An Unusual Zoonosis: Liver Abscess Secondary to Asymptomatic Colonic Foreign Body

A liver abscess may arise following any insult to gut integrity allowing portal drainage of bacteria to hepatocytes. Foreign bodies such as bones, toothpicks and items of stationery have previously been implicated in compromising gut epithelium. Here we present the case of a 57 year old man suffering from a left liver abscess. This was defined on CT which incidentally also identified a chicken bone protruding through the wall of the distal sigmoid colon. Whilst unwell with upper abdominal pain and sepsis, the presumed source of portal sepsis within the colon remained asymptomatic throughout. Following percutaneous drainage, the liver abscess resolved but the chicken bone had not passed at two months, necessitating atraumatic removal at colonoscopy. A high rate of incidental diagnoses suggests that unidentified foreign bodies may be vastly under recognised in cases of hepatic sepsis. Thus, identification of the precise mechanism of the liver insult demands thorough consideration; foreign body should be considered in all cases

Outcomes of a first point of contact speech language therapy clinic for patients requiring vocal cord check pre and post thyroid/parathyroid surgery

Introduction Speech Language Therapy First Point of Contact Clinic (SLT-FPOCC) models can assist assessment of low-risk patient populations referred to ear, nose and throat (ENT) services. To further improve ENT waitlist management and compliance with best-practice care, consideration of other low-risk populations that could be safely managed through this service model is needed. The aims of this paper are to evaluate the clinical and service outcomes of completing vocal cord check (VCC) assessments for patients’ pre and post thyroid/parathyroid surgery within an SLT-FPOCC model and examine consumer perceptions. Methods & Procedures The service followed existing SLT-FPOCC procedures, with ENT triaging referrals, then SLT completing pre- and postoperative VCC assessment (interview, perceptual assessment, flexible nasendoscopy), with assessment data later reviewed by ENT to diagnose laryngeal pathology. Clinical and service outcomes were collected prospectively. Patients completed an anonymous post-service satisfaction survey. Results Of the first 100 patients referred for preoperative VCCs, SLT assessment identified 42 with dysphonia and 30 reporting dysphagia, while ENT confirmed 9 with significant preoperative anatomical findings. Eighty-three underwent surgery, with 63 (95 nerves at surgical risk) returning for a postoperative VCC. Postoperative VCC identified three temporary neuropraxias (3.2%) and three unilateral vocal fold paresis (3.2%). Patients were highly satisfied with the service. All 163 pre-/postoperative VCCs were completed with no adverse events. Conclusion & Implications The current data support SLT-FPOCC service expansion to include pre and post thyroid/parathyroid surgery VCC checks, with positive consumer perception. The model supports delivery of best practice management (i.e., pre- and postoperative VCC) for patients receiving surgery for thyroid/parathyroid dysfunction, and associated efficiencies for ENT services

Multivisceral resection of pancreatic neuroendocrine tumours: a report of two cases

Pancreatic neuroendocrine tumours (pNETs) are rare and surgical resection offers the only possibility of cure for localised disease. The role of surgery in the setting of locally advanced and metastatic disease is more controversial. Emerging data suggests that synchronous surgical resection of pancreas and liver may be associated with increased survival. We report two cases of synchronous, one stage multivisceral resections for pNET and associated reconstruction. We highlight the technical issues involved in such extensive resections and demonstrate that one stage multivisceral operations can be achieved safely

Infected pancreatic necrosis: outcomes and clinical predictors of mortality. A post hoc analysis of the MANCTRA-1 international study

