Spontaneous cecal perforation secondary to acute fulminant gastroenteritis: report of a rare case

Acute gastroenteritis and food poisoning are the two common diagnoses considered when two or more family members present with vomiting, diarrhea, and abdominal pain. Acute fulminant gastroenteritis is usually seen in immunocompromised patients and is associated with significant morbidity and mortality. We report a 15-year-old boy who presented with acute onset abdominal pain, vomiting, and diarrhea, along with three other family members. He developed abdominal distension and signs of hollow viscus perforation after 3 days; by that time he had developed  respiratory distress requiring ventilatory assistance. During laparotomy, a 1-cm cecal perforation with feculent peritoneal contamination was noted. Limited ileocolic resection and ileostomy was performed and ileostomy closure was carried out at 6 weeks. This case is being reported to highlight the unusual presentation of fulminant gastroenteritis, leading to spontaneous cecal perforation.Keywords: acute gastroenteritis, fulminant gastroenteritis, spontaneous cecal perforatio

Prognostic model to predict postoperative acute kidney injury in patients undergoing major gastrointestinal surgery based on a national prospective observational cohort study.

Background: Acute illness, existing co-morbidities and surgical stress response can all contribute to postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery. The aim of this study was prospectively to develop a pragmatic prognostic model to stratify patients according to risk of developing AKI after major gastrointestinal surgery. Methods: This prospective multicentre cohort study included consecutive adults undergoing elective or emergency gastrointestinal resection, liver resection or stoma reversal in 2-week blocks over a continuous 3-month period. The primary outcome was the rate of AKI within 7 days of surgery. Bootstrap stability was used to select clinically plausible risk factors into the model. Internal model validation was carried out by bootstrap validation. Results: A total of 4544 patients were included across 173 centres in the UK and Ireland. The overall rate of AKI was 14·2 per cent (646 of 4544) and the 30-day mortality rate was 1·8 per cent (84 of 4544). Stage 1 AKI was significantly associated with 30-day mortality (unadjusted odds ratio 7·61, 95 per cent c.i. 4·49 to 12·90; P < 0·001), with increasing odds of death with each AKI stage. Six variables were selected for inclusion in the prognostic model: age, sex, ASA grade, preoperative estimated glomerular filtration rate, planned open surgery and preoperative use of either an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker. Internal validation demonstrated good model discrimination (c-statistic 0·65). Discussion: Following major gastrointestinal surgery, AKI occurred in one in seven patients. This preoperative prognostic model identified patients at high risk of postoperative AKI. Validation in an independent data set is required to ensure generalizability

Chlorhexidine versus povidone–iodine skin antisepsis before upper limb surgery (CIPHUR) : an international multicentre prospective cohort study

Introduction Surgical site infection (SSI) is the most common and costly complication of surgery. International guidelines recommend topical alcoholic chlorhexidine (CHX) before surgery. However, upper limb surgeons continue to use other antiseptics, citing a lack of applicable evidence, and concerns related to open wounds and tourniquets. This study aimed to evaluate the safety and effectiveness of different topical antiseptics before upper limb surgery. Methods This international multicentre prospective cohort study recruited consecutive adults and children who underwent surgery distal to the shoulder joint. The intervention was use of CHX or povidone–iodine (PVI) antiseptics in either aqueous or alcoholic form. The primary outcome was SSI within 90 days. Mixed-effects time-to-event models were used to estimate the risk (hazard ratio (HR)) of SSI for patients undergoing elective and emergency upper limb surgery. Results A total of 2454 patients were included. The overall risk of SSI was 3.5 per cent. For elective upper limb surgery (1018 patients), alcoholic CHX appeared to be the most effective antiseptic, reducing the risk of SSI by 70 per cent (adjusted HR 0.30, 95 per cent c.i. 0.11 to 0.84), when compared with aqueous PVI. Concerning emergency upper limb surgery (1436 patients), aqueous PVI appeared to be the least effective antiseptic for preventing SSI; however, there was uncertainty in the estimates. No adverse events were reported. Conclusion The findings align with the global evidence base and international guidance, suggesting that alcoholic CHX should be used for skin antisepsis before clean (elective upper limb) surgery. For emergency (contaminated or dirty) upper limb surgery, the findings of this study were unclear and contradict the available evidence, concluding that further research is necessary

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

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

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

Next-generation Virtual and Augmented Reality in surgical education: a narrative review

Background: Virtual and Augmented Reality (VR/AR) has been used in surgery for several decades. Over the past 5-10 years, however, new technological advances, including high-resolution screens, mobile graphical processing units (mGPUs) and position-sensing technologies, have been incorporated into relatively low-cost VR and AR devices. This review focuses on the current impact of the application of these “Phase 2” VR/AR technology in surgical training.Methods: A narrative literature review was undertaken using PubMed and Web of Science to identify comparative studies related to the impact of Phase 2 VR or AR tools on surgical training, defined in terms of the acquisition of technical surgical skills. Eleven studies on the effectiveness of VR/AR in surgical education were identified for full review. Further, the grey literature was searched for articles describing the current state of VR/AR in surgical education. A quality analysis using the Newcastle Ottawa scale showed a median score of 7 (out of a maximum achievable score of 9).Results: All studies showed a positive association between the use of VR/AR in surgical training and skill acquisition in terms of improving the speed of acquisition of surgical skills, the surgeon’s ability to multitask, the ability to perform a procedure accurately, hand-eye coordination and bimanual operation. The grey literature presented a common, positive theme of the benefits of VR/AR in surgical training.Conclusions: Based on the limited evidence available, VR/AR appears to have positive training benefits in improving the speed of acquisition of surgical skills. However, the significant heterogeneity in study methodology and the relative recency of wider VR/AR adoption in surgical training mean that only tentative conclusions can be drawn at this stage. Further research, ideally with large sample sizes, robust outcome measures and longer follow-up periods, is recommended. </br

