Crohn’s disease

44-year-old female known case of Crohn’s disease and depression who presented with a few hours’ history of severe abdominal pain and multiple episodes of vomiting faeculant matter. An inflamed terminal ileum and ascending colon were found at laparatomy and resection of terminal ileum and caecum (right hemicolectomy) was carried out. Crohn’s is a chronic inflammatory bowel disorder of unknown aetiology which can affect the whole gastrointestinal system (from mouth to anus) and is typified by asymmetric, focal, transmural inflammation and sometimes granuloma formation in the bowel wall. Signs of extraintestinal manifestation can be marked. The life-long disease is punctuated by periods of exacerbation and remission15. Genetic and environmental contributors, as well as immunological factors are implicated in the pathogenesis and severity of Crohn’s disease.peer-reviewe

Surgical admissions to intensive therapy unit at Mater Dei Hospital : a prospective 3 month study

Introduction: Patient care in an acute hospital is divided into 4 levels, with level 0 being least demanding and level 3 comprising intensive care. A surgical high dependency unit (HDU) offers level 2 (intermediate) care and is indispensable when escalating or de-escalating from lower or higher levels of care respectively. Mater Dei Hospital lacks such a unit. -- Methods: Data was prospectively collected over a 3-month period and included all surgical patients admitted to the intensive therapy unit (ITU), including subspecialties. The duration and reasons for admission to hospital and ITU were documented. Hospital admissions were either planned or emergency. Reasons for ITU admission were either planned or unplanned after elective surgery, following emergency surgery, directly from the Emergency Department or following clinical deterioration in a level 0 ward. Number of organs supported, any surgical interventions during admission and the final outcome were noted. -- Results: There were 173 surgical patients admitted to ITU (116 males) with mean age 61.2 years. Most were post-surgery (71.7%, n=124) or after being stabilised at the Emergency Department (21.4%, n=37). Fewer required escalation from normal ward-based care (6.94%, n=12). Transfers from other hospitals occupied 3 ITU beds (1.73%). Mean ITU stay was 3.4 days per patient, with 6.5 beds being occupied by surgical cases on a daily basis. Forty-one percent of patients met the criteria for HDU. -- Conclusion: With an ever growing population, there is a need to set up a local surgical HDU. This will help relieve the recurrent shortage of ITU beds without compromising the level of healthcare delivered.peer-reviewe

Efficacy of cyanoacrylate glue ablation of primary truncal varicose veins compared to existing endovenous techniques : a systematic review of the literature

Introduction One-third of adults in the United States and United Kingdom suffer from varicose veins. n-butyl-2-cyanoacrylate (NBCA) glue is a novel endovascular, nontumescent, nonthermal ablation technique for treatment of this condition. It has proved effective in multiple studies since its first use in 2013. The aim of this systematic review is to assess the efficacy of NBCA in ablating primary truncal varicose veins and eliminating reflux compared with existing endovascular techniques. Secondary out- comes include complications and quality of life. Methods PRISMA was used as a guide and studies were screened for risk of bias and methodological quality. Subjects had to be 18 years of age and followed-up posttreat- ment with color Duplex ultrasound (DUS). Eligibility criteria included saphenofemoral junction (SFJ) or saphenopopliteal junction (SPJ) incompetence with reflux down truncal veins lasting >0.5 seconds on DUS interrogation and a Clinical, Etiological, Anatomical, and Pathophysiological classification of venous disorders ranging between C1 and C6. Results Out of 2,910 patients (3,220 veins) in 17 studies, 1,981 were administered NBCA, 445 radiofrequency ablation (RFA), and 484 endovenous laser ablation (EVLA) with mean procedure times of 25.7, 23.2, and 28.7 minutes, respectively. Mean recruitment period was 9 months (1–36 months) and followed-up for an average of 12.3 months (1–36 months). The majority were C2 to C3. Two-year occlusion rates were 93.7, 90.9, and 91.5% for NBCA, RFA, and EVLA, respectively. NBCA-treated patients experienced the least complications, with bruising, phlebitis, and pain being the most prevalent. Quality of life improved equally in all three modalities. Conclusion NBCA is simple to administer, safe, and effective even without compression stockings. Further studies are required to assess longer-term benefit and the effect of anticoagulation on vein obliteration.peer-reviewe

Covid-19 pandemic lockdown : Uncovering the hard truth on lower limb ischaemic outcomes? A single centre observational study

The COVID-19 pandemic disrupted hospital services worldwide and Malta was no exception. This was especially true for vascular surgery where societies issued recommendations on how to adjust their services during the first wave of the pandemic. Malta has one tertiary hospital, with a vascular unit that was established in 2007. Since then, all lower limb procedures have been registered in the Maltese vascular registry (MaltaVasc), which has been internationally validated. In Malta, COVID-positive patient zero was recorded on 7 March 2020. The closure of the only airport was carried out on 21 March and a partial intelligence lockdown was started on 27 March, whereby vulnerable patients were advised to stay home and avoid going to work. On 5 June 2020, the government of Malta and Public Health authorities eased the lockdown for vulnerable patients and on 1 July 2020 the airport was opened to 19 destinations, with a gradual opening to other countries. Despite the partial lockdown, patients with hospital appointments were advised to keep their appointments unless they were cancelled by medical staff. Elective lists were reduced and non-urgent surgeries postponed. During this time, it was noted that few patients were presenting to hospital with signs and symptoms of chronic limb threatening ischaemia (CLTI). Furthermore, it was felt that patients with CLTI were presenting to hospital late, requiring either palliation or major amputation, and more patients required major amputation than in previous years. The primary aim of this study was to analyse the number of major and minor amputations, elective and/or urgent and emergency revascularisation procedures during the first wave of the COVID-19 pandemic. The secondary aims were to compare the number of lower limb procedures with the previous year and also to compare the rates of major amputations with the prevascular unit time period where few lower limb revascularisations were carried by the same authors.peer-reviewe

Treatment of Peripheral Arterial Occlusive Disease around the Globe : Malta

Introduction: Malta is a small island in the middle of the Mediterranean with a population of 514,564 inhabitants and is served by one public tertiary hospital, Mater Dei Hospital. The Vascular unit was set up in 2007. The aim of this review is to analyse the work related to peripheral arterial occlusive disease (PAOD) in Malta with an in-depth focus on amputations and revascularisation procedures since the introduction of the Vascular unit. Method: Various sources of data have been interrogated to address this subject. Population and prevalence data on obesity and type II diabetes mellitus from 2003 to 2019 was obtained from the National Statistics Office, the World Health Organization, and the International Diabetes Federation, respectively. The Maltese Vascular Register (MaltaVasc), and in-hospital reports from 2003 to 2019 was used to obtain data on revascularisation procedures, major amputations and minor amputation rates in Malta. Results: Malta has one of the highest rates of obesity in Europe. In 2015, the prevalence rate was 30.6%. Similarly, data from the International Diabetes Federation Atlas showed that the prevalence rate of T2DM among adults was 14% in 2017. There was a mean of 33 open/hybrid procedures per 100,000 population (28-38, 95% confidence interval) between 2005 and 2009 and a mean of 57 endovascular procedures per 100,000 population (46-68, 95% confidence interval) during the same time-period. From 2009 to 2019, there was a mean of 16 major amputations and 78 minor amputations per 100,000 population. Conclusion: A significant reduction in major amputation rates with an increase in minor amputation rates and revascularisation rates has been noted since the establishment of the vascular unit in Malta. During this period, there has been an increase in prevalence in obesity and T2DM together with an aging population