Prophylactic mesh placement at index permanent end colostomy creation to prevent parastomal hernia-an updated meta-analysis.

BACKGROUND: Debate persists regarding the efficacy of prophylactic mesh insertion (PMI) at index permanent stoma creation to reduce the rate of parastomal hernia (PSH). This meta-analysis aimed to appraise all the latest evidence from newly published randomized controlled trials (RCTs) on PMI for PSH prevention. METHODS: PubMed, EMBASE, and Cochrane databases were searched for relevant articles from inception until November 2020. All RCTs that reported on PMI at end colostomy creation with ≥ 12 months follow-up were included. The primary objective was the rate of clinical and radiological PSH while secondary objectives included number of PSH requiring repair and stoma (or mesh)-related complications. Random effects models were used to calculate pooled effect size estimates. Sensitivity analyses were also performed. RESULTS: Eleven RCTs were included capturing 1097 patients. The mean (SD) age was 67.9 (±9.4) years. On random effects analysis, prophylactic mesh appeared to reduce the rate of both clinical (OR = 0.27, 95% CI = 0.12 to 0.61, p = 0.002) and radiological (OR = 0.39, 95% CI = 0.24 to 0.65, p = 0.0002) PSH. However, there was no difference in number of PSH requiring repair or stoma-related complications. On sensitivity analysis, when focusing on low-risk of bias studies, the benefit of prophylactic mesh in the retrorectus space was lost for both clinical (OR = 0.97, 95% CI = 0.62 to 1.51, p = 0.89) and radiological PSH (OR = 0.74, 95% CI = 0.46 to 1.18, p = 0.20). CONCLUSION: PMI may reduce the rate of subsequent PSH. However, further studies are required to confirm these findings and to establish the optimal mesh position and shape before definite recommendations can be made.

Fluid and electrolyte pathophysiology in common febrile illness in children and the implications for clinical management.

Achieving fluid homeostasis and the management of fluid and electrolyte complications are constants in the treatment of seriously ill children worldwide. Consensus on the most appropriate fluid strategy for unwell children has been difficult to achieve and has evolved over the last two decades, most notably in high-income countries where adverse events relating to poor fluid management were identified more readily, and official robust inquiries were possible. However, this has not been the situation in many low-income settings where fluids that are prohibited from use in high-income countries may be all that are available, local guidelines and processes to recognise adverse events are not developed, and there has been limited training on safe fluid management for front-line healthcare workers. This narrative review outlines the fluid and electrolyte pathophysiology of common febrile illnesses in children, describes the evolution of this field and concludes with implications and principles of a fluid management strategy for seriously ill children. This review was prepared as a physiological background paper to support evidence presented to the WHO Guideline Development Group for Fluid Guidelines in Children, Geneva, March 2024.

Sham feeding with chewing gum after elective colorectal resectional surgery: a randomized clinical trial.

OBJECTIVE: To determine whether sham feeding with chewing gum improved gastrointestinal recovery after colorectal resection surgery, in the presence of routine postoperative feeding. BACKGROUND: Sham feeding with chewing gum has been shown to accelerate the return of gut function after colorectal surgery. This study sought to determine whether sham feeding with gum, after colorectal resection, accelerates return of gastrointestinal function in patients on a rapid feeding enhanced recovery program. METHODS: A randomized "two armed" controlled clinical trial was performed. Equal groups of open and laparoscopic colorectal resection surgical patients were recruited. Patients in the intervention arm received chewing gum 4 times a day postoperatively. All patients in the trial were placed on an established, standardized Enhanced Recovery After Surgery program. The primary outcome was time to return of gut function, assessed by time to flatus and first bowel motion. Secondary outcomes were time to tolerate diet, symptoms of ileus in the form of nausea, vomiting and distension, pain as assessed by analgesic consumption and visual analogue scales, complications, and length of hospital stay. RESULTS: A total of 161 patients were recruited. Postoperative morbidity was equivalent between groups, with no complications related to gum chewing. There was no difference between groups with respect to the primary outcomes of time to flatus and bowel motion. There was less perception of pain in the intervention group on days 2 to 5, and no difference with respect to all other secondary outcomes. CONCLUSIONS: Sham feeding with gum, after open and laparoscopic colorectal resectional surgery is safe, but does not hasten the return of gastrointestinal function in patients who receive accelerated postoperative feeding. (ACTRN12607000538448).

Anisotropic Tensile Characterisation of Eucalyptus nitens Timber above Its Fibre Saturation Point, and Its Application.

