Impact of Perioperative Enteral Synbiotics in Surgery for Chronic Pancreatitis: A Single Blind Prospective Randomized Control Trial

INTRODUCTION: Despite immense advances in intensive care medicine, surgical technique, and hygiene; nosocomial infections still represent a major clinical problem in modern-day surgery. According to a survey of 3,147 patients admitted to a surgical intensive care unit, infection was identified in 37% of the patients causing 24% mortality. Another recent study has shown that in patients with post surgical sepsis, 85% had an intraabdominal source. Male gender, advanced age, presence of comorbidities, inadequate nutritional status, complications of operations, shock, multisystem organ failure, high APACHE II-score, emergency procedures, and multiple procedures were among the most common risk factors for hospital acquire infections in surgical patients. AIM OF THE STUDY: The objective of the present investigation is to determine the impact of perioperative synbiotic therapy on •postoperative infectious complications, •first bowel movement, •days in intensive care unit, •length of hospital stay, •duration of antibiotic therapy, •mortality in patients undergoing Frey procedure for Chronic Pancreatitis. MATERIALS & METHODS: At the Institute of Surgical Gastroenterology & Liver Transplantation, Govt. Stanley Medical College, Chennai, India a single blind prospective randomized placebo controlled clinical trial was conducted. Randomization was computer generated using an on-site computer system with randomization software. The study was single blind, with the patients being blinded for the intervention. The study design was as presented in figure 1. The patients were assessed for eligibility using the inclusion and exclusion criteria (detailed below), and those who were planned for a Frey procedure were randomized. The patients in whom the surgery could not be completed were excluded from the study. All patients who were suffering from chronic pancreatitis and scheduled for Frey procedure were included in this prospective monocentric single-blind randomized control study. Inclusion Criteria: • All Adults between the ages of 18 and 75 years with good performance status (Karnofsky performance score >80). • Patients with Chronic pancreatitis undergoing Frey Procedure Exclusion criteria: • Renal insufficiency defined as Creatinine > 1.1 mg/dl. • Presence of Intestinal obstruction. • Patients who underwent emergency surgery. • Patients with cerebral disorders with a danger of aspiration. • Any other contraindications for enteral nutrition. RESULTS: Four patients (all four in group B) were excluded from the study after randomization because Frey procedure was not possible due to the presence of active pancreatitis and extensive collaterals channels over the pancreas. All the other 75 randomized patients {Group A (n=39) and Group B (n=36)} completed the study. The two groups were homogenous with regards to demographic data; there were no differences in the age, gender, and American Society of Anaesthesiologists classification between the 2 groups. CONCLUSIONS: In patients undergoing pancreatic surgery for Chronic Pancreatitis Synbiotics significantly reduce: • infective complications, • hospital stay, • antibiotic requirement. Synbiotics did not influence: • Day to first bowel movement, • length of ICU stay, • Peroperative haematological and biochemical parameters

Xanthogranulomatous Cholecystitis Masquerading as Gallbladder Cancer: Can It Be Diagnosed Preoperatively?

Background. Xanthogranulomatous cholecystitis (XGC) is often misdiagnosed as gallbladder cancer (GBC). We aimed to determine the preoperative characteristics that could potentially aid in an accurate diagnosis of XGC masquerading as GBC. Methods. An analysis of patients operated upon with a preoperative diagnosis of GBC between January 2008 and December 2012 was conducted to determine the clinical and radiological features which could assist in a preoperative diagnosis of XGC. Results. Out of 77 patients who underwent radical cholecystectomy, 16 were reported as XGC on final histopathology (Group A), while 60 were GBC (Group B). The incidences of abdominal pain, cholelithiasis, choledocholithiasis, and acute cholecystitis were significantly higher in Group A, while anorexia and weight loss were higher in Group B. On CT, diffuse gallbladder wall thickening, continuous mucosal line enhancement, and submucosal hypoattenuated nodules were significant findings in Group A. CT findings on retrospect revealed at least one of these findings in 68.7% of the cases. Conclusion. Differentiating XGC from GBC is difficult, and a definitive diagnosis still necessitates a histopathological examination. An accurate preoperative diagnosis requires an integrated review of clinical and characteristic radiological features, the presence of which may help avoid radical resection and avoidable morbidity in selected cases

