Association of COVID 19 pneumonitis and acute mesenteric ischemia.

Key Clinical Message: D. dimer could be useful as an indicator in diagnosis of mesenteric ischemia in COVID patients. A two staged damage control emergency laparotomy is of good benefits in such patients. Abstract: Bowel ischemia in COVID 19 patients is extremely rare condition results from migrating thrombus formed by a hypercoagulable inflammatory state that is frequently associated COVID 19 infection. A two staged damage control emergency laparotomy is of good benefits in general especially in those with active COVID 19 infection.

Meta-analysis of randomized controlled trials only exploring the role of single incision laparoscopic surgery versus conventional multiport laparoscopic surgery for colorectal resections.

BACKGROUND: The objective of this article is to evaluate the surgical outcomes in patients undergoing single incision laparoscopic surgery (SILS) versus conventional multi-incision laparoscopic surgery (MILS) for colorectal resections. METHODS: The data retrieved from the published randomized controlled trials (RCTs) reporting the surgical outcomes in patients undergoing SILS versus MILS for colorectal resections was analysed using the principles of meta-analysis. The combined outcome of dichotomous data was represented as risk ratio (RR) and continuous data was shown as standardized mean difference (SMD). RESULTS: Five RCTs on 525 patients reported the colorectal resections by SILS versus MILS technique. In the random effects model analysis using the statistical software Review Manager 5.3, the operation time (SMD, 0.20; 95% CI, -0.11 to 0.52; z=1.28; P=0.20), length of in-patient stay (SMD, -0.18; 95% CI, -0.51 to 0.14; z=1.10; P=0.27) and lymph node harvesting (SMD, 0.09; 95% CI, -0.14 to 0.33; z=0.76; P=0.45) were comparable between both techniques. Furthermore, post-operative complications (RR, 1.00; 95% CI, 0.65-1.54; z=0.02; P=0.99), post-operative mortality, surgical site infection rate (RR, 3.00; 95% CI, 0.13-70.92; z=0.68; P=0.50), anastomotic leak rate (RR, 0.43; 95% CI, 0.11-1.63; z=1.24; P=0.21), conversion rate (P=0.13) and re-operation rate (P=0.43) were also statistically similar following SILS and MILS. CONCLUSIONS: SILS failed to demonstrate any superiority over MILS for colorectal resections in all post-operative surgical outcomes.

A critical appraisal of the cost effectiveness of laparoscopic colorectal surgery for oncological and non-oncological resections.

The aim of this study was to critically appraise the cost effectiveness of the laparoscopic colorectal (LCRS) surgery using published randomised, control trials (RCTs). Published RCTs comparing the cost effectiveness of LCRS with conventional open surgery were selected from the search of standard electronic databases and the extracted data were analysed using the statistical software RevMan 5.3. Seven RCTs on 2197 patients reported the cost effectiveness of the LCRS. There was significant heterogeneity (τ 2 = 161,772.25, χ 2 = 166.69, df = 6, p = 0.00001, I 2 = 96%) among included randomised, controlled trials. In the random effects model analysis (MD 320.37, 95% CI -38.21, 678.95, z = 1.75, p < 0.08), the LCRS was costing £320.37 more than open colorectal resection but it failed to reach the statistical significance indicating that LCRS is as much cost effective as the open approach. LCRS is a cost effective intervention and should be offered routinely to all patients requiring colorectal resections provided the resources and expertise are available.

Systematic review of oncological outcomes following laparoscopic vs open total mesorectal excision.

AIM: To systematically analyze the randomized trials comparing the oncological and clinical effectiveness of laparoscopic total mesorectal excision (LTME) vs open total mesorectal excision (OTME) in the management of rectal cancer. METHODS: Published randomized, controlled trials comparing the oncological and clinical effectiveness of LTME vs OTME in the management of rectal cancer were retrieved from the standard electronic medical databases. The data of included randomized, controlled trials was extracted and then analyzed according to the principles of meta-analysis using RevMan(®) statistical software. The combined outcome of the binary variables was expressed as odds ratio (OR) and the combined outcome of the continuous variables was presented in the form of standardized mean difference (SMD). RESULTS: Data from eleven randomized, controlled trials on 2143 patients were retrieved from the electronic databases. There was a trend towards the higher risk of surgical site infection (OR = 0.66; 95%CI: 0.44-1.00; z = 1.94; P < 0.05), higher risk of incomplete total mesorectal resection (OR = 0.62; 95%CI: 0.43-0.91; z = 2.49; P < 0.01) and prolonged length of hospital stay (SMD, -1.59; 95%CI: -0.86--0.25; z = 4.22; P < 0.00001) following OTME. However, the oncological outcomes like number of harvested lymph nodes, tumour recurrence and risk of positive resection margins were statistically similar in both groups. In addition, the clinical outcomes such as operative complications, anastomotic leak and all-cause mortality were comparable between both approaches of mesorectal excision. CONCLUSION: LTME appears to have clinically and oncologically measurable advantages over OTME in patients with primary rectal cancer in both short term and long term follow ups.

