A rare case of ruptured appendiceal diverticulitis: A significant surgical pathology.

Appendiceal diverticulitis is a rare pathology which is distinctly different to acute appendicitis and associated with higher rates of morbidity and mortality. Furthermore, diagnosis is often retrospective on histopathological analysis of appendicectomy specimens due to the atypical clinical and radiological features. Herein, we present a case of ruptured appendiceal diverticulitis in a young patient with atypical clinical features and a radiologically normal appearing appendix in close proximity to an inflammatory phlegmon. This case highlights the importance of maintaining a high clinical suspicion of surgical pathology and considering atypical diagnosis in patients with inflammatory changes in the right iliac fossa.

Is preoperative hypoalbuminemia or hypoproteinemia a reliable marker for anastomotic leakage risk in patients undergoing elective colorectal surgery in an enhanced recovery after surgery (ERAS) program?

PURPOSE: Preoperative hypoalbuminemia has traditionally been used as a marker of nutritional status and is considered a significant risk factor for anastomotic leak (AL). METHODS: The Westmead Enhanced Recovery After Surgery (WERAS) prospectively collected database, consisting of 361 patients who underwent colorectal surgery with primary anastomosis, was interrogated. Preoperative serum albumin and protein levels (measured within 1 week of surgery) were plotted on receiver operating characteristic curves (ROC curves) and statistically analyzed for cutoff values, sensitivity, specificity, positive predictive values (PPV), and negative predictive values (NPV). RESULTS: The incidence of AL was 4.4% (16/361). Overall mortality was 1.4% (5/361), 6.3% (1/16) in the AL group, and 1.2% (4/345) in the no AL group. The median preoperative albumin and protein level in the AL group were 39 g/L and 75 g/L, respectively. The median preoperative albumin and protein level in the no AL group were 38 g/L and 74 g/L, respectively. The Mann-Whitney U test showed no statistically significant difference in albumin levels (p = 0.4457) nor protein levels (p = 0.6245) in the AL and no AL groups. ROC curves demonstrated that preoperative albumin and protein levels were not good predictors of anastomotic leak. Cutoff values for albumin (38 g/L) and protein (75 g/L) both had poor PPV for AL (4.8% and 3.8% respectively). CONCLUSION: In patients undergoing elective colorectal surgery as part of an ERAS program, preoperative serum albumin and protein levels are not reliable in predicting AL. This may be because of nutritional supplementation provided as part of an ERAS program may correct nutritional deficits to protect against AL or that low albumin/protein is not as robust a marker of AL as previously reported.

The impact of variations in care and complications within a colorectal Enhanced Recovery After Surgery program on length of stay.

PURPOSE: Enhanced Recovery After Surgery (ERAS) has become standard of care in colorectal surgery. However, there is not a universally accepted colorectal ERAS protocol and significant variations in care exist between institutions. The aim of this study was to examine the impact of variations in ERAS interventions and complications on length of stay (LOS). METHODS: This study was a single-center review of the first 200 consecutive patients recruited into our prospectively collected ERAS database. The primary outcome of this study was to examine the rate of compliance to ERAS interventions and the impact of these interventions on LOS. The secondary outcome was to assess the impact of complications (anastomotic leak, ileus, and surgical site infections) on LOS. ERAS interventions, rate of adherence, LOS, readmissions, morbidity, and mortality were recorded, and statistical analysis was performed. RESULTS: ERAS variations and complications significantly influenced patient LOS on both univariate and multivariate analysis. ERAS interventions identified as the most important strategies in reducing LOS included laparoscopic surgery, mobilization twice daily postoperative day (POD) 0 to 1, discontinuation of intravenous fluids on POD 0 to 1, upgrading to solid diet by POD 0 to 2, removal of indwelling catheter by POD 0 to 2, avoiding nasogastric tube reinsertion and removing drains early. Both major and minor complications increased LOS. Anastomotic leak and ileus were associated with the greatest increase in LOS. CONCLUSION: Seven high-yield ERAS interventions reduced LOS. Major and minor complications increased LOS. Reducing variations in care and complications can improve outcomes following colorectal surgery.