Worldwide variations in COVID-19 vaccination policies and practices in liver transplant settings: results of a multi-society global survey

BackgroundDespite the WHO's report of 24 available SARS-CoV-2 vaccines, limited data exist regarding vaccination policies for liver transplant (LT) patients. To address this, we conducted a global multi-society survey (EASL-ESOT-ELITA-ILTS) in LT centers.MethodsA digital questionnaire assessing vaccine policies, safety, efficacy, and center data was administered online to LT centers.ResultsOut of 168 responding centers, 46.4%, 28%, 13.1%, 10.7%, and 1.8% were from European, American, Western Pacific, Southeast Asian, and Eastern Mediterranean Regions. Most LT centers prioritized COVID-19 vaccine access for LT patients (76%) and healthcare workers (86%), while other categories had lower priority (30%). One-third of responders recommended mRNA vaccine exclusively, while booster doses were widely recommended (81%). One-third conducted post-vaccine liver function tests post COVID-19 vaccine. Only 16% of centers modified immunosuppression, and mycophenolate discontinuation or modification was the main approach. Side effects were seen in 1 in 1,000 vaccinated patients, with thromboembolism, acute rejection, and allergic reaction being the most severe. mRNA showed fewer side effects (−3.1, p = 0.002).ConclusionCOVID-19 vaccines and booster doses were widely used among LT recipients and healthcare workers, without a specific vaccine preference. Preventative immunosuppression adjustment post-vaccination was uncommon. mRNA vaccines demonstrated a favorable safety profile in this population

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Risk factors and management of post-liver transplant recurrence of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is one of the most common indications for liver transplantation (LT). With expanding criteria and increasing number of transplants, post-transplant recurrence of HCC remains an important cause for concern and portends a poor survival in these patients. Traditionally, HCC recurrence post-LT has been notoriously difficult to manage and their outcomes dismal. A better understanding of the tumour biology and its interplay with the immune system, combined with newer oncological interventions has allowed for improved survivals in these patients. A useful classification of HCC recurrence is where it is divided into oligo-recurrence and disseminated recurrence. This system helps strategize their multi-disciplinary management algorithm and prognosticate outcomes. We provide an overview of the factors which may predict recurrence and summarise the current evidence on the management of post-LT HCC recurrence

Corrosive Injury of the Upper Gastrointestinal Tract: A Review

Ingestion of a corrosive substance can produce severe injury to the gastrointestinal tract and can even result in death. The degree and extent of damage depends on several factors like the type of substance, the morphologic form of the agent, the quantity, and the intent. In the acute stage, perforation and necrosis may occur. Long-term complications include stricture formation in the esophagus, antral stenosis and the development of esophageal carcinoma. Endoscopy should be attempted and can be safely performed in most cases to assess the extent of damage. Procedure related perforation is rare. Stricture formation is more common in patients with second and third degree burns. This review summarizes our current knowledge and evidence based management of this unique but not uncommon pathology of the upper gastrointestinal tract.</p

Capsule Endoscopy: New Technology, Old Complication

Wireless capsule endoscopy is a new tool in the armamentarium of the gastroenterologist to evaluate the small bowel non-invasively. It allows improved diagnostic yield with low complication rates relative to traditional modalities. But this new technology has its own set of complications, some which can lead to significant morbidity. Here, we present a case of complete small bowel obstruction following a capsule endoscopy. A 65-year-old female with a long standing history of anemia and obscure gastrointestinal bleed presented to the Emergency Department 72 hours after a wireless capsule endoscopy procedure complaining of worsening abdominal pain, distension, and frequent vomiting. An X-ray was suggestive of complete distal small bowel obstruction with the capsule at the transition point of dilated proximal and collapsed distal small bowel. The patient was resuscitated and taken up for an explorative laparotomy where a short segment stricture was noted with the capsule endoscope caught proximal to it. The segment was resected and patient made an uneventful recovery. Wireless capsule endoscopy is now becoming the preferred method to image the small bowel. Our report illustrates the importance of appropriate patient selection and evaluation of functional patency of the small bowel may be with a contrast series prior to wireless capsule endoscopy to avoid any post procedural morbidity