The role of physician reminders in faecal occult blood testing for colorectal cancer screening.

BACKGROUND: Colorectal cancer screening in the form of faecal occult blood (FOB) testing can significantly reduce the burden of this disease and has been used as early as the 1970s. Effective involvement of GPs along with reminding physicians prior to seeing a patient may improve uptake. OBJECTIVE: This article is a systematic review of published literature examining the uptake of FOB testing after physician reminders as part of the colorectal cancer screening process. METHODS: Electronic databases were searched from January 1975 to October 2010. All studies comparing physician reminders (Rem) with controls (NRem) were identified. A meta-analysis was performed to obtain a summary outcome. RESULTS: Five comparative studies involving 25 287 patients were analyzed. There were 12 641 patients were in the Rem and 12 646 in the NRem group. All five studies obtained a higher percentage uptake when physician reminders were given. However, in only two of the studies were the percentage uptake significantly higher. There was significant heterogeneity among trials (I2 = 95%). The combined increase in FOB test uptake was not statistically significant (random effects model: risk difference = 6.6%, 95% CI: -2-14.7%; z = 1.59, P = 0.112). CONCLUSION: Reminding physicians about those patients due for FOB testing may not improve the effectiveness of a colorectal cancer screening programme. Further studies are required and should focus on areas where there is a lower baseline uptake and areas with high levels of deprivation.

Ogilvie's syndrome-related right colon perforation after cesarean section: a case series.

The objective of this article is to discuss and report three cases of right colon perforation secondary to postcesarean Ogilvie's syndrome (OS; colonic pseudo-obstruction) requiring right hemicolectomy. We retrospectively reviewed the case notes of three patients who underwent caesarean section and postoperatively developed OS. OS is an uncommon problem in patients undergoing caesarean section. Abdominal X-ray and water-soluble contrast enema are the main diagnostic modalities. Drip-suck therapy along with endoscopic or pharmacological decompression should be performed in early stages. In a significant percentage of patients, diagnosis is delayed resulting in bowel ischemia and perforation requiring surgical resection and adding significant mortality/morbidity. We recommend our obstetric colleagues to involve surgical team in earlier stages to avoid surgery-related mortality and morbidity. We also advocate general surgeons to be aware of OS in patients after caesarean section and recommend a stepwise systematic approach toward the diagnosis and management of OS.

The role of perioperative warming in surgery: a systematic review.

OBJECTIVE: The objective of this review was to systematically analyze the trials on the effectiveness of perioperative warming in surgical patients. METHODS: A systematic review of the literature was undertaken. Clinical trials on perioperative warming were selected according to specific criteria and analyzed to generate summative data expressed as standardized mean difference (SMD). RESULTS: Twenty-five studies encompassing 3,599 patients in various surgical disciplines were retrieved from the electronic databases. Nineteen randomized trials on 1785 patients qualified for this review. The no-warming group developed statistically significant hypothermia. In the fixed effect model, the warming group had significantly less pain and lower incidence of wound infection, compared with the no-warming group. In the random effect model, the warming group was also associated with lower risk of post-anesthetic shivering. Both in the random and the fixed effect models, the warming group was associated with significantly less blood loss. However, there was significant heterogeneity among the trials. CONCLUSION: Perioperative warming of surgical patients is effective in reducing postoperative wound pain, wound infection and shivering. Systemic warming of the surgical patient is also associated with less perioperative blood loss through preventing hypothermia-induced coagulopathy. Perioperative warming may be given routinely to all patients of various surgical disciplines in order to counteract the consequences of hypothermia.

The role of perioperative warming in surgery: a systematic review / O papel do aquecimento perioperatório em cirurgia: uma revisão sistemática

OBJECTIVE: The objective of this review was to systematically analyze the trials on the effectiveness of perioperative warming in surgical patients. METHODS: A systematic review of the literature was undertaken. Clinical trials on perioperative warming were selected according to specific criteria and analyzed to generate summative data expressed as standardized mean difference (SMD). RESULTS: Twenty-five studies encompassing 3,599 patients in various surgical disciplines were retrieved from the electronic databases. Nineteen randomized trials on 1785 patients qualified for this review. The no-warming group developed statistically significant hypothermia. In the fixed effect model, the warming group had significantly less pain and lower incidence of wound infection, compared with the no-warming group. In the random effect model, the warming group was also associated with lower risk of post-anesthetic shivering. Both in the random and the fixed effect models, the warming group was associated with significantly less blood loss. However, there was significant heterogeneity among the trials. CONCLUSION: Perioperative warming of surgical patients is effective in reducing postoperative wound pain, wound infection and shivering. Systemic warming of the surgical patient is also associated with less perioperative blood loss through preventing hypothermia-induced coagulopathy. Perioperative warming may be given routinely to all patients of various surgical disciplines in order to counteract the consequences of hypothermia.

