Sustained improved emergency laparotomy outcomes over 3 years after a transdisciplinary perioperative care pathway-A 1:1 propensity score matched study.

BACKGROUND: Emergency laparotomy is associated with high morbidity and significant global health burden. This study aims to compare postoperative outcomes of patients who underwent emergency laparotomy before and after implementation of a emergency laparotomy pathway. METHODS: This is a single-center study of all patients who presented with an acute abdomen and/or conditions requiring emergency laparotomy during pre-emergency laparotomy pathway (retrospective cohort from January 2016 to December 2018) and after the emergency laparotomy pathway (prospective cohort from January 2019 to December 2021). Patients who underwent emergency laparotomy for trauma or vascular surgery were excluded. A 1:1 propensity score matching was performed to address for confounding factors. RESULTS: There were 888 patients (emergency laparotomy pathway, n = 428, and pre-emergency laparotomy pathway, n = 460) in the unmatched cohort. The mean age was 63.0 ± 15.4 years, and 43.8% had predicted mortality >10% using Portsmouth-Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity. The most common indication for emergency laparotomy was intestinal obstruction (30.5%). Overall incidence rates of major morbidity and 30-day mortality were 16.2% and 3.5%, respectively. There were 736 patients (n = 368 patients per arm) after propensity score matching. Demographic characteristics were comparable after propensity score matching. The emergency laparotomy pathway was associated with more patients assessed by geriatric medicine (odds ratio = 15.22; P < .001), reduced major morbidity (odds ratio = 0.63; P = .024), reduced intra-abdominal collection (odds ratio = 0.39; P = .006), and need for unplanned radiological and/or surgical intervention after index emergency laparotomy (odds ratio = 0.63; P = .024). Length of stay and 30-day mortality were comparable between the emergency laparotomy pathway and pre-emergency laparotomy pathway in both the unmatched and propensity score matched cohort. CONCLUSION: Sustained improved postoperative outcomes were achieved 3 years postimplementation of the emergency laparotomy pathway .

Evaluating a Single Surgeon's Learning Curve for Laparoscopic Totally Extraperitoneal Repair of Inguinal Hernia with Telescopic Dissection: A Cumulative Sum Control Chart Analysis.

Background: Laparoscopic totally extraperitoneal (TEP) inguinal hernia repair (IHR) reduces risk of injury to intraperitoneal structures. Balloon dissection is more costly and has theoretical risk of injury to the surrounding structures compared with telescopic dissection (TD). This study aims to evaluate the learning curve (LC) for TEP IHR with TD of a single surgeon. Methods: This is a 3-year retrospective cohort study from January 2020 to December 2022 on patients who underwent elective laparoscopic TEP unilateral IHR with TD. Exclusion criteria were recurrent inguinal hernia. Cumulative sum (CUSUM) analysis was performed to evaluate the number of cases required to surmount the LC, that is, NLC for operating time (OT) and open conversion. One way analysis of variance was used to perform groupwise comparison. Results: There were 69 patients who underwent laparoscopic TEP unilateral IHR with TD. The median age was 58.0 years (range 24.0-80.0) and body mass index was 23.0 (range 18.6-30.0). Majority of the hernia was indirect (n = 48, 69.6%). The median OT was 70 minutes (range 35-210). Three cases (4.3%) had open conversion. One-year recurrence was 4.2% (n = 1/24). CUSUM analysis showed improvement in OT after the eighth case. However, this was followed by multiple inflection points with no apparent stabilization in OT. Pairwise comparison showed a decrease in OT between cases 18-36 and cases 37-54. There was no incidence of open conversion until the 56th case. Conclusion: Laparoscopic TEP IHR using TD is safe in the absence of a practor. A minimum of 36 cases is required to surmount the initial LC.

Technical considerations for laparoscopic transabdominal preperitoneal repair of concurrent Spigelian-inguinal hernia complex: A case report and review of literature.

