Surgical management of duodenal web in an adult presenting with melaena; Case report and literature review.

INTRODUCTION: Duodenal web is a rare pathology presenting infrequently in adults. Diagnosis is challenging and definitive management is commonly delayed. We present a case of a patient with a late diagnosis of duodenal web, who underwent laparotomy, intraoperative gastroscopy and surgical removal of the web performed by two general surgeons. CASE PRESENTATION: A 32-year-old woman with a previous diagnosis of irritable bowel syndrome presented with a three day history of abdominal pain, nausea and anorexia, and a one day history of melaena and haematemesis. Investigations including a magnetic resonance enterography, barium swallow study and gastroscopy revealed the diagnosis. The patient underwent laparotomy and excision of duodenal web. Intraoperative gastroscopy assisted with identification of the web's anatomical location. A longitudinal duodenotomy was performed and this was closed in a transverse fashion using the Heineke-Mikulicz technique. DISCUSSION: This case reports successful application of intraoperative gastroscopy during laparotomy and duodenotomy. Longitudinal duodenotomy with excision of the web and transverse closure of the duodenum appears to be the best approach. There are no previous publications detailing gastroscopy at the time of laparotomy with duodenal web. This technique may be utilised in appropriate situations to improve operative accuracy. CONCLUSION: Duodenal web is a rare entity in adults, and delayed diagnosis may lead to significant patient morbidity. Incorporating intraoperative endoscopy ensures accurate anatomical visualisation. This technique avoids duodenectomy, organ damage, bypass, or an unnecessarily large incision.

Glutamine supplementation in acute pancreatitis: a meta-analysis of randomized controlled trials.

BACKGROUND: There is emerging evidence that glutamine supplementation should be considered in patients with acute and critical illness associated with a catabolic response. There are reports of glutamine supplementation in acute pancreatitis but the results of these studies are conflicting. The aim of this study was to systematically review the randomised controlled trials (RCT) of glutamine in patients with acute pancreatitis. METHODS: The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, SCOPUS and 3 major Chinese databases were searched. The outcomes studied were mortality, total infectious complications, and length of hospital stay. A random effects model was used for meta-analysis of the outcomes in the included trials. A number of pre-specified subgroup analyses were also conducted. The summary estimates were reported as risk ratio (RR) for categorical variables and mean difference (MD) for continuous variables together with the corresponding 95% confidence interval. RESULTS: Twelve RCT that enrolled 505 patients with acute pancreatitis were included in the final analysis. Overall, glutamine supplementation resulted in a significantly reduced risk of mortality (RR 0.30; 95% CI, 0.15 to 0.60; P < 0.001) and total infectious complications (RR 0.58; 95% CI, 0.39 to 0.87; P = 0.009) but not length of hospital stay (MD -1.35; 95% CI, -3.25 to 0.56, P = 0.17). In the subgroup analyses, only patients who received parenteral nutrition and those who received glutamine in combination with other immunonutrients demonstrated a statistically significant benefit in terms of all the studied outcomes. CONCLUSIONS: This meta-analysis demonstrates a clear advantage for glutamine supplementation in patients with acute pancreatitis who receive total parenteral nutrition. Patients with acute pancreatitis who receive enteral nutrition do not require glutamine supplementation. Further studies are warranted to determine whether patients who receive combined enteral and parenteral nutrition need glutamine supplementation.

Gentamicin-collagen implants to reduce surgical site infection: systematic review and meta-analysis of randomized trials.

OBJECTIVE: To determine whether gentamicin-impregnated collagen sponges (gentamicin-collagen implants) decrease the incidence of surgical site infection (SSI). BACKGROUND: SSIs cause substantial morbidity and increase the costs of healthcare. Antibiotic prophylaxis is a cornerstone of SSI reduction. Prophylactic local delivery of antibiotics with novel biodegradable drug carrier systems, such as the gentamicin-collagen implant, is a potential avenue for SSI reduction. Gentamicin-collagen implants have been previously assessed in multiple randomized controlled trials (RCTs) with conflicting results. Therefore, a systematic review and meta-analysis of all relevant RCTs was conducted to determine whether gentamicin-collagen implants reduce SSI. METHODS: Major medical databases and trial registers were searched for published and unpublished RCTs. The endpoint of interest was the incidence of SSI. A random effects model was used and pooled estimates were reported as odds ratios (ORs), with the corresponding 95% confidence interval (CI). A subset analysis by incision type was planned a priori. RESULTS: Fifteen RCTs encompassing a total of 6979 patients were included in the final analysis. The included studies were of moderate to high quality. Gentamicin-collagen implants significantly reduced SSI [OR = 0.51; 95% CI: 0.33-0.77; P = 0.001; number needed to treat (NNT) = 21; I = 75%]. These results were seen in subset analysis of clean (OR = 0.53; 95% CI: 0.33-0.87; P = 0.01; NNT = 30) and clean-contaminated surgery (OR = 0.43; 95% CI: 0.20-0.93; P = 0.03; NNT = 9) specifically. CONCLUSIONS: Gentamicin-collagen implants decrease the rate of SSI.

Triclosan-impregnated sutures to decrease surgical site infections: systematic review and meta-analysis of randomized trials.

OBJECTIVE: To determine the efficacy and safety of triclosan-impregnated sutures. BACKGROUND: Surgical-site infections (SSIs) produce considerable morbidity and increase health care costs. A potential strategy to decrease the rates of SSIs may be the use of triclosan-impregnated sutures. These have been endorsed and/or funded by professional and governmental bodies in numerous countries. Laboratory studies and nonsystematic reviews have suggested that these sutures may reduce SSIs but there has been no summative assessment of this intervention with regard to clinical efficacy and safety. Hence, a systematic review and meta-analysis of all randomized controlled trials (RCTs) investigating triclosan-impregnated sutures were conducted. METHODS: The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, Pubmed databases, and trial registries were searched for published and unpublished RCTs. The endpoints of interest were the incidence of SSIs and wound breakdown. A random effects model was used and pooled estimates were reported as odds ratios (ORs) with the corresponding 95% confidence interval (CI). RESULTS: Seven RCTs encompassing a total of 836 patients were included in the final analysis. The studies were of moderate quality. Triclosan-impregnated sutures did not statistically significantly reduce the rates of SSIs (OR = 0.77; 95% CI: 0.40-1.51; P = 0.45; I² = 24%). There was no difference in the rates of wound breakdown between the 2 groups (OR = 1.07; 95% CI: 0.21-5.43; P = 0.93; I = 44%) CONCLUSIONS: Triclosan-impregnated sutures do not decrease the rate of SSIs or decrease the rate of wound breakdown. Further high-quality independent studies within the right context are required before routine clinical use can be considered.