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.

Human subcutaneous dirofilariasis caused by Dirofilaria immitis in a Greek adult.

Human dirofilariasis is a zoonotic infection caused by worms of the genus Dirofilaria. Most reported cases involve Dirofilaria repens, and D. immitis infection has been rarely reported. Canines act as a reservoir for the infection, while human infections are sporadic. Human dirofilariasis has been widely reported in South Europe; however, the worldwide distribution constantly changes. We herein report an extremely rare case of subcutaneous trunk dirofilariasis in a 45-year-old immunosuppressed woman, caused by D. immitis. The parasitic infection was detected using ultrasonography. The infection was confirmed by a polymerase chain reaction-based method and was attributed to D. immitis.

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.

Asymptomatic extraperitoneal inguinoscrotal hernia involving ureter: A case presentation and review of the literature.

An inguinoscrotal hernia is a common disorder that usually contains intraperitoneal organs (small intestine, colon, appendix, ovaries). Extraperitoneal ureteral herniation into an inguinoscrotal hernia is a rare condition and often associated with congenital abnormalities or postoperative anatomic changes. A high index of suspicion is needed in order to avoid intraoperative ureteric injuries. We herein report the case of a ureteric herniation into an inguinoscrotal hernia incidentally found during a scheduled hernia repair.

Neuroprotective Effects of Erythropoietin in Patients with Severe Closed Brain Injury.

AIM: Our research was focused on the neuroprotective function of erythropoietin (Epo) in patients with severe closed traumatic brain injury (TBI). MATERIAL AND METHODS: Our model examined the influence of the outcome and neurological recovery in 42 adults with TBI who were admitted to ICU within 6 hours of their injury and were recruited into a randomized controlled study of two groups; only the patients of the intervention group received 10,000 i.u. of Epo for 7 consecutive days. A prognostic model based on CRASH II injury model and outcome was measured by survival and Glasgow Outcome Scale-Extended version (GOS-E) score at 6 months post-injury. RESULTS: Six patients (18.7%) died during the first two weeks; 4 of the control group and 2 of the intervention group. A mortality rate of 22.2% and 8.3% for the control and intervention group respectively was observed. A lower rate of good outcome (GOS-E score > 4) at 6 months was mentioned among patients of the control group. CONCLUSION: The study provides evidence of lower mortality and better neurological outcome for the patients who received Epo increasing the possibility that Epo therapy could be used in clinical practice, limiting neuronal damage induced by TBI.

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.