Vitamin C deficiency in an Australian cohort of metropolitan surgical patients

Vitamin C is an essential micronutrient in the human diet. While large population studies measuring vitamin C have been performed in other countries, there are few studies of deficiency in the Australian population. This study aimed to quantify vitamin C deficiency, identify scorbutic symptoms and examine dietary associations in a cohort of preoperative general surgical patients. Vitamin C levels were determined in a cohort of patients referred to a single surgeon between January 2011 and December 2013. Baseline data were collected along with data on fruit consumption, weekly citrus fruit intake and presence of scorbutic symptoms. A total of 309 patients were included in the study and 21.4% of our cohort showed a vitamin C level ≤11.4 μmol/L (deficient). Mean citrus fruit intake was significantly higher in the normal vitamin C groups (>28.4 μmol/L) and patients with vitamin C levels ≤28.4 were more likely to consume no fruit (p=0.0004) which was also significant on multivariate analysis. Neither age nor gender appeared predictive of suboptimal vitamin C levels. No symptoms were significantly related to vitamin C levels on multivariate analysis. Vitamin C deficiency was common in Australian adults attending a surgical practice within south western Sydney. Review of the Australian recommended daily allowance for vitamin C is suggested, not only in clinically well patients but particularly in ICU and hospital inpatients. Larger studies examining the prevalence and impact of vitamin C deficiency in the Australian population are required to further investigate these findings

Pancreatitis from intra-gastric balloon insertion : case report and literature review

INTRODUCTION: Intra-Gastric Balloon (IGB) is increasingly used as a non-operative management strategy in bariatric patients. However, as IGB use has become more prevalent, new potentially life-threatening adverse effects have emerged. We report a case of IGB-related acute pancreatitis from a tertiary referral hospital. A literature review of electronic databases was conducted to identify other cases. PRESENTATION OF CASE: A 20-year-old female presented to the emergency department with acute onset ofepigastric pain on day-1 post-insertion of an IGB (Orbera®). The diagnosis of acute pancreatitis was made on the basis of the clinical picture, with radiological and serological confirmation. Complete resolution of symptoms promptly followed endoscopic removal of the balloon.DISCUSSION: We examine all prior reported cases of IGB associated pancreatitis in the literature, as well as the impact of the particular balloon subtypes. Mass effect of the device on the pancreas or dislodgementof the rigid catheter into the second part of the duodenum appear to be the underlying cause in all cases.While there were no deaths reported, major sequelae have been noted, including presence of mucosalischemia and failure to retrieve the balloon endoscopically, necessitating laparotomy.CONCLUSION: Although the incidence of IGB-induced pancreatitis is still rare, this complication which must be highlighted as a potentially serious adverse outcome

C-reactive protein trajectory in the first 48 hours predicts the need for intervention in conservative management of acute diverticulitis

Background: C-reactive protein (CRP) is a useful marker for monitoring response to treatment in sepsis. The aim of this study was to examine the use of CRP trajectory in predicting the need for intervention in conservatively managed patients with acute diverticulitis (AD). Methods: A retrospective review of patients with AD who were managed conservatively was performed. They were divided into four groups based on CRP relative to the median at day 0 and 2: ‘Low rise’ (levels below median at day 0 and 2), ‘High rise’ (levels above median at day 0 and 2), ‘Rapid rise’ (levels below median at day 0 but above median at day 2) and ‘Decline’ (levels above median at day 0 but below median at day 2). Results: Intervention was required in 64 of 456 (14%) with 30 (48%) of these performed after day 2 of admission. There were 150 patients (54%) in the ‘Low rise’, 76 (27%) in the ‘Decline’, 26 patients (9%) in the ‘Rapid rise’ and 25 patients (9%) in the ‘High rise’ groups. Within these groups 5%, 8%, 19% and 32% of patients required intervention (P = 0.001). On multivariate analysis, patients with a pelvic abscess were more likely to need intervention (odds ratio 19.1 (confidence interval 6.2–59.4), P < 0.0001). Conclusion: The CRP trajectory during the initial 48 h of admission can predict the need for intervention in AD patients being managed conservatively. Patients with a ‘Rapid rise’ or ‘High rise’ in CRP from day 0 to 2 are more likely to need intervention

Clinical significance of appendiceal diverticulum : a significant marker for appendiceal neoplasia in Australian patients