Plantation-grown Eucalyptus nitens (E. nitens) has been grown predominantly for the pulp and paper industry. In this study, the suitability of E. nitens as a structural material is examined using static tensile tests in a universal testing machine. The anisotropic tensile behaviour of 240 Eucalyptus nitens small clear wood samples with a diversity of grain angles was examined in both dry and wet conditions. The samples had a highly anisotropic tensile characterisation in the context of both a low moisture content (MC = 12%) and a high moisture content (MC > its fibre saturation point, FSP). The results showed that, in a high moisture content condition, the wood showed a lower failure strength and more ductility at all grain angles than in a low moisture content condition. The underlying failure mechanism of Eucalyptusnitens timber in tension was determined in detail from the perspective of the microstructure of wood cellulose polymer composites. The mean tensile failure strengths perpendicular and parallel to the fibre direction were, respectively, 5.6 and 91.6 MPa for the low MC and 3.8 and 62.1 MPa for the high MC condition. This research provides a basis for using E. nitens as a potential structural tensile member. The moisture modification factors of Eucalyptus timber at a mean level are higher than those of the traditional construction material, Pinus radiata, implying that E. nitens is promising as a material to be used for tensile members in water saturated conditions.

Incidence of Clostridioides difficile in patients post loop ileostomy reversal in an Australian tertiary hospital: a retrospective study.

INTRODUCTION: The purpose of a loop ileostomy is to temporarily divert faeces away from a distal anastomosis, to reduce the consequences of anastomotic leak. This ultimately requires a second procedure to restore bowel continuity, which confers risk of complications including the development of Clostridioides difficile infection (CDI). It is hypothesized that patients who undergo loop ileostomy reversal are at increased risk of CDI when compared with other patients undergoing elective colorectal surgical procedures, and that these patients also experience an increased length of stay (LOS). METHODS: A retrospective cohort study was performed on all patients who underwent loop ileostomy reversal at the Gold Coast Hospital and Health Service between 1 January 2012 and 31 December 2019. RESULTS: Two hundred and twenty-eight patients were identified. Eight tested positive for CDI on faecal PCR (3.51%), a higher incidence than that in patients who underwent an elective colorectal surgical procedure during the same period (0.83%) (RR = 4.23). Additionally, median LOS for ileostomy reversal patients was significantly increased in those who also had CDI when compared with those without CDI (11 versus 4 days; P = 0.0003). CONCLUSION: The study confirmed that the incidence of CDI was higher in those who underwent ileostomy reversal when compared with an otherwise comparable hospital population (elective colorectal surgery patients). Additionally, those patients who underwent ileostomy reversal and had CDI experienced an increased LOS which translates to increased cost to the healthcare system. Further investigation into pre-operative screening and prophylactic antibiotics should be considered as a measure to mitigate this post-operative complication.

Omentoplasty to reduce anastomotic leak in colorectal surgery: a meta-analysis.

BACKGROUND: Anastomotic leaks (AL) remain a devastating complication following intestinal anastomoses resulting in increased morbidity and mortality. Wrapping the anastomosis with omentum may be protective although data are conflicting. We performed a meta-analysis to assess the effect of omentoplasty on colorectal anastomoses. METHODS: PubMed, EMBASE and Cochrane databases were searched for relevant articles from inception until August 2021. All randomized controlled trials (RCT) that reported on the use of omentoplasty in colon and rectal surgery were included. The primary outcome was rate of overall AL while secondary outcomes included clinical and radiological AL, overall reoperation and mortality. Random effects models were used to calculate pooled effect size estimates. Sensitivity analyses were also performed. RESULTS: Four RCTs were included capturing 1067 patients. The mean (SD) age of the cohort was 61.5 (±14.8) years. On random effects analysis, omentoplasty reduced rate of overall (OR 0.43, 95% CI = 0.21-0.87, p = 0.02) and clinical AL (OR = 0.35, 95% CI = 0.15-0.81, p = 0.01). However, there was no difference in radiological AL (OR = 0.77, 95% CI = 0.40-1.47, p = 0.42), overall reoperations (OR 0.48, 95% CI = 0.18-1.32, p = 0.16) or mortality (OR 0.52, 95% CI = 0.12 to-2.18, p = 0.37). On sensitivity analysis, assessing rectal anastomoses only, the results for overall AL remained similar (OR 0.28, 95% CI = 0.12-0.61, p = 0.002). CONCLUSION: Although omentoplasty appears to reduce the rate of overall and clinical AL, the heterogeneity in the data prevents definitive recommendations from being made. Further well-designed trials are needed to investigate this technique.

