Synchronous presentation of acute acalculous cholecystitis and appendicitis: a case report

<p>Abstract</p> <p>Introduction</p> <p>Acute acalculous cholecystitis is traditionally associated with elderly or critically ill patients.</p> <p>Case presentation</p> <p>We present the case of an otherwise healthy 23-year-old Caucasian man who presented with acute right-sided abdominal pain. An ultrasound examination revealed evidence of acute acalculous cholecystitis. A laparoscopy was undertaken and the dual pathologies of acute acalculous cholecystitis and acute appendicitis were discovered and a laparoscopic cholecystectomy and appendectomy were performed.</p> <p>Conclusion</p> <p>Acute acalculous cholecystitis is a rare clinical entity in young, healthy patients and this report describes the unusual association of acute acalculous cholecystitis and appendicitis. A single stage combined laparoscopic appendectomy and cholecystectomy is an effective treatment modality.</p

Mesenteric manifestations in Crohn’s disease

Background Mesenteric manifestations are of pathobiologic relevance in Crohn’s disease. Clarification of mesenteric morphology provides an opportunity to re-appraise their pathogenic significance. Therefore, we examined the relationship between mesenteric, mucosal and systemic manifestations in Crohn’s disease. Methods A multi-institutional study was conducted in which mesenteric disease was quantified (mesenteric disease score) in patients undergoing resection (n=34) for CD. The mesenteric disease score was correlated with a mucosal disease score, and Crohn’s Disease Activity Index (CDAI). The relationship between mesenteric manifestations and surgical recurrence was retrospectively determined in a second cohort (n=94). Local mesenteric and systemic fibrocyte levels were determined using a combination of histology, immunohistochemistry and flow cytometry. Mesenteric and mucosal gene expressions were compared in Crohn’s disease patients, in silico using Chipster©, an R based bio-informatic software. Results Mesenteric disease scores correlated with mucosal disease scores (r=0.8, p<0.0001) and CDAI (r=0.7, p<0.0001) and were significantly increased in smokers (p<0.04). Mesenteric disease manifestations independently predicted increased risk of surgical recurrence (HR 4.7, 95% CI: 1.71-13.01, p=0.003) and reduced time to recurrence (p<0.001). Mesenchymal abnormalities included fibrocytosis and adipocyte hyperplasia and were contiguous between mesentery and adjacent intestine. The fibrocyte proportion of circulating monocytes was increased in Crohn’s disease compared with healthy controls (6.4 ± 2.82% vs. 2.0 ± 1.04%, p<0.001). Levels normalized following ileocolic resection (5.7 ± 2.12% vs. 1.7 ± 1.20%, p=0.005), in patients with ileocolic disease. Fibrocyte percentages correlated with mesenteric and mucosal disease scores as well as with the CDAI (r=0.94, p<0.0001). Mesenteric, but not mucosal, gene expression profiles were associated with connective tissue, immunologic and inflammatory disorders. Conclusions Mesenteric manifestations are an important part of the pathogenesis of Crohn’s disease; they are associated with smoking and disease severity, and have predictive value for surgical recurrence. Therefore, they should be formally scored and recorded at the time of surgery

Grading operative findings at laparoscopic cholecystectomy- a new scoring system

Introduction: Variation in outcomes from surgery is a major challenge and defining surgical findings may help set benchmarks, which currently do not exist in laparoscopic cholecystectomy. This study outlines a new surgical scoring system incorporating key operative findings. Methods: English language studies (from January 1965 to July 2014) pertaining to severity scoring and predictors of difficult laparoscopic cholecystectomy were searched for in PubMed, Embase and Cochrane databases using the search terms \u27Laparoscopic cholecystectomy or Lap chole\u27 and/or \u27Scoring Index or Grading system or Prediction of difficulty or Conversion to open\u27 in various combinations. Cross-referencing from papers retrieved in the original search identified additional articles. Results: Sixteen published papers report a gallbladder (GB) scoring system, but all relate to pre-operative clinical and imaging findings, rather than operative findings. The current scoring system, using operative findings incorporates the appearance of the GB, presence of GB distension, ease of access, potential biliary complications and time taken to identify cystic duct and artery. A score of &amp;lt;2 would imply mild difficulty, 2-4 moderate, 5-7 severe and 8-10 extreme. Conclusion: This paper reports one of the first operative classifications of findings at laparoscopic cholecystectomy. It has the potential to allow benchmarks for international collaboration of operative and patient outcomes in patients undergoing laparoscopic cholecystectomy

Botulinum toxin injection versus topical nitrates for chronic anal fissure- an updated systematic review and meta-analysis of randomised controlled trials