OBJETIVO: O objetivo desta revisão é analisar sistematicamente os ensaios sobre a eficácia do aquecimento perioperatório em pacientes cirúrgicos. MÉTODOS: Uma revisão sistemática da literatura foi realizada. Ensaios clínicos sobre aquecimento perioperatório foram selecionados segundo critérios específicos e analisados para gerar dados sumativo expresso na diferença média padronizada (standardized mean difference, SMD). RESULTADOS: Vinte e cinco estudos englobando 3.599 pacientes de várias disciplinas de cirurgia foram obtidos a partir de bases de dados eletrônicas. Dezenove ensaios aleatórios em 1.785 pacientes qualificados para esta revisão. Nenhum grupo de aquecimento desenvolveu estatisticamente significativa hipotermia. No modelo de efeito fixo, grupo de aquecimento tiveram significativamente menos dor e menor incidência de infecção na ferida quando comparado com o grupo de não-aquecimento. No modelo de efeito aleatório, grupo de aquecimento também foi associado a um menor risco de tremores pós-anestesia. Em ambos os modelos de efeitos fixos e aleatórios, o aquecimento foi significativamente associado com menor perda de sangue. No entanto, houve significativa heterogeneidade entre os ensaios. CONCLUSÃO: O aquecimento perioperatório de pacientes cirúrgicos é eficaz na redução da dor pós-operatória ferida, infecção ferida, e tremores. O aquecimento sistêmico do paciente cirúrgico também está associado com menor perda de sangue no perioperatório prevenindo hipotermia e induzindo coagulopatia. O aquecimento perioperatório pode ser administrado rotineiramente a todos os pacientes cirúrgicos de diversas disciplinas, a fim de neutralizar as consequências da hipotermia.

Needlescopic versus laparoscopic appendectomy: a systematic review.

BACKGROUND: Needlescopic appendectomies (NA) have been performed since the 1990s. We sought to systematically analyze trials comparing NA with laparoscopic appendectomies (LA) in the management of appendicitis. METHODS: We performed a systematic review of the literature. We compared and analyzed clinical trials on NA and LA to generate summative data expressed as standardized mean differences (SMD). RESULTS: Of 5 retrieved trials from the electronic database 2 trials involving 412 patients met our inclusion criteria. In the fixed-effects models, NA took longer than LA, and this time difference was statistically significant: SMD 0.20 min, 95% confidence interval 0.01-0.40, p = 0.030, z(1) = 2.09. In both fixed-and random-effects models, the difference in total hospital stay and in perioperative complications between the NA and LA groups were nonsignificant. Furthermore, in both fixed-and random-effects models, NA was associated with a higher conversion rate to open appendectomy than LA. There was no heterogeneity between the trials (Q = 0.34, p = 0.55). CONCLUSION: Needlescopic appendectomy can be a safe and effective procedure for the management of appendicitis. It is comparable to LA in terms of hospital stay and perioperative complications. However, NA is associated with a longer duration of surgery and a higher conversion rate, indicating technical challenges of the procedure. Before recommending routine use of the needlescopic technique for appendectomy, a major multicentre randomized controlled trial is necessary.

Effect of heated and humidified carbon dioxide on patients after laparoscopic procedures: a meta-analysis.

OBJECTIVE: To systematically analyze the role of heated humidified carbon dioxide (CO2) in laparoscopy. METHODS: Clinical trials on laparoscopic procedures using standard dry CO2 versus heated humidified CO2 for pneumoperitoneum were analyzed. RESULTS: Ten randomized controlled trials on 565 patients were analyzed. In both the fixed and random effect models, postoperative pain was significantly less in heated humidified CO2 group. Heated humidified CO2 group was also associated with significantly lower risk of hypothermia and lower analgesic requirement. However, statistically there was no difference in total hospital stay and lens fogging rate. CONCLUSIONS: The use of heated humidified CO2 for pneumoperitoneum in laparoscopic procedures is associated with lesser postoperative pain, lower risk of postoperative hypothermia, and lower analgesic requirements. However, total hospital stay and lens fogging rates do not differ. Hence, the heated and humidified CO2 may be considered as the first choice for pneumoperitoneum in laparoscopic procedures.

Use of health-related quality of life tools in hepatobiliary surgery.

