Randomised clinical trials comparing antibiotic therapy with appendicectomy for uncomplicated acute appendicitis: meta-analysis

BackgroundThis aim of this study was to provide an updated meta-analysis comparing antibiotic therapy with appendicectomy in adults (16 years or older) with uncomplicated acute appendicitis.MethodsA search for randomized clinical trials comparing antibiotic therapy with appendicectomy in adults with uncomplicated acute appendicitis from inception to 3 October 2021 in MEDLINE, Embase and CENTRAL with no language constraints was performed. Studies were excluded if they included paediatric participants or those with complicated appendicitis. Data on complications of treatment, treatment efficacy (defined in the antibiotic group as not undergoing appendicectomy within 1 year of enrolment, versus surgery without complications or no negative histology in the appendicectomy group), readmissions, and length of stay (LOS) were presented.ResultsEight RCTs involving 3203 participants (1613 antibiotics/1590 appendicectomy; 2041 males/1162 females) were included. There was no significant benefit of antibiotic treatment on complication rates (risk ratio (RR) 0.66, 95 per cent c.i. 0.41 to 1.04). Antibiotics had a reduced treatment efficacy compared with appendicectomy (RR 0.75, 95 per cent c.i. 0.63 to 0.89). Antibiotic treatment at 1 year was successful in 1016 of 1613 (62.9 per cent) participants. There was a six-fold increase in hospital readmissions within 1 year of enrolment in participants receiving antibiotic treatment (RR 6.28, 95 per cent c.i. 2.87 to 13.74). There was no difference in index admission LOS (mean difference 0.15 days (95 per cent c.i. −0.05 to 0.35)).ConclusionsEarlier optimism regarding the benefits of antibiotic therapy for uncomplicated acute appendicitis does not persist at the same level now that further, large trials have been included. If antibiotic treatment is to be offered routinely as first-line therapy, patients should be counselled appropriately

Three Centuries of Appendicectomy

BackgroundSave for the contribution of Charles McBurney, who described his eponymous point and the appendicectomy incision, the history of appendicectomy is largely unknown among the medical profession. This review traces the history from the first anatomical depiction of the appendix to the development of open appendicectomy and the recent minimally invasive and non-operative methods.MethodsHistorical articles, monographs and books containing anatomical descriptions of the vermiform appendix and reports of appendicitis and its surgical treatment were retrieved after searching the PubMed, Google Scholar and Embase databases from their inception to 31 March 2022.ResultsThe first inadvertent appendicectomy was performed during an operation for a groin hernia by Cookesley in 1731, and Mestivier was the first to drain a right iliac fossa abscess, due to appendicitis, in 1757. Krönlein performed the first appendicectomy for acute appendicitis in 1884 but his patient died. The first successful appendicectomy for acute appendicitis leading to patient survival was by Morton in 1887. In 1976, Wirschafter and Kaufman performed an inadvertent colonoscopic appendicectomy and, in 1980, Semm carried out the first laparoscopic appendicectomy. The first appendicectomy via a natural orifice (transgastric) appendicectomy was by Rao and Reddy in 2004.ConclusionThis historical review charts the development of surgical knowledge concerning the management of appendicitis, from the first anatomical drawings of the appendix and descriptions of appendicitis to the development of surgical and conservative treatments up to the present day. It also corrects some inaccuracies of attribution in previous historical reviews

Surgical interventions for the treatment of sacrococcygeal pilonidal sinus disease in children: a systematic review and meta-analysis

BackgroundPilonidal sinus disease (PNS) is not uncommon in children. Controversy remains over the best treatment and there is limited evidence. This systematic review and meta-analysis aims to establish which techniques have the best outcomes in children.MethodsMEDLINE, EMBASE and CENTRAL databases were searched. Studies reporting treatment outcomes for PNS in children were included.ResultsOpen healing has pooled risk of recurrence of 26% (95%CI 15–38%), risk of wound complication of 21% (9–36%) and wound healing ranged from 38–92 days. Midline primary closure has pooled risk of recurrence of 12% (8–18%), risk of wound complication of 30% (19–46%) and wound healing ranged from 8 to 32 days. Off-midline primary closure has pooled risk of recurrence of 6% (1–15%), risk of wound complication of 14% (6–25%) and wound healing was 27 days. VAC therapy has pooled risk of recurrence of 20% (0–65%) and wound healing ranged from 38 to 92 days. Minimally invasive techniques has pooled risk of recurrence of 7% (1–16%) and wound healing ranged from 21-30 days. Marsupialisation has pooled risk of recurrence of 6% (0–22%), and wound healing ranged from 6 to 41 days.ConclusionEvidence for management of PNS in children is poor. Off-midline primary closure, minimally invasive techniques, and marsupialisation have the best outcomes

NICE guidance on sepsis is of limited value in postoperative colorectal patients: the scores that cry ‘wolf!’