Delay to Adjuvant Chemotherapy: Survival and Recurrence in Patients of Rectal Cancer Treated with Neo-adjuvant Chemoradiotherapy and Surgery.

PURPOSE: This aim of the study is to evaluate the survival function and hazard risks of delayed adjuvant chemotherapy (ChT) to distant recurrence risk in patients with non-metastatic rectal cancer treated with neoadjuvant chemoradiotherapy (CRT) and surgery. METHODS: A single tertiary hospital retrospective cohort study of a duration of 5 years between January 2012 and December 2016 was performed. As no previous study shown a temporal relationship of delay to adjuvant/systemic ChT leading to increased risk of metastatic disease, we compared between our proposed cut-off with the median and mean value determined by our dataset. Time to event analysis and log rank tests were conducted. RESULTS: A total of 269 patients with rectal cancer were identified. Two hundred eighteen patients were ineligible, leaving 51 patients for final analysis. Patients in the non-delayed group at 23 (proposed) and 25 (median) weeks' cut-off reported better 5 years' disease free survival (DFS) compared with the delayed group by 4.1% and 0.8%. Inversely, at the cut-off 28 (mean) weeks, the delayed group had a better DFS by 4.4%. Females and patients less than 60 years old had better 5-year DFS by 22.8% and 24%. Delayed group has a higher hazard risk ratio (HR) of 1.28 of distant recurrence compared with non-delayed at 23 weeks' cut-off. CONCLUSION: This study has demonstrated delaying a patient to adjuvant ChT will lower their DFS and increase their HR compared with those whose treatment is not delayed. We have long been too focused on local control; hence, priority needs to be shifted to efforts in managing potential distant disease in a timely manner.

Increasing rate of colorectal cancer in younger patients: a review of colonoscopy findings in patients under 50 at a tertiary institution.

BACKGROUND: In Australia, colorectal cancer (CRC) is the third most common cancer and the second leading cause of cancer death. It is more common in patients over 50 years, with previous evidence showing patients under 50 years account for only 9% of CRC. However, recent Australian and International studies have shown an increase in CRC incidence in patients under 50 years of age. The main aim of this study was to analyse the incidence of CRC in patients under 50 and to determine if screening would be beneficial in this population. METHODS: A retrospective cohort study was performed on all patients under 50 years of age who underwent a colonoscopy, performed by a colorectal surgeon, at the Gold Coast Hospital and Health Service between January 2013 and December 2017. RESULTS: A total of 557 patients were included in the study; 120 (21.5%) colonoscopies had a significant finding (CRC or adenoma with malignant potential). 1.9% of patients were diagnosed with CRC, all were symptomatic at time of diagnosis, the majority were stage 3 or 4. CONCLUSION: A total of 1.9% of patients under 50 who underwent colonoscopy were diagnosed with CRC, whilst 21.5% of patients had significant findings. These rates are greater than previously quoted figures and data for patients under 50, and provides evidence to support lowering of the CRC faecal occult blood testing screening age.

Transanal total mesorectal excision the Gold Coast experience: learning curve and comparison to traditional technique.

BACKGROUND: Laparoscopic and open techniques in rectal cancer are well-published, however, technical challenges remain for mid to low rectal cancer resections in the narrow pelvis. Transanal total mesorectal excision (taTME) has been pioneered to potentially circumvent these challenges. The aims of this study were to evaluate the learning curve associated with our first cases of taTME as well as compare outcomes to that of conventionally performed rectal resections. METHODS: This was a single-centre retrospective study with data collated from all elective resections by the colorectal unit from 2015 to 2017. Primary outcome was completeness of total mesorectal excision and secondary outcomes were intra- and post-operative morbidity and mortality. RESULTS: A total of 43 patients were identified. Of which, 20 underwent taTME. Mesorectal completeness was obtained in only 47.4% in the taTME group compared to 78.3% in the anterior resection group (p = 0.115). 5.9% of patients in our taTME group had positive circumferential resection margin compared to nil in the anterior resection. Conversion rates were greater in the taTME group (15% versus 0%; 0.028). Operative time, length of stay and clavien IV and V complications were greater in the taTME group. CONCLUSION: This study highlights the difficulty in introducing a novel technique given the learning curve. Our results would expect to improve with increased caseload.