Spigelian hernia with concurrent inguinal hernia is not uncommon. The hernia location makes conventional laparoscopic repair challenging and this is commonly repaired by the open method. We present the technical considerations and feasibility, as well as literature review, of such a hernia repaired via a minimally invasive fashion. We performed a laparoscopic transabdominal preperitoneal hernia repair for a 59-year-old woman who presented with symptomatic irreducible large Spigelian-inguinal complex hernia, with a hernia neck of 4 cm on computed tomography scan. The hernia contents were reduced transabdominally and subsequently, the preperitoneal space was created via a transabdominal preperitoneal method to allow for hernia defect closure and subsequent mesh placement. The patient was discharged on postoperative day 2 without complication. At 6 months follow-up, she had no complications or recurrence. With increased experience, the laparoscopic repair of complex Spigelian-inguinal concurrent hernias is safe and feasible.

An Affordable Approach of Mesenchymal Stem Cell Therapy in Treating Perianal Fistula Treatment.

The application of stem cells to treat perianal fistula due to Crohn's disease has attracted a lot of interest in recent decades. Though still a popular procedure, the existing surgical methods may be an ideal form of therapy since the recurrence rate is high, which affects the quality of life badly. Stem cell therapy offers to be a better solution in treating PF, but the utilisation is often restricted because of the manufacturing cost. Hence in this review, the selection of suitable cell sources, the use of bioreactors and preconditioning MSCs as well as modified stem cells will be discussed for a more affordable as compared with the current MSC therapy towards PF. We anticipate that exploring these approaches may give a complete picture in understanding stem cells in order to make them effective and affordable for long-term therapeutic applications.

Index admission laparoscopic cholecystectomy for acute cholecystitis restores Gastrointestinal Quality of Life Index (GIQLI) score.

BACKGROUNDS/AIMS: Previous studies have evaluated quality of life (QoL) in patients who underwent laparoscopic cholecystectomy (LC) for cholelithiasis. The purpose of this study was to evaluate QoL after index admission LC in patients diagnosed with acute cholecystitis (AC) using the Gastrointestinal Quality of Life Index (GIQLI) questionnaire. METHODS: Patients ≥21 years admitted to Tan Tock Seng Hospital, Singapore for AC and who underwent index admission LC between February 2015 and January 2016 were evaluated using the GIQLI questionnaire preoperatively and 30 days postoperatively. RESULTS: A total of 51 patients (26 males, 25 females) with a mean age of 60 years (24-86 years) were included. Median duration of abdominal pain at presentation was 2 days (1-21 days). 45% of patients had existing comorbidities, with diabetes mellitus being most common (33%). 31% were classified as mild AC, 59% as moderate and 10% as severe AC according to Tokyo Guideline 2013 (TG13) criteria. Post-operative complications were observed in 8 patients, including retained common bile duct stone (n=1), wound infection (n=2), bile leakage (n=2), intra-abdominal collection (n=1) and atrial fibrillation (n=2). 86% patients were well at 30 days follow-up and were discharged. A significant improvement in GIQLI score was observed postoperatively, with mean total GIQLI score increasing from 106.0±16.9 (101.7-112.1) to 120.4±18.0 (114.8-125.9) (p<0.001). Significant improvements were also observed in GIQLI subgroups of gastrointestinal symptoms, physical status, emotional status and social function status. CONCLUSIONS: Index admission LC restores QoL in patients with AC as measured by GIQLI questionnaire.

The role of type III secretion system and lens material on adhesion of Pseudomonas aeruginosa to contact lenses.

PURPOSE: To determine the distribution of invasive and cytotoxic genotypes among ocular isolates of P. aeruginosa and investigate the influence of the type III secretion system (T3SS) on adhesion to conventional, cosmetic, and silicone hydrogel contact lenses (CL). METHODS: Clinical isolates from 2001 to 2010 were analyzed by multiplex PCR for exoS, exoU, and exoT genes. Bacterial adhesion to etafilcon, nelfilcon (gray colored), balafilcon, and galyfilcon CL with or without artificial tear fluid (ATF) incubation were compared. Surface characteristics were determined with scanning electron microscopy (SEM). RESULTS: Among 87 total isolates, 64 strains were from microbial keratitis cases. CL-related microbial keratitis (CLMK) isolates were mostly of the cytotoxic genotype (expressing exoU) (P = 0.002). No significant differences were found in bacterial adhesion to all types of CL between the genotypes under T3SS-inducing conditions. A trend for least bacterial adhesion of galyfilcon compared to the other CL was noted for both genotypes. Needle complex pscC mutants adhered less to all materials than the wild type (P < 0.05), indicating a role of the T3SS in contact lens adhesion. ATF-incubated CL had significantly more bacterial adhesion (P < 0.05). SEM showed most of the bacteria adhering on CL surfaces. CONCLUSIONS: CLMK isolates were mostly of cytotoxic genotype. Different genotypes did not significantly differ in its adhesion to various CL. T3SS and other adhesins are involved in bacteria-contact lens adhesion through complex interactions. Contact lens materials may also play an important role in the adherence of both genotypes of P. aeruginosa.

