The utility of intraperitoneal drain placement after laparoscopic appendectomy for perforated appendicitis in postoperative intraperitoneal abscess prevention.

BACKGROUND: Perforated appendicitis is associated with postoperative development of intraperitoneal abscess. Intraperitoneal drain placement during appendectomy is thought to reduce the risk of developing postoperative intraperitoneal abscess. The aim of this study was to determine whether intraperitoneal drainage could reduce the incidence of intraperitoneal abscess formation after laparoscopic appendectomy for perforated appendicitis. METHODS: This is a retrospective study of all patients (aged 7 and above) who were diagnosed with perforated appendicitis and subsequently underwent laparoscopic appendectomy between January 2018 and December 2022 at two government hospitals in the state of Kuwait. Demographic, clinical, and perioperative characteristics were compared between patients who underwent intraoperative intraperitoneal drain placement and those who did not. The primary outcome was the development of postoperative intraperitoneal abscess. Secondary outcomes included overall postoperative complications, superficial surgical site infection (SSI), length of stay (LOS), readmission and postoperative percutaneous drainage. RESULTS: A total of 511 patients met the inclusion criteria between 2018 and 2022. Of these, 307 (60.1%) underwent intraoperative intraperitoneal drain placement. Patients with and without drains were similar regarding age, sex, and Charlson Comorbidity Index (CCI) (Table 1). The overall rate of postoperative intraperitoneal abscess was 6.1%. Postoperatively, there was no difference in postoperative intraperitoneal abscess formation between patients who underwent intraperitoneal drain placement and those who did not (6.5% vs. 5.4%, p = 0.707). Patients with intraperitoneal drains had a longer LOS (4 [4, 6] vs. 3 [2, 5] days, p < 0.001). There was no difference in the overall complication (18.6% vs. 12.3%, p = 0.065), superficial SSI (2.9% vs. 2.5%, p = 0.791) or readmission rate (4.9% vs. 4.4%, p = 0.835). CONCLUSIONS: Following laparoscopic appendectomy for perforated appendicitis, intraperitoneal drain placement appears to confer no additional benefit and may prolong hospital stay.

The predictors of depression and burnout among surgical residents: A cross-sectional study from Kuwait.

BACKGROUND: Surgical residency often poses a challenge to residents, with long working hours and a stressful work environment. Surgical residents are at an increased risk of burnout and depression. Such mental health burdens could go so far as to affect treatment outcomes. AIM: To assess the prevalence and risk factors for depression and burnout among residents across surgical specialties in Kuwait. MATERIALS AND METHODS: An online questionnaire was sent to the residents enrolled to the surgical residency programs in Kuwait, from the period of January 2020-February 2020. Variables collected included; age, gender, marital status, smoking history, exercise, specialty, year of training, on-call frequency, assessment of burnout (using the abbreviated Maslach Burnout Inventory (aMBI)) and assessment of depressive symptoms (using the Patient Health Questionnaire-9 (PHQ-9) score). RESULTS: A total of 85 surgical residents between the age of 20 and 40 years responded. Most (64.7%) were male and 35.3% female. More than half were married (51.8%) and 41.2% were single. The majority of the residents were in general surgery (43.5%), with the least being in otolaryngology (7.1%) and neurosurgery (5.9%). The prevalence of depressive symptoms was 55.3%, and 51.8% had a high overall burnout score. CONCLUSION: Addressing burnout at all stages during residency training is paramount in improving standard of care as well as increasing the wellness of residents.

Clinical presentation and outcomes of acute diverticulitis in a Middle Eastern population.