Bowel Preparation and Oral Antibiotic Agents for Selective Decontamination in Colorectal Surgery: Current Practice, Perspectives, and Trends in Australia and New Zealand, 2019-2020.

Background: There has been much debate as to the importance of mechanical bowel preparation (MBP) and oral antibiotic agents (OAB) prior to elective colorectal surgery over the past two decades. There is no consensus between international guidelines. Methods: The Australia and New Zealand Mechanical Bowel Preparation and Oral Antibiotics (ANZ-MBP-OAB) questionnaire was distributed to colorectal surgeons after institutional board approval assessing specialist attitudes toward 18 enhanced recovery after surgery (ERAS) interventions. Data were analyzed using a rating scale and graded response model in item response theory (IRT) on Stata MP, version 15 (StataCorp LP, College Station, TX). Specialist attitudes toward the effectiveness of MBP and OAB strategies in providing better short-term outcomes was ranked alongside other ERAS interventions. This was followed by specific questions examining current practice, perspectives, and trends. Results: Ninety-five of 300 (31.7%) colorectal surgeons in Australia and New Zealand participated in the survey. Statistical modeling was achieved in 13 ERAS interventions. Compared with other ERAS interventions, the use of MBP with OAB and MBP alone ranked nine of 13 and 10 of 13, respectively, in order of effectiveness in providing better short-term outcomes after colorectal surgery. Oral antibiotic agents alone was not considered effective. Mechanical bowel preparation with OAB was considered to be the best strategy in both colon (37%) and rectal surgery (48%) but current practice varied substantially from perspective. Mechanical bowel preparation alone was strongly favored in rectal surgery (81%) with only 14% using MBP with OAB. In colon surgery, only 10% used MBP with OAB, with MBP alone (45%) and no preparation (45%) being equally the most commonly used strategies. Conclusions: Among Australian and New Zealand colorectal surgeons, MBP with OAB was considered the best bowel preparation strategy. However, despite an awareness of its benefits, MBP with OAB has yet to be widely adopted into clinical practice or guidelines in Australia and New Zealand.

Process measure aimed at reducing time to haemorrhage control: outcomes associated with Code Crimson activation in exsanguinating truncal trauma.

BACKGROUND: Major trauma activation is a process that mobilizes personnel and resources required to care for severely injured patients. Exsanguinating truncal trauma patients require an additional response beyond major trauma activation aimed at expediting haemorrhage control. To address this requirement, 'Code Crimson' (CC) activation was developed. Our aim was to examine the performance of CC activation as a process measure in the identification and management of patients with exsanguinating truncal trauma. METHODS: Retrospective cohort study (2010-2015) of all adult patients who underwent operative intervention within 6 h of arrival for truncal trauma was performed. Patients were classified into: (i) major haemorrhage (assessment of blood consumption score ≥2, base deficit ≥5 and/or transfusion ≥5 U of red blood cells pre-/intra-operatively), or (ii) no major haemorrhage. We evaluated the proportion of patients with/without major haemorrhage in which a CC was activated as well as time to operating theatre across groups. RESULTS: A total of 210 patients were included with a median Injury Severity Score of 20 (interquartile range (IQR) 9-29) and overall mortality of 13%. Eighty-nine patients were classified as major haemorrhage and 61 patients underwent CC activation. The majority of CC activations (92%) fulfilled major haemorrhage criteria (sensitivity 63%, specificity 96%). Time to theatre was lower in those with CC activation with median time of 23 min (IQR 15-39.5) versus non-CC with median of 95 min (IQR 43-180, P < 0.001). CONCLUSION: CC was primarily activated in patients with major haemorrhage and led to a decrease in time to theatre for patients with operative truncal trauma.