Introduction: Diverticula of the appendix (DA) have a reported incidence of up to 2.1%. They are primarily detected incidentally, through imaging and intraoperative or histologic diagnosis. This study’s objective was to examine the prevalence of DA, and its relationship with inflammation and neoplasia, as well as review the literature with respect to clinical outcomes and ability to identify DA preoperatively. Methodology: A retrospective search of all patients undergoing an appendicectomy for right lower quadrant pain at a single institution between 2004 and 2017 was conducted. Histopathology reports for evidence of DA, location of the DA, presence of inflammation, and any relationship between DA and neoplasms (adenoma, carcinoma, carcinoid, lymphoma, and mucinous neoplasm) within the appendix were reviewed. Clinical notes, operative records, and preoperative imaging were also reviewed. Results: Two thousand seven hundred eleven patient were included in the study, with a mean age of 34 years, with acute appendicitis found in 82.5%. 31.6% of patients with DA had associated inflammation of the DA. DA was present in 57 patients (2.1%), with 55 patients in the total cohort having neoplasia (2.0%). Patients with DAs were ten times more likely to have appendicular neoplasm than patients without a DA (17.5 vs 1.8%; p < 0.0001, OR 11.8 95%, CI 5.6–24.8). Conclusion: This is the first Australian study demonstrating DAs are a significant marker of appendiceal neoplasm. Appendicectomy in all incidentally discovered diverticulum should be considered. Due to a paucity of data, research is required into this area to assess for the need for endoscopy following diagnosis

Systematic review and meta‐analysis of the association between diverticulosis of the appendix and neoplasia

Background Diverticula of the appendix (DA) are infrequent and their clinical implications are often overlooked. Several studies have found a significantly increased prevalence of neoplasms in appendiceal specimens with diverticula. Despite the potential clinical implications, there is a paucity of literature. A systematic review and meta‐analysis was performed to evaluate the prevalence of DA and its association with neoplasia. Methods A systematic search of literature (Cochrane, EMBASE, PubMed and Medline) reporting the prevalence of DA and association with neoplasia was performed in November 2019. Relevant articles were assessed in accordance with the PRISMA guidelines. Risk of bias assessment was carried out using modified Newcastle–Ottawa scale. Meta‐analysis with risk ratio and random‐effects model was performed using RevMan. Results The initial search identified 1122 potential articles of which 11 were appropriate for quantitative analysis. The prevalence rate of DA was 1.74%. The mean age of patients with DA and those without DA was 41.2 and 33.9 years, respectively. The ratio of male to female was 1.8:1. The prevalence of neoplasia in specimens without DA versus those with DA was 1.28% and 26.94%, respectively. Only four studies addressed the prevalence of locoregional neoplasia in the setting of DA compared to control. Meta‐analysis with random‐effects model demonstrated that pooled risk ratio was 25.46 (95% confidence interval 12.77–50.75, P < 0.00001). Conclusion The strong association with neoplasia in this meta‐analysis reinforces the clinical significance of DA. Surgeons, pathologists and radiologists should be mindful of this uncommon pathology and consider individualized patient management, until further evidence can direct clinical guidelines for the management of patients with DA

Minimally invasive Venetian blinds ventral hernia repair with botulinum toxin chemical component separation

Background: Laparoscopic ventral repair is safe, with lower wound infection rates compared with open repair. ‘Venetian blinds’ technique of plication in combination with mesh reinforcement, is totally intra‐corporeal, with hernia defect and sac plication to reduce seroma formation. While laparoscopic suturing of the abdominal wall can represent a technical challenge, pre‐operative botulinum toxin A (BTA) injections as an adjunct can assist. This study aims to demonstrate feasibility and efficacy of this technique in abdominal wall hernia repair, with BTA adjunct in midline hernias. Methods: A single‐centre case series was conducted using minimally invasive ‘Venetian blinds’ technique for repair of complex ventral abdominal hernias. Twelve patients (seven midline, five non‐midline) underwent repair (11 laparoscopic; one robotic). Midline hernias received BTA (200–300 units Botox) 4–6 weeks prior to surgery. Repairs were mesh‐reinforced following fascial closure. Results: Twelve (10 female, two male) patients, with a median age 72 years (range 31–83) and body mass index of 27.3 kg/m2 (range 22.8–61.7) were included. The median length of operation was 133 min (range 45–290) and length of hospital stay 3 days (range 1–28). To date there has been no recurrence of hernia. A single symptomatic seroma was treated with antibiotics and did not require mesh removal. One patient developed hospital‐acquired pneumonia and pseudomembranous colitis. Conclusion: Minimally invasive ‘Venetian blinds’ technique has promising early results with both midline and non‐midline ventral hernias. The addition of BTA is a novel and feasible combination for repair of midline ventral hernias