Summary Acute appendicitis is one of the most common abdominal emergencies worldwide. The cause remains poorly understood, with few advances in the past few decades. To obtain a confident ...preoperative diagnosis is still a challenge, since the possibility of appendicitis must be entertained in any patient presenting with an acute abdomen. Although biomarkers and imaging are valuable adjuncts to history and examination, their limitations mean that clinical assessment is still the mainstay of diagnosis. A clinical classification is used to stratify management based on simple (non-perforated) and complex (gangrenous or perforated) inflammation, although many patients remain with an equivocal diagnosis, which is one of the most challenging dilemmas. An observed divide in disease course suggests that some cases of simple appendicitis might be self-limiting or respond to antibiotics alone, whereas another type often seems to perforate before the patient reaches hospital. Although the mortality rate is low, postoperative complications are common in complex disease. We discuss existing knowledge in pathogenesis, modern diagnosis, and evolving strategies in management that are leading to stratified care for patients.
A substantial challenge facing multicentre audit and research projects is timely recruitment of collaborators and their study centres. Cost-effective strategies are required and fee-free social media ...has previously been identified as a potential conduit. We investigated and evaluated the effectiveness of a novel multi-format social media and Internet strategy for targeted recruitment to a national multicentre cohort study.
Interventions involved a new Twitter account, including weekly live question-and-answer sessions, a new Facebook group page, online YouTube presentations and an information page on a national association website. Link tracking analysis was undertaken using Google Analytics, which was then related to subsequent registration. Social influence was calculated using the proprietary Klout score.
Internet traffic analysis identified a total of 1562 unique registration site views, of which 285 originated from social media (18.2%). Some 528 unique registrations were received, with 96 via social media platforms (18.2%). Traffic source analysis identified a separate national association webpage as resulting in the majority of registration page views (15.8%), followed by Facebook (11.9%), Twitter (4.8%) and YouTube (1.5%). A combination of publicity through Facebook, Twitter and the dedicated national association webpage contributed to the greatest rise in registration traffic and accounted for 312 (48%) of the total registrations within a 2-week period. A Twitter 'social influence' (Klout) score of 42/100 was obtained during this period.
Targeted social media substantially aided study dissemination and collaborator recruitment. It acted as an adjunct to traditional methods, accounting for 18.2% of collaborator registration in a short time period with no associated financial costs. We provide a practical model for designing future recruitment campaigns, and recommend Facebook, Twitter and targeted websites as the most effective adjuncts for maximising cost-effective study recruitment.
Background
Enhanced recovery programs following colorectal resection recommend the use of nonsteroidal anti-inflammatory drugs (NSAIDs) as part of multimodal analgesia. The present study aimed to ...assess whether postoperative NSAID use increased the risk of anastomotic leak.
Methods
A systematic review of published literature was performed for studies comparing anastomotic leak following NSAID administration versus control. Meta-analysis was conducted for studies in human patients and experimental animal models. The primary endpoint was anastomotic leak.
Results
The final analysis included 8 studies in humans and 12 experimental animal studies. Use of NSAIDs was significantly associated with anastomotic leak in humans (8 studies, 4,464 patients, odds ratio OR 2.14;
p
< 0.001). This effect was seen with nonselective NSAIDs (6 studies, 3,074 patients, OR 2.37;
p
< 0.001), but not with selective NSAIDs (4 studies, 1,223 patients, OR 2.32;
p
= 0.170). There was strong evidence of selection bias from all clinical studies, with additional inconsistent definitions and outcomes assessment. From experimental animal models, anastomotic leak was more likely with NSAID use (ten studies, 575 animals, OR 9.51;
p
< 0.001). Bursting pressures at day 7 were significantly lower in NSAID versus controls (7 studies, 168 animals, weighted mean difference −35.7 mmHg;
p
< 0.001).
Conclusions
Emerging data strongly suggest that postoperative NSAIDs are linked to anastomotic leak, although most studies are flawed and may be describing pre-existing selection bias. However, when combined with experimental data, these increasing concerns suggest caution is needed when prescribing NSAIDs to patients with pre-existing risk factors for leak, until more definitive evidence emerges.