Maintenance of mitochondrial DNA copy number and expression are essential for preservation of mitochondrial function and cell growth.

To examine whether a reduction in the mtDNA level will compromise mitochondrial biogenesis and mitochondrial function, we created a cell model with depleted mtDNA. Stable transfection of small interfering (si)RNA of mitochondrial transcription factor A (Tfam) was used to interfere with Tfam gene expression. Selected stable clones showed 60-95% reduction in Tfam gene expression and 50-90% reduction in cytochrome b (Cyt b) gene expression. Tfam gene knockdown clones also showed decreased mtDNA-encoded cytochrome c oxidase subunit I (COX I) protein expression. However, no significant differences in protein expression were observed in nuclear DNA (nDNA)-encoded mitochondrial respiratory enzyme subunits. The cell morphology changed from a rhombus-like to a spindle-like form as determined in clones with decreased expressions of Tfam, mtRNA, and mitochondrial proteins. The mitochondrial respiratory enzyme activities and ATP production in such clones were significantly lower. The proportions of mtDNA mutations including 8-hydroxy-2'-deoxyguanosine (8-OHdG), a 4,977-bp deletion, and a 3,243-point mutation were also examined in these clones. No obvious increase in mtDNA mutations was observed in mitochondrial dysfunctional cell clones. The mitochondrial respiratory activity and ATP production ability recovered in cells with increased mtDNA levels after removal of the specific siRNA treatment. These experimental results provide direct evidence to substantiate that downregulation of mtDNA copy number and expression may compromise mitochondrial function and subsequent cell growth and morphology.

The role of protein tyrosine phosphorylation in the cell-cell interactions, junctional permeability and cell cycle control in post-confluent bovine corneal endothelial cells.

Cell-cell interaction, junctional permeability and contact inhibition are important mechanisms that allow corneal endothelial cells to maintain stable corneal hydration status and also keep these cells in non-proliferative status. Protein tyrosine phosphatases (PTPs) are well known to play an important role in regulating cell-cell contacts, growth and differentiation. Inhibition of PTPs activity by a general PTP inhibitor has been proved to trigger post-confluent rat corneal endothelial cells to reenter cell cycles. In this study, we aimed to evaluate whether protein tyrosine phosphorylation is involved in cell-cell interactions, junctional permeability and cell cycle control in post-confluent, contact inhibited bovine corneal endothelial cells. Confluent cultures of bovine corneal endothelial cells were treated with different concentrations of general phosphatase inhibitor, sodium orthovanadate (vanadate) for several different durations. Protein tyrosine phosphorylation was confirmed by Western blot analysis. Immunocytochemistry was used to evaluate the effect of vanadate on adherens-type junctional proteins by staining of p120, N-cadherin and alpha-catenin. Paracelluar permeability was evaluated by transepithelial electric resistance. The effect of vanadate on cell cycle progression was confirmed by immunostaining of Ki67. Western blot analysis was used to evaluate the expression level of cell-cycle-associated proteins, including PCNA, cyclin D1, cyclin E and cyclin A. Time-dependent effects of vanadate on protein tyrosine phosphorylation were confirmed by Western blot analysis. ICC demonstrated the effect of vanadate on the disruption of p120, N-cadherin and alpha-catenin. Time- and dose-effects of vanadate on the severity of p120 disruption were also found. TER demonstrated the time- and dose-effect of vanadte on paracellular permeability. Although cell-cell junctions can be broken through by vanadate, no significant increase of Ki67 positive cells was found among the control group and all groups with different concentrations/durations of vanadate treatment. Western blot also showed no change of PCNA, cyclin D1, cyclin E and cyclin A after treatment with vanadate. In conclusion, protein tyrosine phosphatase inhibition can induce time-dependent release of cell-cell contacts and increase transepithelial permeability in post-confluent cultures of bovine corneal endothelial cells. However, such phenomenon is not enough to promoted cell cycle progression as seen in rat corneal endothelial cells.