Background and aimsLate recognition of sepsis and consequent death remains a problem. To address this, the National Institute for Health and Care Excellence has published updated guidance recommending the use of the Quick Sequential Organ Failure Assessment (Q-SOFA) score when assessing patients at risk of sepsis following the publication of the Third International Consensus Definitions for Sepsis and Septic Shock. The trauma from major surgery produces a systemic inflammatory response syndrome (SIRS) postoperatively as part of its natural history, which may falsely trigger scoring systems. We aimed to assess the accuracy of Q-SOFA and SIRS criteria as recommended scores for early detection of sepsis and septic complications in the first 48hrs after colorectal cancer surgery.MethodsWe reviewed all elective major colorectal operations in a single centre during a 12-month period from prospectively maintained electronic records.ResultsOne hundred and thirty nine patients were included in this study. In all, 29 patients developed postoperative infective complications in hospital. Nineteen patients triggered on SIRS without developing infective complications, while 42 patients triggered on Q-SOFA with no infective complications. The area under the ROC curve was 0.52 for Q-SOFA and 0.67 for SIRS.DiscussionQ-SOFA appears to perform little better than a coin toss at identifying postoperative sepsis after colorectal cancer resection and is inferior to the SIRS criteria. More work is required to assess whether a combination of scoring criteria, biochemical markers and automated tools could increase accurate detection of postoperative infection and trigger early intervention

Fibrin glue is a quick and effective treatment for primary and recurrent pilonidal sinus disease

BackgroundPilonidal sinus disease (PSD) is a common, chronic inflammatory condition involving hair follicles within the natal cleft. It mainly affects young males and creates a significant health, social and economic burden. Traditional surgery is often radical resulting in pain, wound complications, long recovery times and poor cosmesis. The aim of our study was to evaluate fibrin glue as a primary treatment for PSD.MethodsFibrin glue procedures for a single surgeon at our institution were identified from operative coding databases and the logbook from January 2011 to January 2016. Patients had curettage of the sinus with fibrin glue obliteration. Recurrence data was collected retrospectively.ResultsOne hundred and forty-six patients were identified; (115 (79%) males, mean age 30 (range 16–78 years). One hundred and forty-four (99%) were discharged the same day. Four (2.7%) were treated conservatively for wound discharge. Median operating time was 9 (range 4–28) min. There were 40 (27%) recurrences after one glue application. Median time to recurrence was 4 (range 0.25–36) months. Twenty-four (60%) of the recurrences had repeat glue treatment with 4 (16.6%) recurrences. After 2 rounds of treatment with glue alone, 126 out of 130 (96.9%) patients had healed.ConclusionsFibrin glue application following curettage of the sinus is a quick and effective procedure for first and second line treatment of PSD

Exponentiation of the Drell-Yan cross section near partonic threshold in the DIS and MSbar schemes

It has been observed that in the DIS scheme the refactorization of the Drell-Yan cross section leading to exponentiation of threshold logarithms can also be used to organize a class of constant terms, most of which arise from the ratio of the timelike Sudakov form factor to its spacelike counterpart. We extend this exponentiation to include all constant terms, and demonstrate how a similar organization may be achieved in the MSbar scheme. We study the relevance of these exponentiations in a two-loop analysis.Comment: 20 pages, JHEP style, no figure

Six weeks high-intensity interval training enhances contractile-activity induced vascular reactivity and skeletal muscle perfusion in older adults

Background:Impairments in muscle microvascular function are associated with the pathogenesis of sarcopenia and cardiovascular disease. High-intensity interval training (HIIT) is an intervention by which a myriad of beneficial skeletal muscle/ cardiovascular adaptations have been reported across age, including capillarisation and improved endothelial function. Herein, we hypothesised HIIT would enhance muscle microvascular blood flow and vascular reactivity to acute contractile activity in older adults, reflecting HIIT-induced vascular remodelling.Methods:In a randomised controlled-trial, twenty-five healthy older adults aged 65-85 y (mean BMI 27.0) were randomised to 6 weeks HIIT or a no-intervention control period of an equal duration. Measures of microvascular responses to a single bout of muscle contractions (i.e. knee extensions) were made in the m. vastus lateralis using contrast-enhanced ultrasound during a continuous intravenous infusion of Sonovue™ contrast agent, before and after the intervention period, with concomitant assessments of cardiorespiratory fitness and resting blood pressure. Results: HIIT led to improvements in anaerobic threshold (13.2±3.4 vs. 15.3±3.8 ml/kg/min,

Long-term outcomes of biological mesh repair following extra levator abdominoperineal excision of the rectum: an observational study of 100 patients