Surgical site infection remains a major challenge in surgery. Delayed primary closure of dirty wounds is widely practiced in war surgery; we present a meta-analysis of evidence to help guide ...application of the technique in wider context.
To determine using meta-analysis whether delayed primary skin closure (DPC) of contaminated and dirty abdominal incisions reduces the rate of surgical site infection (SSI) compared with primary skin closure (PC).
A systematic review of the literature published after 1990 was conducted of the Medline, PubMed, Current Controlled Trials, and Cochrane databases. The last search was performed on October 6, 2012. No language restrictions were applied.
Randomized clinical trials comparing PC vs DPC were included.
Two of us independently selected studies based on quality assessment using the Cochrane Collaboration tool for assessing risk of bias in randomized trials. Data were pooled using fixed- and random-effects models.
Rate of SSI, as defined by the individual study.
The final analysis included 8 studies randomizing 623 patients with contaminated or dirty abdominal wounds to either DPC or PC. The most common diagnosis was appendicitis (77.4%), followed by perforated abdominal viscus (11.5%), ileostomy closure (6.5%), trauma (2.7%), and intra-abdominal abscess/other peritonitis (1.9%). The time to first review for DPC was provided at between 2 and 5 days postoperatively. All studies were found to be at high risk of bias, with marked deficiencies in study design and outcome assessment. When SSI was assessed across all studies using a fixed-effect model, DPC significantly reduced the chance of SSI (odds ratio, 0.65; 95% CI, 0.40-0.93; P = .02). However, heterogeneity was high (72%), and using a random-effects model, the effect was no longer significant (odds ratio, 0.65; 95% CI, 0.25-1.64; P = .36).
Delayed primary skin closure may reduce the rate of SSI, but current trials fail to provide definitive evidence because of poor design. Well-designed, large-numbered randomized clinical trials are warranted.
Abstract Background This study aimed to analyse predictive factors and outcomes of failure of non-operative management (NOM) following blunt splenic trauma. Methods A systematic review of the ...literature was performed for studies comparing failed NOM (fNOM) to successful NOM (sNOM) in adults (≥16 years). The main endpoints were fNOM and associated mortality. Between-study heterogeneity was assessed. Meta-analysis of high quality studies, identified using the Newcastle–Ottawa Scale, was performed using fixed or random models. Results Four prospective and 21 retrospective studies were included. From 24,615 unselected patients, 3025 experienced fNOM (12%, range 4–52%). Meta-analysis of the high quality studies revealed that mortality was significantly higher with fNOM in unselected age groups (odds ratio 1.93, 95% confidence interval 1.04–3.57, p = 0.04, I2 = 0%), in those <55 years old (OR 3.42, 95% CI 1.73–6.77, p = 0.02, I2 = 0%) and in those ≥55 years old (OR 2.65, 95% CI 1.20–5.82, p = 0.02, I2 = 0%). There was a significant improvement in sNOM following introduction of angioembolisation protocols (OR 0.26, 95% CI 0.13–0.53, p < 0.002, I2 = 51%), although these five studies were non-randomised. American Association for the Surgery of Trauma injury grades 4–5, the presence of moderate or large haemoperitoneum, increasing injury severity score and increasing age were all significantly associated with increased risk of fNOM. fNOM led to significantly longer intensive care unit and overall lengths of stay. Conclusions fNOM leads to increased resource use and increased mortality. Methods of preventing fNOM, such as angioembolisation, warrant further assessment. Patients with increasing age, AAST scores and moderate or large haemoperitoneums may benefit from closer monitoring.