: The identification of high-risk patients in the early stages of infected pancreatic necrosis (IPN) is critical, because it could help the clinicians to adopt more effective management strategies. We conducted a post hoc analysis of the MANCTRA-1 international study to assess the association between clinical risk factors and mortality among adult patients with IPN. Univariable and multivariable logistic regression models were used to identify prognostic factors of mortality. We identified 247 consecutive patients with IPN hospitalised between January 2019 and December 2020. History of uncontrolled arterial hypertension (p = 0.032; 95% CI 1.135-15.882; aOR 4.245), qSOFA (p = 0.005; 95% CI 1.359-5.879; aOR 2.828), renal failure (p = 0.022; 95% CI 1.138-5.442; aOR 2.489), and haemodynamic failure (p = 0.018; 95% CI 1.184-5.978; aOR 2.661), were identified as independent predictors of mortality in IPN patients. Cholangitis (p = 0.003; 95% CI 1.598-9.930; aOR 3.983), abdominal compartment syndrome (p = 0.032; 95% CI 1.090-6.967; aOR 2.735), and gastrointestinal/intra-abdominal bleeding (p = 0.009; 95% CI 1.286-5.712; aOR 2.710) were independently associated with the risk of mortality. Upfront open surgical necrosectomy was strongly associated with the risk of mortality (p < 0.001; 95% CI 1.912-7.442; aOR 3.772), whereas endoscopic drainage of pancreatic necrosis (p = 0.018; 95% CI 0.138-0.834; aOR 0.339) and enteral nutrition (p = 0.003; 95% CI 0.143-0.716; aOR 0.320) were found as protective factors. Organ failure, acute cholangitis, and upfront open surgical necrosectomy were the most significant predictors of mortality. Our study confirmed that, even in a subgroup of particularly ill patients such as those with IPN, upfront open surgery should be avoided as much as possible. Study protocol registered in ClinicalTrials.Gov (I.D. Number NCT04747990)

Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

Background: Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.Methods: This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.Results: The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P < 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (beta coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.Conclusion: Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely

Intra-operative amylase in peri-pancreatic fluid independently predicts for pancreatic fistula post pancreaticoduodectomy

Background: Post-operative pancreatic fistula (POPF) is a common and potentially life-threatening complication following pancreaticoduodectomy. The aim of this study was to assess the predictive value of intra-operative amylase concentration (IOAC) in peri-pancreatic fluid after resection for the diagnosis of POPF. Methods: Consecutive patients who underwent a pancreaticoduodectomy between September 2014 and October 2015 were included in the analysis. IOAC was measured intraoperatively followed by drain fluid analysis for amylase on post-operative days (POD) 1, 3 and 5. Receiver operator characteristic (ROC) analysis was performed to evaluate the discriminative capacity of IOAC as a predictor of POPF. Results: IOAC was measured after pancreaticoduodectomy in 62 patients. The IOAC correlated significantly with i) POD 1 and 3 drain amylase (p < 0.01), ii) the development of POPF (p < 0.01), iii) the development of clinically relevant fistula (Type B, C) (p < 0.01), iv) delayed gastric emptying (p < 0.01), and v) grade of complication as per the Clavien-Dindo definition (p = 0.02). ROC curve analysis confirmed the predictive relationship of IOAC and POPF as a good test with an area under the curve of 0.93, 95% CI 0.87–0.99, p < 0.01. In patients with IOAC of 200 U/L or higher the POPF rate was 80% (OR = 50.1, p < 0.0001). Discussion: Measurement of IOAC allows early and accurate categorization of patients at risk for POPF.7 page(s

Early outcomes of emergency ventral hernia repair in a cohort of poorly optimized patients

Background: Strangulated and obstructed ventral hernias require emergent repair to mitigate the risk of life-threatening complications. Emergency ventral hernia repairs are associated with a higher rate of surgical complications and recurrence compared to elective repairs. The purpose of this study was to explore the impact of patient factors, hernia and operative characteristics on post-operative outcomes in patients requiring emergency ventral hernia repairs. Methods: Data were collected from a prospectively held database on 86 consecutive patients undergoing emergency ventral hernia repairs between January 2016 and January 2019 at Logan Hospital. Patient, hernia and operative characteristics were collected for reporting and analysis. Results: Of the 86 patients, 29 (34%) developed a surgical complication, of which 17 patients (59%) had surgical site infections. We identified obesity (P = 0.017), history of smoking (P = 0.008), American Society of Anesthesiologists class of III–IV (P = 0.008), hernia defect size ≥3 cm (P = 0.048) and concomitant small bowel resection (P = 0.028) to be associated with post-operative surgical complication. Multivariate analysis identified smoking (P = 0.005) and concomitant small bowel resection (P = 0.026) as independent predictors for developing surgical complications. Seven patients (8%) recurred at a median of 221 days. Incisional hernias (P = 0.001), recurrent hernias (P < 0.001), greater than one defect (P < 0.001) and bowel involvement (P = 0.049) were associated with higher rates of hernia recurrence. Conclusion: Patient factors significantly influence outcomes in the emergency setting. Given that this is not modifiable at the time of surgery, greater emphasis needs to be placed on optimizing the physical and behavioural factors of patients with early symptomatic hernias for an elective repair