Impact of three-dimensional imaging in acquisition of laparoscopic skills in novice operators.

BACKGROUND: Three-dimensional (3D) laparoscopes have been developed to maintain the perception of depth in the operating field. Two-dimensional (2D) imaging relies on tactile feedback, visual cues, and previous experience. The aim of this study was to test if 3D laparoscopic vision is superior to 2D laparoscopic vision in training novice operators in completing set laparoscopic tasks. MATERIALS AND METHODS: The study population consisted of 20 interns and medical students. The participants were randomized to completing tasks using a 2D or 3D system. These included pegboard transfer (PT), continuous suturing (CS), and intracorporeal knot-tying (IK). The time to complete the task and number of errors made were recorded. RESULTS: Following adjustment for potential confounders, time to complete CS and IK was significantly longer among participants who used the 2D laparoscope compared with those who used the 3D laparoscope (CS, P<.0001; IK, P<.0001). This same effect was not demonstrated in time to perform PT (PT, P=.04). The 2D laparoscope was associated with a significant increase in the number of errors on the IK task (P<.0001) but not on the PT or CS tasks (PT, P=.35; CS, P=.26). CONCLUSIONS: The 3D system assists novice operators perform more complex laparoscopic tasks in a decreased amount of time and with fewer errors.

Re-operation for hyperparathyroidism.

INTRODUCTION: Re-operation for hyperparathyroidism (HPT) represents a challenge for experienced endocrine surgeons. The present study reviews the technical and pathological factors for failure of initial surgery and identifies strategies to approach re-operative parathyroidectomy. METHODS: Clinical details, operation notes, pathology, localization studies and complications for re-operative cases performed by three surgeons were reviewed. RESULTS: Over a 10-year period there were 40 re-operative cases with a 98% success rate. There were 31 patients with primary HPT, 21 with persistent primary (PP) and 10 with recurrent primary (RP). Multigland disease (MGD) was present in 19 of the 31 (61%) primary HPT cases. The culprit gland was ectopic in 14 cases, at a normal location in 10 and there was regrowth at previously excised sites or remnant disease in 10. There were nine patients with secondary HPT, four with persistent secondary (PS) and five with recurrent secondary (RS). The culprit gland was ectopic in five, at a normal location in four and regrowth at a previously excised site in two. Pre-operative investigations were employed in all cases and the most helpful were sestamibi scan (S) and selective venous sampling (SVS) for parathyroid hormone (PTH) concentration. True positive localizations for S was in 20 of 34 cases (59%), SVS in seven of nine (78%), computed tomography (CT) in seven of 17 (41%) and ultrasound scan (USS) in 10 of 28 (36%). CONCLUSIONS: Re-operative parathyroidectomy can be performed by experienced surgeons with a very high success rate and minimal complications.

Overweight and obesity alters the cumulative transverse strain in the Achilles tendon immediately following exercise.

This research evaluated the effect of obesity on the acute cumulative transverse strain of the Achilles tendon in response to exercise. Twenty healthy adult males were categorized into 'low normal-weight' (BMI <23 kg m(-2)) and 'overweight' (BMI >27.5 kg m(-2)) groups based on intermediate cut-off points recommended by the World Health Organization. Longitudinal sonograms of the right Achilles tendon were acquired immediately prior and following weight-bearing ankle exercises. Achilles tendon thickness was measured 20-mm proximal to the calcaneal insertion and transverse tendon strain was calculated as the natural log of the ratio of post- to pre-exercise tendon thickness. The Achilles tendon was thicker in the overweight group both prior to (t18 = -2.91, P = 0.009) and following (t18 = -4.87, P < 0.001) exercise. The acute transverse strain response of the Achilles tendon in the overweight group (-10.7 ± 2.5%), however, was almost half that of the 'low normal-weight' (-19.5 ± 7.4%) group (t18 = -3.56, P = 0.004). These findings suggest that obesity is associated with structural changes in tendon that impairs intra-tendinous fluid movement in response to load and provides new insights into the link between tendon pathology and overweight and obesity.

Laparoscopic drainage of an intramural duodenal haematoma: a novel technique and review of the literature.

Intramural Duodenal Haematoma (IDH) is an uncommon complication of blunt abdominal trauma. IDH's are most often treated non-operatively. We describe laparoscopic treatment of an IDH after failed conservative management. To our knowledge, successful laparoscopic drainage of an IDH in an adult has not been described previously in the literature.