BackgroundCurrent evidence suggests that pelvic floor reconstruction following extralevator abdominoperineal excision of rectum (ELAPER) may reduce the risk of perineal herniation of intra-abdominal contents. Options for reconstruction include mesh and myocutaneous flaps, for which long-term follow-up data is lacking. The aim of this study was to evaluate the long-term outcomes of biological mesh (Surgisis®, Biodesign™) reconstruction following ELAPER.MethodsA retrospective review of all patients having ELAPER in a single institution between 2008 and 2018 was perfomed. Clinic letters were scrutinised for wound complications and all available cross sectional imaging was reviewed to identify evidence of perineal herniation (defined as presence of intra-abdominal content below a line between the coccyx and the lower margin of the pubic symphysis on sagittal view).ResultsOne hundred patients were identified (median age 66, IQR 59–72 years, 70% male). Median length of follow-up was 4.9 years (IQR 2.3–6.7 years). One, 2- and 5-year mortality rates were 3, 8 and 12%, respectively. Thirty three perineal wounds had not healed by 1 month, but no mesh was infected and no mesh needed to be removed. Only one patient developed a symptomatic perineal hernia requiring repair. On review of imaging a further 7 asymptomatic perineal hernias were detected. At 4 years the cumulative radiologically detected perineal hernia rate was 8%.ConclusionsThis study demonstrates that pelvic floor reconstruction using biological mesh following ELAPER is both safe and effective as a long-term solution, with low major complication rates. Symptomatic perineal herniation is rare following mesh reconstruction, but may develop sub clinically and be detectable on cross-sectional imaging

Association between surgeon special interest and mortality after emergency laparotomy

© 2019 BJS Society Ltd Published by John Wiley & Sons Ltd Background: Approximately 30 000 emergency laparotomies are performed each year in England and Wales. Patients with pathology of the gastrointestinal tract requiring emergency laparotomy are managed by general surgeons with an elective special interest focused on either the upper or lower gastrointestinal tract. This study investigated the impact of special interest on mortality after emergency laparotomy. Methods: Adult patients having emergency laparotomy with either colorectal or gastroduodenal pathology were identified from the National Emergency Laparotomy Audit database and grouped according to operative procedure. Outcomes included all-cause 30-day mortality, length of hospital stay and return to theatre. Logistic and Poisson regression were used to analyse the association between consultant special interest and the three outcomes. Results: A total of 33 819 patients (28 546 colorectal, 5273 upper gastrointestinal (UGI)) were included. Patients who had colorectal procedures performed by a consultant without a special interest in colorectal surgery had an increased adjusted 30-day mortality risk (odds ratio (OR) 1·23, 95 per cent c.i. 1·13 to 1·33). Return to theatre also increased in this group (OR 1·13, 1·05 to 1·20). UGI procedures performed by non-UGI special interest surgeons carried an increased adjusted risk of 30-day mortality (OR 1·24, 1·02 to 1·53). The risk of return to theatre was not increased (OR 0·89, 0·70 to 1·12). Conclusion: Emergency laparotomy performed by a surgeon whose special interest is not in the area of the pathology carries an increased risk of death at 30 days. This finding potentially has significant implications for emergency service configuration, training and workforce provision, and should stimulate discussion among all stakeholders

Fasting and surgery timing (FaST) audit

Background & aimsInternational guidance advocates the avoidance of prolonged preoperative fasting due to its negative impact on perioperative hydration. This study aimed to assess the adherence to these guidelines for fasting in patients undergoing elective and emergency surgery in the East Midlands region of the UK.MethodsThis prospective audit was performed over a two-month period at five National Health Service (NHS) Trusts across the East Midlands region of the UK. Demographic data, admission and operative details, and length of preoperative fasting were collected on adult patients listed for emergency and elective surgery.ResultsOf the 343 surgical patients included within the study, 50% (n = 172) were male, 78% (n = 266) had elective surgery and 22% (n = 77) underwent emergency surgery. Overall median fasting times (Q1, Q3) were 16.1 (13.0, 19.4) hours for food and 5.8 (3.5, 10.7) hours for clear fluids. Prolonged fasting >12 h was documented in 73% (n = 250) for food, and 21% (n = 71) for clear fluids. Median fasting times from clear fluids and food were longer in the those undergoing emergency surgery when compared with those undergoing elective surgery: 13.0 (6.4, 22.6) vs. 4.9 (3.3, 7.8) hours, and 22.0 (14.0, 37.4) vs. 15.6 (12.9, 17.8) hours respectively, p < 0.0001.ConclusionsDespite international consensus on the duration of preoperative fasting, patients continue to fast from clear fluids and food for prolonged lengths of time. Patients admitted for emergency surgery were more likely to fast for longer than those having elective surgery