A prospective observational study of the utility of early diagnostic laparoscopy for right lower abdominal pain: a safe and effective diagnostic and therapeutic tool.

BACKGROUND AND AIMS: Diagnostic laparoscopy is commonly performed for diagnosis of right lower abdominal pain and its use is increasing in the emergency setting. Some studies have reported that diagnostic laparoscopy and laparoscopic appendicectomy have advantages over conventional surgery. Many emergency surgeons now perform diagnostic laparoscopy for both clinically diagnosed appendicitis and when the diagnosis is in doubt. The aim of the present study was to assess whether the use of diagnostic laparoscopy is justified and safe for those admitted with right lower abdominal pain. METHODS AND RESULTS: Data were collected prospectively on consecutive patients attending the acute surgical receiving unit with right iliac fossa pain or a suspected diagnosis of acute appendicitis. A total of 284 patients underwent diagnostic laparoscopy. Of them 233 (82%) had a positive finding at laparoscopy, 207 (88%) underwent appendicectomy, the majority of which were carried out laparoscopically. Surgical trainees performed the majority of operations and this did not have a negative impact on operative findings (p 0.856), operation performed (0.642), or operative duration (0.831). No intra-operative complications were sustained. Ultrasound examination was carried out in 49 patients, while CT was carried out in 24. CONCLUSION: The results of the present study highlight the utility of early diagnostic laparoscopy as both a diagnostic and therapeutic tool in the acute setting.

Splenic parenchymal complications in pancreatitis.

CONTEXT: The close proximity of splenic hilum to the tail of pancreas makes it vulnerable to complications in both acute and chronic pancreatitis. In this article, we examine the clinical course of these potentially fatal complications. CASE REPORTS: Citing three clinical cases, we present the spectrum of splenic complications in pancreatitis and explore the anatomical causal relationships and pathological basis of such complications. A literature review was carried out to inform on the incidence, morbidity and mortality rates, and clinical course especially diagnostic and management options for these patients. The spectrum of splenic complications in pancreatitis is wide ranging from pseudo cysts to haematomas, haemorrhages, infarctions and life threatening splenic rupture. Although a contrast enhanced helical CT scan is the investigation of choice a high index of clinical suspicion is essential in their early identification. Splenic complications in pancreatitis incur a high morbidity (79%) and a significant mortality (8%). CONCLUSIONS: Splenic parenchymal complications in pancreatitis are an increasingly recognised entity and should be suspected in patients with inflammation and or necrosis involving the tail of pancreas. Conservative management is feasible with close radiological monitoring for most patients in a tertiary referral centre with appropriate expertise and surgery may be reserved for haemodynamically unstable patients.

Safety and feasibility of retrieval of intragastric balloon followed by antiobesity surgery on the same day.

Intragastric balloon insertion can achieve reasonable weight loss before antiobesity surgery. Removal needs to be followed by surgery to prevent subsequent weight gain. This study aims to establish the feasibility and safety of retrieval of the intragastric balloon and sleeve gastrectomy in the same sitting. Patients who had a laparoscopic sleeve gastrectomy (n=9) were compared with those who had endoscopic removal of intragastric balloon followed by laparoscopic sleeve gastrectomy in the same sitting (n=5). The 5 patients managed with an intragastric balloon were significantly heavier at all stages of their treatment (P=0.04). The operating time for balloon removal and concomitant sleeve gastrectomy was longer than that of sleeve gastrectomy alone (P=0.035). There were no complications in either group and postoperative hospital stay was similar. In conclusion, concomitant retrieval of an intragastric balloon followed by sleeve gastrectomy is feasible, safe, and cost effective.

Occlusion of a neo-esophageal-bronchial fistula using the Amplatzer Vascular Plug 2.

The appearance of a benign fistula between the airway and the gastrointestinal tract is a rare complication of esophagectomy. We report a patient with neo-esophago-bronchial fistula that developed 13 months after two-stage esophagectomy. Repeat thoracotomy was not deemed appropriate given the patient's chronic sepsis and malnutrition. After unsuccessful attempts at endoscopic closure, the fistula was successfully and permanently occluded under radiological guidance with an Amplatzer® Vascular Plug 2. The patient remained asymptomatic, with a measured weight gain, 12 months after the successful fistula occlusion.

The value of procalcitonin at predicting the severity of acute pancreatitis and development of infected pancreatic necrosis: systematic review.

BACKGROUND: Many studies have evaluated serum levels of procalcitonin (PCT) as a predictor in the development of severe acute pancreatitis (SAP) and infected pancreatic necrosis (IPN). This study assesses the value of PCT as a marker of development of SAP and IPN. METHODS: Medline, Web of Science, the Cochrane clinical trials register, and international conference proceedings were searched systematically for prospective studies, which evaluated the usefulness of PCT as a marker of SAP and IPN. The sensitivity, specificity, and diagnostic odds ratios (DORs) were calculated for each study, and the study quality and heterogeneity among the studies were evaluated. RESULTS: Twenty-four of 59 studies identified were included in data extraction. The sensitivity and specificity of PCT for development of SAP were 0.72 and 0.86, respectively (area under the curve [AUC] = 0.87; DOR = 14.9; 95% confidence interval [CI] = 5.6-39.8), albeit with a significant degree of heterogeneity (Q = 28.56, P < .01). The sensitivity and specificity of PCT for prediction of infected pancreatic necrosis were 0.80 and 0.91 (AUC = 0.91; DOR = 28.3; 95% CI = 13.8-58.3) with no significant heterogeneity (Q = 7.83, P = .18). No significant heterogeneity was observed among the studies when only higher quality studies (AUC = 0.91; DOR = 30.7; 95% CI = 10.7-87.8) or studies that used a cutoff PCT level >0.5 ng/mL (AUC = 0.88, 32.8; 95% CI = 10.1-106.6) were included. CONCLUSION: Serum measurements of PCT may be valuable in predicting the severity of acute pancreatitis and the risk of developing infected pancreatic necrosis.