Background Resident surgeons have been identified as a risk factor for worse outcome after appendectomy. The context of grade of resident and impact of supervision require further investigation. The ...objective of this study was to determine whether grade and supervision level of resident-performed appendectomy affects patient outcome. Methods A multicenter, prospective cohort study was performed for consecutive patients undergoing appendectomy during May and June 2013. The primary endpoint for this analysis was the 30-day adverse event rate. Supervision was defined as resident-performed appendectomy with an attending scrubbed. Multivariable binary logistic regression was used to take into account case mix and produce adjusted odds ratios (OR). Results From 2,867 appendectomies, 87% were performed by residents, and 72% were performed unsupervised. Residents operated on significantly younger patients with lower American Society of Anesthesiologists scores. Although wound infection rates were similar between attendings, and senior and junior residents (4.1%, 3.8%, 3.4% respectively; P = .486), pelvic abscess rate was greater for attendings (5.2%, 2.7%, 2.4%; P = .045). In adjusted models, supervised senior, supervised junior, and unsupervised junior residents showed no difference in 30-day adverse event rates compared with attendings (OR, 1.07 P = .834, 0.93 P = .773, and 0.83 P = .264 respectively); unsupervised senior residents had a lesser rate of adverse events (OR, 0.71; P = .045). All resident groups showed no difference for rates of histopathologically normal appendectomy compared with attendings. Conclusion Resident-performed appendectomy does not worsen patient outcomes. These findings support independent resident operating rights for selected cases. The system relies on mutual credentialing of competency between residents and supervising attendings.
Background The optimal technique for gastrointestinal anastomosis remains controversial in emergency laparotomy. The aim of this meta-analysis was to compare outcomes of stapled versus handsewn ...anastomosis after emergency bowel resection. Methods A systematic review was performed for studies comparing outcomes after emergency laparotomy using stapled versus handsewn anastomosis until July 2014 (PROSPERO registry number: CRD42013006183). The primary endpoint was anastomotic failure, a composite measure of leak, abscess and fistula. Odds ratio (OR; with 95% CI) and weighted mean differences were calculated using meta-analytical techniques. Subgroup analysis was conducted for trauma surgery (TS) and emergency general surgery (EGS) cohorts. Risk of bias for each study was calculated using the Newcastle–Ottawa scale for cohort studies, and Cochrane Collaboration's tool for randomized trials. Results The final analysis included 7 studies of 1,120 patients, with a total of 1,205 anastomoses. There were 5 TS studies and 2 EGS studies. There were no differences in anastomotic failure between handsewn and stapled techniques on an individual anastomosis level (OR, 1.53; 95% CI, 0.97–2.43; P = .070), or on an individual patient level (OR, 1.44; 95% CI, 0.92–2.25; P = .110). There were no differences in the individual rates of anastomotic leak, abscess, fistulae, or postoperative deaths between techniques. Subgroup analysis of EGS and TS studies demonstrated no superior operative technique. Conclusion Available evidence is sparse and at high risk of bias, and neither stapling nor handsewing is justifiably favored in emergency laparotomy. Surgeons might therefore select the technique of their own choice with caution owing to unresolved uncertainty.
Malnutrition is an independent predictor for postoperative complications in low- and middle-income countries (LMICs). We systematically reviewed evidence on the impact of preoperative oral nutrition ...supplementation (ONS) on patients undergoing gastrointestinal cancer surgery in LMICs. We searched EMBASE, Cochrane Library, Web of Science, Scopus, WHO Global Index Medicus, SciELO, Latin American and Caribbean Health Sciences Literature (LILACS) databases from inception to March 21, 2022 for randomised controlled trials evaluating preoperative ONS in gastrointestinal cancer within LMICs. We evaluated the impact of ONS on all postoperative outcomes using random-effects meta-analysis. Seven studies reported on 891 patients (446 ONS group, 445 control group) undergoing surgery for gastrointestinal cancer. Preoperative ONS reduced all cause postoperative surgical complications (risk ratio (RR) 0.53, 95% CI 0.46-0.60, P < 0.001, I
= 0%, n = 891), infection (0.52, 0.40-0.67, P = 0.008, I
= 0%, n = 570) and all-cause mortality (0.35, 0.26-0.47, P = 0.014, I
= 0%, n = 588). Despite heterogeneous populations and baseline rates, absolute risk ratio (ARR) was reduced for all cause (pooled effect -0.14, -0.22 to -0.06, P = 0.006; number needed to treat (NNT) 7) and infectious complications (-0.13, -0.22 to -0.06, P < 0.001; NNT 8). Preoperative nutrition in patients undergoing gastrointestinal cancer surgery in LMICs demonstrated consistently strong and robust treatment effects across measured outcomes. However additional higher quality research, with particular focus within African populations, are urgently required.
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