BACKGROUND AND STUDY AIMS: There is lack of literature describing the presentation of diverticulitis in the Middle East population. The aim of this study is to provide an analysis of the epidemiological indicators, patterns of presentation and outcomes of acute diverticulitis in a Middle Eastern population. PATIENTS AND METHODS: A retrospective review of all adult patients over the age of 17 who were admitted to the surgical service with a diagnosis of acute diverticulitis between January 2010 and May 2018 at a major university affiliated government hospital in the state of Kuwait. Data collected included patients' demographics, clinical presentation, management and outcome. RESULTS: Between January 2010 and May 2018 there were 132 patients admitted with a diagnosis of acute diverticulitis. The mean age was 49.2 [±14.3] years. There were 89 (67.4%) men and 43 (32.6%) women. One-hundred and fifteen patients (87.1%) were Arabs, of which Kuwaiti citizens represented 58.3%. Most patients (76.5%) presented with uncomplicated diverticulitis. One hundred and twelve patients (84.8%) had sigmoid colon diverticulitis. There were nine patients that were readmitted within thirty days. The mean length of hospital stay was 5.3 days [±4.5]. The median follow-up period was 15.6 weeks (IQR 1.8, 118.4), during which time recurrent attacks occurred in 25 patients (18.9%). CONCLUSIONS: It appears that there is a low prevalence of acute diverticulitis in Arabs living in Kuwait, and that when they do present with acute diverticulitis the majority present at a relatively younger age with uncomplicated disease.

The effects of tranexamic acid on blood loss and transfusion rate in colorectal surgery.

BACKGROUND: The present study aimed to evaluate safety of tranexamic acid (TA) administration and to assess bleeding risk in colorectal surgery (CRS). METHODS: Retrospective cohort study including consecutive patients undergoing elective CRS by a single surgeon between August 2014 and May 2015. All patients received 1 g of TA intravenously at induction and at closure. Demographics, operative and postoperative details were prospectively assessed and compared to a historical control cohort. RESULTS: 213 patients were evaluated. TA did not increase complications, readmissions, or reoperation rates. Significant postoperative hemoglobin (Hgb) drop (≥3 g/dL) (TA: n = 6, 7.4%, Control: n = 22, 16.6%; p = 0.193) and transfusion rates (intraoperative: TA: n = 2, 2.5%, Control: n = 2, 1.5%; p = 0.586, postoperative: TA: n = 1, 1.2%, Control: 9, 6.8%; p = 0.065) were not statistically different. CONCLUSIONS: Postoperative hemoglobin drop and transfusion rates were not decreased statistically. Further study is warranted given the large clinical differences in favor of TA.

Retrospective Clinical and Microbiologic Analysis of Patients with Anorectal Abscess.

BACKGROUND: We conducted a clinical and microbiologic analysis of patients presenting with anorectal abscess. METHODS: A total of 505 adult patients presenting from January 2011 to December 2017 were analyzed retrospectively. Microbiologic data were available for 211 patients. RESULTS: The mean age at presentation was 39.5 (standard deviation 12.4) years, and 81.4% of the cohort were men. One hundred fifteen patients (22.8%) had diabetes mellitus, and 15 patients (3.0%) had inflammatory bowel disease. There were 184 patients (36.4%) who required admission for more than 24 hours with a median length of stay of two days (interquartile range 2, 4) days. The most common microorganism was Escherichia coli (37.6%), followed by Bacteroides spp. (13.2%) and Streptococcus spp. (13.2%). Escherichia coli accounted for 34.9% of the microorganisms cultured from patients with diabetes mellitus followed by Streptococcus spp. (27%) and Klebsiella pneumoniae (20.6%). CONCLUSIONS: Escherichia coli is the most common micro-organism cultured from patients presenting with anorectal abscess. Despite an increase in community-acquired multi-resistant strains, our results show a low overall incidence of such isolate. Our study provides a large microbiologic sample of patients with anorectal abscess to expand the present knowledge of the etiology of a common surgical condition.

