Bedside Drainage of Perianal Abscesses: Is It Safe and Effective?

BACKGROUND: Perianal abscesses require immediate incision and drainage (I&D). However, prompt bedside drainage is controversial as it may compromise exposure and thorough anal examination. OBJECTIVES: To examine outcomes of bedside I&D of perianal abscesses in the emergency department (ED) vs. the operating room (OR). METHODS: We conducted a retrospective review of all patients presented to the ED with a perianal abscesses between January 2018 and March 2020. Patients with Crohn's disease, horseshoe or recurrent abscesses were excluded. RESULTS: The study comprised 248 patients; 151 (60.89%) underwent I&D in the OR and 97 (39.11%) in the ED. Patients elected to bedside I&D had smaller abscess sizes (P = 0.01), presented with no fever, and had lower rates of inflammatory markers. The interval time from diagnosis to intervention was significantly shorter among the bedside I&D group 2.13 ± 2.34 hours vs. 10.41 ± 8.48 hours (P < 0.001). Of patients who underwent I&D in the OR, 7.3% had synchronous fistulas, whereas none at bedside had (P = 0.007). At median follow-up of 24 months, recurrence rate of abscess and fistula formation in patients treated in the ED were 11.3% and 6.2%, respectively, vs. 19.9% and 15.23% (P = 0.023, 0.006). Fever (OR 5.71, P = 0.005) and abscess size (OR 1.7, P = 0.026) at initial presentation were risk factors for late fistula formation. CONCLUSIONS: Bedside I&D significantly shortens waiting time and does not increase the rates of long-term complications in patients with small primary perianal abscesses.

Restoring Intestinal Continuity in a Hostile Abdomen: The Deloyers Procedure.

BACKGROUND: Deloyers procedure enables anastomosis of the ascending colon to the rectum following extended resections that prevent usual fashion anastomosis. During the procedure, the right colon is completely mobilized and counterclockwise rotated to allow tension free and well-vascularized anastomosis while preserving the ileocecal valve. The purpose of this manuscript is to report our experience with laparoscopic Deloyers procedure in a hostile abdomen due to adhesions from previous surgeries. METHODS: We report the outcomes and our technique of laparoscopic Deloyers procedure in three patients. All patients had a surgical complication necessitating the creation of end colostomy with a short colonic remnant. The bowel status prevented restoration of continuity by the common colorectal anastomosis and laparoscopic Deloyers was elected. RESULTS: The procedure was successful in all patients, with no intra-operative complication and average surgery duration of three hours. Patients had uneventful postoperative recovery with only one case of minor complication and an adequate functional outcome. CONCLUSION: Laparoscopic Deloyers is safe and allows the restoration of bowel continuity with preservation of ileocecal valve and good functional outcome even in hostile abdomen.

A surgical solution to regain bowel continuity following an extended left colectomy-reviving and extending the indication for a "Flip-Flop" procedure.

BACKGROUND AND AIMS: Extended left hemicolectomy might be necessary for several indications. Once the resection is completed, it would be difficult or impossible to anastomose the transverse colon to the rectum due to the difficulty in mobilizing the transverse colon to reach for a tension-free rectal anastomosis. The aim of this report is to present the "Flip-Flop" technique to overcome this challenging situation. The procedure is based on a surgical technique published in the early 1960s to avoid permanent stoma after proctectomy and consists of changing the location of the right colon to reach the rectum. METHODS: Clinical parameters, surgical aspects, and postoperative outcome of patients that underwent the flip-flop procedure following an extended left colectomy in our medical service was reviewed. RESULTS: Three patients underwent a flip-flop procedure after an extended left colectomy performed for various reasons. The surgical technique is detailed in a step by step manner. Patients had uneventful postoperative recovery with an adequate functional outcome. CONCLUSIONS: We believe that this approach should be revived and be considered also in cases when the full length of the rectum is preserved to avoid ileo-rectal anastomosis or a high-tension colocolonic anastomosis. Popularization of this surgical solution among surgeons is highly important.

Safety and Efficacy of Memantine in Children with Autism: Randomized, Placebo-Controlled Study and Open-Label Extension.