BACKGROUND: The objective of this article is to review the literature and discuss the various tools used in hepatobiliary surgery for the measurement of health related quality of life (HR-QOL) and highlight various outcome variables that affect the HR-QOL among patients with common hepatobiliary disorders. DATA SOURCES: We reviewed HR-QOL articles published in the last 20 years on different hepatobiliary curative or palliative procedures in all languages. RESULTS: HR-QOL is a questionnaire tool which is utilized to assess the changes in the health status of patients after a hepatobiliary intervention. These surveys are of increasingly importance, as health care providers are challenged to justify treatment approaches and rationale for any surgical intervention. These HR-QOL tools are very helpful for the evaluation of subjective outcome of common hepatobiliary procedures like gastrointestinal quality of life index (GIQLI) for cholecystectomy, functional assessment in cancer therapy (FACT) for liver resection, short form 36 (SF-36) for liver transplantation, and quality of life questionnaire for patients with pancreatic cancer (QLQ-PAN). CONCLUSIONS: Use of validated and reliable health instruments in hepatobiliary surgery is directed at measuring the impact in a reproducible and valid fashion. Curative or palliative procedures should be offered to the patients of hepatobiliary disorders after the assessment by HR-QOL tools. Because the impairments of function that may occur after different operations vary considerably, an operation-specific assessment of HR-QOL for each type of surgical procedure is becoming an essential principle to follow in a successful healthcare system.

Lengthening of small bowel mesentery: stepladder incision technique.

The surgical option of choice in most patients with mucosal ulcerative colitis or familial adenomatous polyposis is restorative proctocolectomy with ileal pouch anal anastomosis. The tension-free anastomosis is one of the most critical steps but may be technically difficult or impossible in some patients because of shortened small bowel mesentery. Various techniques have been described to increase the length of small bowel mesentery. These techniques usually involve selective division of mesenteric blood vessels and meticulous dissection. We describe a new technique of stepladder transverse, transmesenteric incisions in the avascular windows of small bowel mesentery. This provides additional small bowel length without compromising blood supply to the pouch and a simple and safe method of increasing the length of small bowel mesentery. To date, no complications have been reported using this technique.

Reduced expression of serotonin receptor(s) in the left colon of patients with colonic inertia.

PURPOSE: Serotonin regulates colonic motility receptors expressed on neural fibers and smooth muscle. Colonic inertia is characterized by delayed colonic transit. Abnormalities in serotonin receptor protein, as judged by immunoreactivity levels, could contribute to the origin of colonic inertia. The aim of this study was to investigate the expression of serotonin receptor(s) immunoreactivity in the left colon of patients with colonic inertia compared with controls. METHODS: Sixteen patients who underwent subtotal colectomy for colonic inertia were assessed. Colonic transit time was measured with the radiopaque marker technique and presented as the number of retained markers in the colon on Day 5. The control group consisted of 18 patients who underwent left hemicolectomy for colonic carcinoma; histologically normal tissues from the left colon were used. Immunohistochemical staining for serotonin receptor was performed with a rabbit anti-idiotypic antibody. The average positive area (square pixels) in the mucosa, muscularis mucosa, submucosa, and circular and longitudinal muscles per microscopic field (63x) was calculated based on measurement of the positively stained area in 20 randomly chosen microscopic fields in each related structure. The Scion Image computer analysis system was used. RESULTS: Serotonin receptor(s) immunoreactivity was mainly detected in the muscular mucosa, circular muscles, and longitudinal muscles and rarely in the mucosa and submucosa. In muscularis mucosa and circular muscle, the positive areas were significantly less in the colonic inertia group than in controls (muscularis mucosa: 29.1 +/- 10.8 vs 109.7 +/- 28.2, P < 0.05; circular muscle: 25.6 +/- 6.2 vs 90.2 +/- 19.1, P < 0.01). There were significantly positive correlations in the control group in serotonin receptor(s) immunoreactivity levels between circular muscle and longitudinal muscle (r = 0.54, P < 0.05) and between muscular mucosa and longitudinal muscle (r = 0.57, P < 0.05) but not in colonic inertia patients. In addition, the positive areas in the circular muscle were positively correlated to the colonic transit time (Spearman's rank correlation, 0.83; P < 0.01). CONCLUSION: In colonic inertia patients, the serotonin receptor(s) immunoreactivity level is lower in muscular mucosa and circular muscle. The absence of a correlation of serotonin receptor(s) immunoreactivity in the muscular mucosa and muscularis propria in the patient group implies that an uncoordinated expression of serotonin receptors may also contribute to colonic inertia. However, the positive correlation between serotonin receptor(s) immunoreactivity levels in the circular muscle and the transit time observed in colonic inertia patients suggests a decrease in stimulatory subtypes and at the same time an increase in inhibitory subtypes of serotonin receptors in this tissue.