Next-generation Virtual and Augmented Reality in surgical education: a narrative review

Background: Virtual and Augmented Reality (VR/AR) has been used in surgery for several decades. Over the past 5-10 years, however, new technological advances, including high-resolution screens, mobile graphical processing units (mGPUs) and position-sensing technologies, have been incorporated into relatively low-cost VR and AR devices. This review focuses on the current impact of the application of these “Phase 2” VR/AR technology in surgical training.Methods: A narrative literature review was undertaken using PubMed and Web of Science to identify comparative studies related to the impact of Phase 2 VR or AR tools on surgical training, defined in terms of the acquisition of technical surgical skills. Eleven studies on the effectiveness of VR/AR in surgical education were identified for full review. Further, the grey literature was searched for articles describing the current state of VR/AR in surgical education. A quality analysis using the Newcastle Ottawa scale showed a median score of 7 (out of a maximum achievable score of 9).Results: All studies showed a positive association between the use of VR/AR in surgical training and skill acquisition in terms of improving the speed of acquisition of surgical skills, the surgeon’s ability to multitask, the ability to perform a procedure accurately, hand-eye coordination and bimanual operation. The grey literature presented a common, positive theme of the benefits of VR/AR in surgical training.Conclusions: Based on the limited evidence available, VR/AR appears to have positive training benefits in improving the speed of acquisition of surgical skills. However, the significant heterogeneity in study methodology and the relative recency of wider VR/AR adoption in surgical training mean that only tentative conclusions can be drawn at this stage. Further research, ideally with large sample sizes, robust outcome measures and longer follow-up periods, is recommended

The role of clubfoot training programmes in low- and middle-income countries: a systematic review

While adoption of the Ponseti method has continued gradually, its use to manage patients with congenital talipes equinovarus (CTEV) has been limited in low- and middle-income countries (LMICs) for a number of reasons including a lack of clinical training on technique and lack of appropriate clinical equipment. There are a frequent number of emerging studies that report on the role of clubfoot training programmes; however, little is known in regard to cumulative benefits. A systematic review was undertaken through Medline, the Cochrane Library and Web of Science for studies analysing clubfoot training programmes. There were no limitations on time, up until the review was commenced on January 2020. The systematic review was registered with PROSPERO as 165657. Ten articles complied with the inclusion criteria and were deemed fit for analysis. Training programmes lasted an average of 2–3 days. There was a reported increase in knowledge of applying the Ponseti method in managing clubfoot by participants (four studies P < 0.05). Skill retention was examined by multiple choice (MCQ) examination style questions before and after the training programme in two studies; both showed an improvement (MCQ answers improved from 59% to 73%). All studies showed an improvement in participants' self-reported understanding of the Ponseti method and confidence in its use in future practice (P < 0.05). There were improved benefits of knowledge and clinical application of the Ponseti method by participants in the programmes in all studies examined. However, there was a significant lack of follow-up and exploration of long-term effects of these programmes. Implementing training programmes based on perceived benefits rather than actual long-term benefits may have a negative impact on healthcare delivery and patient management in LMICs.</p

Effect of non-uniform pore pressure fields on hydraulic fracture propagation

In elastic materials, it is evident that the path of a propagating fracture is deflected from its normal course in presence of imperfections of the material or loading conditions. This paper aims at investigating hydraulic fracture deviation induced by non-uniformity of pore pressure fields with the use of a fully coupled poroelastic model based on the finite element method. The model includes a poroelastic domain in which pressurized hydraulic fractures are explicitly embedded, thus allowing to realistically model the fluid flow inside the fracture and to intrinsically consider the fracturing fluid load on the fracture walls as well as fluid leak-off into the formation. The latter process (fluid leak-off into the formation) controls both the length and the orientation of the fracture by changing the local pore pressure which in turn leads to a change in magnitude and direction of local principal stresses around the fracture tip. An innovative method, Mean Rotation Angle (MRA) is utilised for post-processing of evolving stress data at the vicinity of the fracture tip. The MRA predicts the potential growth path of pressurized fractures. In this paper pore pressure induced fracture reorientation is studied for a single fracture as well as closely spaced fractures. Results of this study indicate that presence of a pore pressure anomaly changes the growth path of a hydraulic fracture, towards or away from the anomaly. A higher than average pore pressure zone attracts the fracture while a lower pressure anomaly zone repulses the growing fracture. The fracture growth direction depends on the differential pressure and the distance between the anomaly and the fracture tip. Also in case of two simultaneously growing transverse fractures pressurized by injected fluid, it has been observed that the fluid leak-off controls the potential deviation angle of the fractures through changing the local pore pressure distribution pattern. It is shown that there are three distinct trends for the change of potential deviation angle due to fluid leak-off and that these three trends are linked to three corresponding stages of hydraulic communication between the two fractures. Furthermore, this study shows that change in matrix permeability, stress anisotropy, fracture half-length, spacing and the rate of leak-off influence the timing of each of the stages to the extent to which the corresponding stage of hydraulic communication of the two fractures are affected. This new understanding gives a better insight into the mechanism by which closely spaced hydraulic fractures interact and help optimize the design of multi-stage hydraulic fracture treatments