OBJECTIVE: Abnormal glutamatergic neurotransmission is implicated in the pathophysiology of autism spectrum disorder (ASD). In this study, the safety, tolerability, and efficacy of the glutamatergic N-methyl-d-aspartate (NMDA) receptor antagonist memantine (once-daily extended-release [ER]) were investigated in children with autism in a randomized, placebo-controlled, 12 week trial and a 48 week open-label extension. METHODS: A total of 121 children 6-12 years of age with Diagnostic and Statistical Manual of Mental Disorders, 4th ed., Text Revision (DSM-IV-TR)-defined autistic disorder were randomized (1:1) to placebo or memantine ER for 12 weeks; 104 children entered the subsequent extension trial. Maximum memantine doses were determined by body weight and ranged from 3 to 15 mg/day. RESULTS: There was one serious adverse event (SAE) (affective disorder, with memantine) in the 12 week study and one SAE (lobar pneumonia) in the 48 week extension; both were deemed unrelated to treatment. Other AEs were considered mild or moderate and most were deemed not related to treatment. No clinically significant changes occurred in clinical laboratory values, vital signs, or electrocardiogram (ECG). There was no significant between-group difference on the primary efficacy outcome of caregiver/parent ratings on the Social Responsiveness Scale (SRS), although an improvement over baseline at Week 12 was observed in both groups. A trend for improvement at the end of the 48 week extension was observed. No improvements in the active group were observed on any of the secondary end-points, with one communication measure showing significant worsening with memantine compared with placebo (p = 0.02) after 12 weeks. CONCLUSIONS: This trial did not demonstrate clinical efficacy of memantine ER in autism; however, the tolerability and safety data were reassuring. Our results could inform future trial design in this population and may facilitate the investigation of memantine ER for other clinical applications.

Efficacy of ofloxacin otic solution once daily for 7 days in the treatment of otitis externa: a multicenter, open-label, phase III trial.

BACKGROUND: Otitis externa (OE) is an infection of the external auditory canal that is typically treated with topically applied broad-spectrum antibiotics. Twice-daily topical treatment with ofloxacin otic 0.3% solution for 10 days has been reported to be as effective and well tolerated as the standard of care, neomycin sulfate/polymyxin B sulfate/hydrocortisone solution administered 4 times daily for 10 days. OBJECTIVE: This study evaluated the efficacy and safety profile of 7 days of a once-daily regimen of ofloxacin otic 0.3% solution in the treatment of OE. METHODS: This multicenter, open-label, Phase III study was conducted from June 12, 2002, to October 14, 2002. Eligible patients were aged > or = 6 months and had OE of <2 weeks' duration with moderate to severe edema and tenderness involving 1 or both ears and sufficient exudate for microbiologic culture. Ofloxacin otic solution was instilled once daily for 7 days (5 drops for children aged 6 months to <13 years, 10 drops for adolescents/adults aged > or = 13 years). Assessments were conducted at the end-of-treatment visit and 7 to 10 days later (the test-of-cure visit). Medication was supplied free of charge to study participants who incurred no costs for physician visits. RESULTS: Of 489 patients enrolled at 58 sites in 3 countries, 439 were clinically evaluable (173 children, 266 adolescents/adults; 52 % males, 48% females; 47% Hispanic, 45% white; 5% black, and 3% other). The cure rate among clinically evaluable patients was 91% (95% of children, 88% of adolescents/adults); 68% of patients were cured within 7 days. Forty-three potentially pathogenic strains were isolated from 253 microbiologically evaluable patients. Pseudomonas aeruginosa was isolated from 158 (62%) microbiologically evaluable patients and Staphylococcus aureus from 32 (13%). Eradication rates were 96% overall. No serious adverse events were observed. Minor adverse events were experienced by 15 (3%) of 489 patients included in the safety population. The most common adverse events were pruritus (5 patients), increased earache (4 patients), and application-site reactions (3 patients). Overall mean (SD) adherence to therapy was 98% (11.9). CONCLUSIONS: Ofloxacin otic 0.3% solution administered once daily for 7 days was well tolerated and effective in achieving clinical and microbiologic cure of OE. The compliance rates in this study suggests that this regimen may be better accepted by patients than longer, more repetitive regimens.

Declining susceptibility to neomycin and polymyxin B of pathogens recovered in otitis externa clinical trials.

BACKGROUND: Otitis externa is usually treated empirically with topical neomycin/polymyxin B/hydrocortisone. The predominant pathogens associated with this infection are Pseudomonas aeruginosa and Staphylococcus aureus. METHODS: Two multicenter clinical trials (one in adults and adolescents, and one in children), conducted between 1995 and 1996, compared neomycin/polymyxin B/hydrocortisone with ofloxacin for the treatment of otitis externa; two similar trials were conducted between 1999 and 2000. Assessments included the minimum inhibitory concentrations (MICs) of each antimicrobial drug for the major pathogens, bacterial eradication, and clinical efficacy. RESULTS: The MICs of all bacterial isolates (including P. aeruginosa) for neomycin and polymyxin B increased markedly in the 1999 to 2000 studies compared with the 1995 to 1996 studies. In the later studies, mean MICs for all major pathogens tested had increased above the breakpoint for polymyxin B (> or = 4 microg/ml). In contrast, MICs of all isolates for ofloxacin remained similar between the two study periods and were within the susceptible range for this drug. CONCLUSIONS: Although the bacterial eradication rates for both treatments in each study were equivalent, the clinical cure rate for neomycin/polymyxin B/hydrocortisone was lower (87%) than for ofloxacin (93%). Therefore, the organisms most often causing otitis externa appear to be developing resistance to neomycin and polymyxin B but not to ofloxacin.