Long-term outcomes of (Gore) fistula plug versus ligation of intersphincteric fistula tract for anal fistula / Desfechos de longo prazo do tampão de fístula (Gore) versus ligadura do trato da fístula interesfincteriana (LIFT) para fístula anal

ABSTRACT Background: The surgical treatment of anal fistula is complex due to the possibility of fecal incontinence. Fistulotomy and cutting Setons have the same incidence of fecal incontinence depending on the complexity of the fistula. Sphincter-preserving procedures such as anal fistula plug and ligation of intersphincteric fistula tract procedure may result in more recurrence requiring repeated operations. The aim of this study was to evaluate and compare the outcomes of treating fistula in Ano utilizing two methods: Fistula plug (Gore Bio-A) and ligation of intersphincteric tract (LIFT). Methods: Fifty four patients (33 males; 21 female, median ages 42 [range 32-47] years) with high anal inter-transphenteric fistula were treated with LIFT and fistula plug procedures from September 2011 until August 2016 by a single surgeon and were retrospectively evaluated. All were followed for a median of 23.9 (range 4-54) months with clinical examination. Twenty one patients underwent fistula plug and 33 patients underwent LIFT procedure (4 patients of the LIFT group underwent LIFT and rectal mucosa advancement flap). The healing rate and complications were evaluated clinically and through telephone calls. Results: The mean operative time for the Plug was 25 ± 17 min and for the LIFT was 40 ± 20 min (p = 0.017) and the mean hospital stay was 2.4 ± 1.1 and 1.9 ± 0.3 (p = 0.01) respectively. The early complications of the plug and LIFT procedures included; anal pain (33.3%, 66.6%, p = 0.13), perianal discharge (77.8%, 91%, p = 0.62), anal pruritus (38.9%, 50.0%, p = 0.71) and bleeding per rectum (16.7%, 33.3%, p = 0.39) respectively. The overall mean follow-up was 20.9 ± 16.8 months, p = 0.68. There was no statistically significant difference between the two groups (21.9 ± 7.5 months, 19.9 ± 16.1 months, p = 0.682). The healing rate was 76.2% (16/21 patients) in the fistula plug group and 81.1% (27/33 patients) in the LIFT group (p = 0.73). Patients who had LIFT procedure and a mucosal advancement flap had 100% healing rate (4 out of 4 patients). No incontinence of stool or feces and no fistula plug expulsion were seen in our patients. The healing time ranged from 1 to 6 months after surgery. There was no post-operative perianal abscess, cellulitis or pain. Conclusions: LIFT and anal plug are safe procedures for patients with primary and recurrent anal fistula. Both techniques showed excellent results in terms of healing and complication rate. None of our patients had incontinence after 5 years follow-up. The best success rate in our patients was seen after LIFT procedure with mucosal advancement flap. Larger and controlled randomized trials are needed for better assessment of treatment options.

RESUMO Introdução: O tratamento cirúrgico da fístula anal é complexo devido à possibilidade de incontinência fecal. A fistulotomia e o seton de corte têm a mesma incidência da incontinência fecal, dependendo da complexidade da fístula. Procedimentos de preservação do esfíncter, como o tampão da fístula anal e o procedimento LIFT (ligadura do trato da fístula interesfincteriana), podem resultar em mais recorrência, exigindo cirurgias repetidas. O objetivo deste estudo foi avaliar e comparar os desfechos do tratamento da fístula anal utilizando dois métodos: Tampão de fístula (Gore Bio-A) e Ligadura do Trato Interesfincteriano (LIFT). Métodos: Cinquenta e quatro pacientes (33 homens; 21 mulheres, com mediana de idade de 42 [variação 32-47] anos) foram tratados com LIFT e procedimentos com tampão de fístula de setembro de 2011 até agosto de 2016 por um único cirurgião e foram avaliados retrospectivamente. Todos foram acompanhados por uma mediana de 23,9 (variação de 4 a 54) meses com exame clínico. Vinte e um pacientes foram submetidos a tampão de fístula e 33 pacientes foram submetidos ao procedimento LIFT (4 pacientes do grupo LIFT foram submetidos a LIFT e retalho de avanço da mucosa retal). A taxa de cicatrização e as complicações foram avaliadas clinicamente e por meio de ligações telefônicas. Resultados: O tempo cirúrgico médio para o Tampão foi de 25 ± 17 minutos e para o LIFT foi de 40 ± 20 minutos (p = 0,017) e o tempo médio de internação foi de 2,4 ± 1,1 e 1,9 ± 0,3 (p = 0,01), respectivamente. As primeiras complicações dos procedimentos de tampão e LIFT incluíram: dor anal (33,3%, 66,6%, p = 0,13), secreção perianal (77,8%, 91%, p = 0,62), prurido anal (38,9%, 50,0%, p = 0,71) e sangramento pelo reto (16,7%, 33,3 %, p = 0,39) respectivamente. A média geral de acompanhamento foi de 20,9 ± 16,8 meses, p = 0,68. Não houve diferença estatisticamente significativa entre os dois grupos (21,9 ± 7,5 meses, 19,9 ± 16,1 meses, p = 0,682). A taxa de cicatrização foi de 76,2% (16/21 pacientes) no grupo com tampão de fístula e 81,1% (27/33 pacientes) no grupo LIFT (p = 0,73). Pacientes submetidos ao procedimento LIFT e um retalho de avanço da mucosa tiveram 100% de taxa de cura (4 de 4 pacientes). Nenhuma incontinência fecal e nenhuma expulsão do tampão da fístula foram observadas em nossos pacientes. O tempo de cicatrização variou de 1 a 6 meses após a cirurgia. Não houve abscesso perianal, celulite ou dor no pós-operatório. Conclusões: LIFT e tampão anal são procedimentos seguros para pacientes com fístula anal primária e recorrente. Ambas as técnicas apresentaram excelentes resultados em termos de cicatrização e taxa de complicações. Nenhum de nossos pacientes teve incontinência após 5 anos de acompanhamento. A melhor taxa de sucesso em nossos pacientes foi observada após o procedimento LIFT com retalho de avanço da mucosa. Ensaios clínicos randomizados de maior porte e controlados são necessários para melhor avaliação das opções de tratamento.

Medical students' logbook case loads do not predict final exam scores in surgery clerkship.

Purpose: To investigate the reliability of medical student logbook data in assessing student performance and predicting outcomes in an objective standardized clinical exam and a multiplechoice exam during surgery rotation. In addition, we examined the relationship between exam performance and the number of clinical tutors per student. Materials and methods: A retrospective review of the logbooks of first and third clinical year medical students at the Faculty of Medicine, Kuwait University, was undertaken during their surgery rotation during the academic year 2012-2013. Results: Logbooks of 184 students were reviewed and analyzed. There were 92 and 93 students in the first and third clinical years, respectively. We did not identify any correlation between the number of clinical encounters and clinical exam or multiple-choice exam scores; however, there was an inverse relationship between the number of clinical tutors encountered during a rotation and clinical exam scores. Conclusion: Overall, there was no correlation between the volume of self-reported clinical encounters and exam scores. Furthermore, an inverse correlation between the number of clinical tutors encountered and clinical exam scores was detected. These findings indicate a need for reevaluation of the way logbook data are entered and used as an assessment tool.

Long-Term Oncologic Outcomes of Minimally Invasive Proctectomy for Rectal Adenocarcinoma.

BACKGROUND: Long-term oncologic outcomes after minimally invasive surgery (MIS) for rectal adenocarcinoma compared to open surgery continue to be debated. We aimed to review our high-volume single-institution outcomes in MIS rectal cancer surgery. METHODS: A retrospective review of a prospectively collected database was completed of all consecutive adult patients with rectal adenocarcinoma treated from January 2005 through December 2011. Stage IV or recurrent disease was excluded. Demographics and operative and pathologic details were reviewed and reported. Primary endpoints include survival and recurrence. RESULTS: A total of 324 patients were included and median follow-up was 54 months (IQR = 37.0, 78.8). The mean age was 58.2 ± 14.1 years. Tumors were in the upper rectum in 111 patients, mid-rectum in 113 patients, and lower rectum in 100 patients. Stage III disease was most common (49.4%). Overall conversion to open procedure rate was 13.9%. The circumferential radial margin was positive in only 1 patient (0.3%) and the mean lymph node yield was 24.7 ± 17.2. Cancer recurred in 42 patients (13%), 10 (2.5%) patients developed local recurrence, 32 (9.8%) developed distant metastasis, and 2 (0.6%) patients had both. The 5-year overall survival for stage 0, 1, 2, and 3 disease is 96, 91, 80, and 77%, respectively (p = 0.015). CONCLUSION: In carefully selected rectal cancer patients treated with MIS, long-term outcomes of survival and recurrence appear to compare favorably to previously published series.

The role of neoadjuvant radiotherapy for locally-advanced rectal cancer with resectable synchronous metastasis.

BACKGROUND: Although neoadjuvant radiotherapy is typically administered for locally-advanced rectal cancer to reduce local recurrence (LR), its role for patients who present with synchronous resectable liver and/or lung metastasis is not well defined. The aim of this study was to evaluate the role of neoadjuvant radiotherapy for patients with stage IV rectal cancer undergoing curative-intent surgery. METHODS: This study is a retrospective review of a prospectively maintained surgical registry of all consecutive adult patients who underwent curative-intent resection at Mayo Clinic in Rochester, MN, from January 1990 until December 2014 with a median follow-up time of 43 (IQR 16-67) months. Eligible patients had locally-advanced rectal cancer (T3, T4 and/or nodal involvement) with synchronous resectable liver and/or lung metastasis. Exclusion criteria were as follows: patients with primary tumor stage of T1N0 or T2N0, patients with metastasis to organs other than the liver or lung, patients who had palliative resection, patients who had non-surgical treatment of synchronous metastasis (e.g., radiofrequency ablation), patients who received postoperative radiotherapy, or absence of research authorization. Ninety three patients were included of which 47 received neoadjuvant radiotherapy and 46 did not. All patients received neoadjuvant chemotherapy +/- radiotherapy followed by curative-intent surgery with metastasectomy performed either simultaneously with resection of the primary tumor or as a planned staged resection. The primary outcomes of this study are LR, distant metastasis, overall and disease-specific survival (DSS). RESULTS: LR was observed in 12 patients (26%) who did not receive radiotherapy, while no LR developed in those who received neoadjuvant radiotherapy, P<0.001. Univariate analysis showed that neither age, sex, ASA class, BMI, tumor location, procedure performed, or neoadjuvant chemotherapy were associated with subsequent LR. The 5-year overall survival (OS) rates were: 43.3% (95% CI: 30.1, 62.3) for no radiotherapy vs. 58.3% (95% CI: 43.4, 78.2) with radiotherapy. CONCLUSIONS: Neoadjuvant radiotherapy should be considered in patients with locally-advanced stage IV rectal cancer. These data add to the evidence supporting neoadjuvant radiotherapy in the setting of resectable metastatic disease.

Detection of clinically important colorectal surgical site infection using Bayesian network.

BACKGROUND: Despite extensive efforts to monitor and prevent surgical site infections (SSIs), real-time surveillance of clinical practice has been sparse and expensive or nonexistent. However, natural language processing (NLP) and machine learning (i.e., Bayesian network analysis) may provide the methodology necessary to approach this issue in a new way. We investigated the ability to identify SSIs after colorectal surgery (CRS) through an automated detection system using a Bayesian network. MATERIALS AND METHODS: Patients who underwent CRS from 2010 to 2012 and were captured in our institutional American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) comprised our cohort. A Bayesian network was applied to detect SSIs using risk factors from ACS-NSQIP data and keywords extracted from clinical notes by NLP. Two surgeons provided expertise informing the Bayesian network to identify clinically meaningful SSIs (CM-SSIs) occurring within 30 d after surgery. RESULTS: We used data from 751 CRS cases experiencing 67 (8.9%) SSIs and 78 (10.4%) CM-SSIs. Our Bayesian network detected ACS-NSQIP-captured SSIs with a receiver operating characteristic area under the curve of 0.827, but this value increased to 0.892 when using surgeon-identified CM-SSIs. CONCLUSIONS: A Bayesian network coupled with NLP has the potential to be used in real-time SSI surveillance. Moreover, surgeons identified CM-SSI not captured under current NSQIP definitions. Future efforts to expand CM-SSI identification may lead to improved and potentially automated approaches to survey for postoperative SSI in clinical practice.