancreas are uncommon and generally slow growing. It is important not to assume that a cystic lesion in the pancreas, especially in middle-aged women, is a pseudocyst. Satisfactory surgical resection may be possible even after previous operative procedures on the pancreas. Prognosis after resection remains good.

Colovesical fistula presenting with epididymitis.

This article reports a case of colovesical fistula presenting with epididymitis. A 75-year-old man with a recent conservatively managed localised diverticular perforation presented to hospital with acute pain and swelling of his left testicle and epididymis. On further questioning, the patient reported passing air in his urine. Urine cultures grew Enterococcus faecalis. Ultrasound scan confirmed a diagnosis of bacterial epididymitis and the patient was treated with intravenous antibiotics. Subsequent CT imaging revealed air in the bladder and a colovesical fistula. The patient went on to have Hartmann's procedure with repair of the bladder defect. This case highlights that: (1) Colovesical fistulae may rarely present with epididymitis. (2) Colovesical fistulae are the most common cause of pneumaturia.