AimChronic anal fissures (CAFs) are frequently encountered in coloproctology clinics. Chemical sphincterotomy with pharmacological agents is recommended as first-line therapy. Topical nitrates (TN) heal CAF effectively but recurrences are common. An alternative treatment modality is injection of botulinum toxin (BT) into the anal sphincter. We aimed to perform an updated systematic review and meta-analysis to compare the effectiveness of BT and TN in the management of CAF. MethodPubMed, EMBASE and Cochrane databases were searched for relevant articles from inception until March 2017. All randomized controlled trials (RCTs) that reported direct comparisons of BT and TN were included. Two independent reviewers performed methodological assessment and data extraction. Random effects models were used to calculate pooled effect size estimates. ResultsSix RCTs describing 393 patients (194 BT, 199 TN) were included. There was significant heterogeneity among the trials. On random effects analysis there were no significant differences in incomplete fissure healing (OR=0.47, 95% CI 0.13-1.68, P=0.24) or recurrence (OR=0.70, 95% CI 0.39-1.25, P=0.22) between BT and TN, respectively. BT was associated with a higher rate of transient anal incontinence (OR=2.53, 95% CI 0.98-6.57, P=0.06) but significantly fewer total side effects (OR=0.12, 95% CI 0.02-0.63, P=0.01) and headache (OR=0.10, 95% CI 0.02-0.60, P=0.01) compared with TN. ConclusionBT is associated with fewer side effects than TN but there is no difference in fissure healing or recurrence. Patients need to be warned regarding the risk of transient anal incontinence associated with BT

Grading operative findings at laparoscopic cholecystectomy- a new scoring system

Introduction: Variation in outcomes from surgery is a major challenge and defining surgical findings may help set benchmarks, which currently do not exist in laparoscopic cholecystectomy. This study outlines a new surgical scoring system incorporating key operative findings. Methods: English language studies (from January 1965 to July 2014) pertaining to severity scoring and predictors of difficult laparoscopic cholecystectomy were searched for in PubMed, Embase and Cochrane databases using the search terms 'Laparoscopic cholecystectomy or Lap chole' and/or 'Scoring Index or Grading system or Prediction of difficulty or Conversion to open' in various combinations. Cross-referencing from papers retrieved in the original search identified additional articles. Results: Sixteen published papers report a gallbladder (GB) scoring system, but all relate to pre-operative clinical and imaging findings, rather than operative findings. The current scoring system, using operative findings incorporates the appearance of the GB, presence of GB distension, ease of access, potential biliary complications and time taken to identify cystic duct and artery. A score of &amp;lt;2 would imply mild difficulty, 2-4 moderate, 5-7 severe and 8-10 extreme. Conclusion: This paper reports one of the first operative classifications of findings at laparoscopic cholecystectomy. It has the potential to allow benchmarks for international collaboration of operative and patient outcomes in patients undergoing laparoscopic cholecystectomy

Should patients with infrainguinal arterial bypasses using autologous vein conduit undergo follow-up surveillance with duplex ultrasound?

This best evidence topic was investigated according to a structured format. The question asked was: should duplex ultrasound (DUS) scanning be a routine component of surveillance following infrainguinal arterial bypass using vein conduit? We performed a systematic literature search and identified 4 studies (3 randomised controlled trials and 1 meta-analysis) that provided the best evidence.The highest quality study was a multi-centre randomised controlled trial (n = 594). At 18 months following surgery, it found no difference in patency rates, amputations, vascular mortality or mortality. However it achieved just over half of anticipated recruitment and thus was underpowered. The remaining two randomised controlled trials had smaller sample sizes and methodological weaknesses and found conflicting results. Lundell et al. (n = 106) found improved primary assisted and secondary patency rates and fewer graft occlusions with a routine DUS policy. Ihlberg et al. (n = 152) found no difference in primary assisted patency or amputations although secondary patency was improved. A meta-analysis of mostly observational data (n = 6649) found fewer occlusions with routine DUS surveillance and no effect on amputations or mortality.Results are conflicting. The strongest evidence comes from the single high quality multi-centre trial. It appears as though routine DUS surveillance does not yield benefits in patient important outcomes. Further studies are needed. (C) 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.PUBLISHEDpeer-reviewe

Should patients with infrainguinal arterial bypasses using autologous vein conduit undergo follow-up surveillance with duplex ultrasound?

This best evidence topic was investigated according to a structured format. The question asked was: should duplex ultrasound (DUS) scanning be a routine component of surveillance following infrainguinal arterial bypass using vein conduit? We performed a systematic literature search and identified 4 studies (3 randomised controlled trials and 1 meta-analysis) that provided the best evidence.The highest quality study was a multi-centre randomised controlled trial (n = 594). At 18 months following surgery, it found no difference in patency rates, amputations, vascular mortality or mortality. However it achieved just over half of anticipated recruitment and thus was underpowered. The remaining two randomised controlled trials had smaller sample sizes and methodological weaknesses and found conflicting results. Lundell et al. (n = 106) found improved primary assisted and secondary patency rates and fewer graft occlusions with a routine DUS policy. Ihlberg et al. (n = 152) found no difference in primary assisted patency or amputations although secondary patency was improved. A meta-analysis of mostly observational data (n = 6649) found fewer occlusions with routine DUS surveillance and no effect on amputations or mortality.Results are conflicting. The strongest evidence comes from the single high quality multi-centre trial. It appears as though routine DUS surveillance does not yield benefits in patient important outcomes. Further studies are needed. (C) 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved