Systematic review and meta-analysis of the management of acute uncomplicated diverticulitis:time to change traditional practice

Background: To evaluate comparative outcomes of outpatient (OP) versus inpatient (IP) treatment and antibiotics (ABX) versus no antibiotics (NABX) approach in the treatment of uncomplicated (Hinchey grade 1a) acute diverticulitis. Methods: A systematic online search was conducted using electronic databases. Comparative studies of OP versus IP treatment and ABX versus NABX approach in the treatment of Hinchey grade 1a acute diverticulitis were included. Primary outcome was recurrence of diverticulitis. Emergency and elective surgical resections, development of complicated diverticulitis, mortality rate, and length of hospital stay were the other evaluated secondary outcome parameters. Results: The literature search identified twelve studies (n = 3,875) comparing NABX (n = 2,008) versus ABX (n = 1,867). The NABX group showed a lower disease recurrence rate and shorter length of hospital stay compared with the ABX group (P = 0.01) and (P = 0.004). No significant difference was observed in emergency resections (P = 0.33), elective resections (P = 0.73), development of complicated diverticulitis (P = 0.65), hospital re-admissions (P = 0.65) and 30-day mortality rate (P = 0.91). Twelve studies (n = 2,286) compared OP (n = 1,021) versus IP (n = 1,265) management of uncomplicated acute diverticulitis. The two groups were comparable for the following outcomes: treatment failure (P = 0.10), emergency surgical resection (P = 0.40), elective resection (P = 0.30), disease recurrence (P = 0.22), and mortality rate (P = 0.61). Conclusion: Observation-only treatment is feasible and safe in selected clinically stable patients with uncomplicated acute diverticulitis (Hinchey 1a classification). It may provide better outcomes including decreased length of hospital stay. Moreover, the OP approach in treating patients with Hinchey 1a acute diverticulitis is comparable to IP management. Future high-quality randomised controlled studies are needed to understand the outcomes of the NABX approach used in an OP setting in managing patients with uncomplicated acute diverticulitis

APPLICATION OF COST-EFFECTIVE ADSORBENTS AGAINST THE REMOVAL OF DYE INDIGO CARMINE

Elimination of Indigo carmine color by adsorption method on eggshell (ESP), date palm seeds (DPS) and papaya seeds powder (PSP) from watery arrangement was researched. The examination done by following group mode strategies, for example, dose mg/g, pH, focus, contact time and speed rpm separately. The surface reading examined through; FTIR-Fourier change electron microscopy, SEM-Scanning electron microscopy and EDS-Energy dispersive x-beam investigation. Best adsorption follows dynamic pseudo – second request motor plots. Adsorption isotherms best fitted in Langmuir and Freundlich plots. Results pronounced that most extreme expulsion of color was accomplished at powerful portion for ESP is 500mg, DPSP 100mg while for PSP is 80mg at enhanced pH3, utilizing 50mg/l convergence of color, contact time and 100speed rpm study performed at room temperature

Multi-modality detection of SARS-CoV-2 in faecal donor samples for transplantation and in asymptomatic emergency surgical admissions

Background: Faecal transplantation is an evidence-based treatment for Clostridioides difficile. Patients infected with SARS-CoV-2 have been shown to shed the virus in stool for up to 33 days, well beyond the average clearance time for upper respiratory tract shedding. We carried out an analytical and clinical validation of reverse-transcriptase quantitative (RT-qPCR) as well as LAMP, LamPORE and droplet digital PCR in the detection of SARS-CoV-2 RNA in stool from donated samples for faecal microbiota transplantation (FMT), spiked samples and asymptomatic inpatients in an acute surgical unit.  Methods: Killed SARS-CoV-2 viral lysate and extracted RNA was spiked into donor stool & FMT and a linear dilution series from 10-1 to 10-5 and tested via RT-qPCR, LAMP, LamPORE and ddPCR against SARS-CoV-2. Patients admitted to the critical care unit with symptomatic SARS-CoV-2 and sequential asymptomatic patients from acute presentation to an acute surgical unit were also tested. Results: In a linear dilution series, detection of the lowest dilution series was found to be 8 copies per microlitre of sample. Spiked lysate samples down to 10-2 dilution were detected in FMT samples using RTQPCR, LamPORE and ddPCR and down to 10-1 with LAMP. In symptomatic patients 5/12 had detectable SARS-CoV-2 in stool via RT-qPCR and 6/12 via LamPORE, and in 1/97 asymptomatic patients via RT-qPCR. Conclusion: RT-qPCR can be detected in FMT donor samples using RT-qPCR, LamPORE and ddPCR to low levels using validated pathways. As previously demonstrated, nearly half of symptomatic and less than one percent of asymptomatic patients had detectable SARS-CoV-2 in stool

Intraoperative loss of a surgical needle: a laparoscopic dilemma.

BACKGROUND Increasing awareness around patient safety and efforts to reduce medical errors has become a priority in the modern health care system. Losing needles during laparoscopic procedures is an uncommon occurrence; however, it poses a significant dilemma for the operating surgeon because retrieval can be a major challenge even for highly skilled and experienced operators. OBJECTIVE The objective of this paper was to review the current literature and highlight this potentially serious issue and suggest a method of dealing with this uncommon occurrence. METHODS A comprehensive literature search was conducted using several Internet search engines including PubMed, Google Scholar, and ScienceDirect. CONCLUSIONS The risks associated with retained small foreign bodies remains unknown, and there are few reports and little consensus on how surgeons should manage retained needles or other small foreign bodies during laparoscopic surgery. We propose an algorithm that may be implemented as a standard operating procedure in surgical theatres when a surgeon is faced with such a dilemma

Cloacogenic polyps in an adolescent: a rare cause of rectal bleeding.

Cloacogenic polyps are rare inflammatory lesions occurring around the anal transitional zone and in the lower rectum which can mimic neoplasia. They should be given diagnostic consideration in patients presenting with symptoms of rectal bleeding, tenesmus, and altered bowel habits

Patients with computed tomography-proven acute diverticulitis require follow-up to exclude colorectal cancer

Background/Aims: Traditionally, patients with acute diverticulitis undergo follow-up endoscopy to exclude colorectal cancer (CRC). However, its usefulness has been debated in this era of high-resolution computed tomography (CT) diagnosis. We assessed the frequency and outcome of endoscopic follow-up for patients with CT-proven acute diverticulitis, according to the confidence in the CT diagnosis.Methods: Records of patients with CT-proven acute diverticulitis between October 2007 and March 2014 at Sandwell & West Birmingham Hospitals NHS Trust were retrieved. The National Cancer Registry confirmed the cases of CRC. Endoscopy quality indicators were compared between these patients and other patients undergoing the same endoscopic examination over the same period.Results: We identified 235 patients with CT-proven acute diverticulitis, of which, 187 were managed conservatively. The CT report was confident of the diagnosis of acute diverticulitis in 75% cases. Five of the 235 patients were subsequently diagnosed with CRC (2.1%). Three cases of CRC were detected in the 187 patients managed conservatively (1.6%). Forty-eight percent of the conservatively managed patients underwent follow-up endoscopy; one case of CRC was identified. Endoscopies were often incomplete and caused more discomfort for patients with diverticulitis compared with controls.Conclusions: CRC was diagnosed in patients with CT-proven diverticulitis at a higher rate than in screened asymptomatic populations, necessitating follow-up. CT reports contained statements regarding diagnostic uncertainty in 25% cases, associated with an increased risk of CRC. Follow-up endoscopy in patients with CT-proven diverticulitis is associated with increased discomfort and high rates of incompletion. The use of other follow-up modalities should be considered

Minimally invasive surgery for Inflammatory Bowel Disease:a systematic review and meta-analysis of robotic versus laparoscopic surgical techniques

Background: We aimed to evaluate outcomes of robotic versus conventional laparoscopic colorectal resections in patients with inflammatorybowel disease [IBD].Methods: Comparative studies of robotic versus laparoscopic colorectal resections in patients with IBD were included. The primary outcomewas total post-operative complication rate. Secondary outcomes included operative time, conversion to open surgery, anastomotic leaks,intra-abdominal abscess formation, ileus occurrence, surgical site infection, re-operation, re-admission rate, length of hospital stay, and 30-daymortality. Combined overall effect sizes were calculated using a random-effects model and the Newcastle–Ottawa Scale was used to assessrisk of bias.Results: Eleven non-randomized studies [n = 5566 patients] divided between those undergoing robotic [n = 365] and conventional laparoscopic[n = 5201] surgery were included. Robotic platforms were associated with a significantly lower overall post-operative complication rate com-pared with laparoscopic surgery [p = 0.03]. Laparoscopic surgery was associated with a significantly shorter operative time [p = 0.00001]. Nodifference was found in conversion rates to open surgery [p = 0.15], anastomotic leaks [p = 0.84], abscess formation [p = 0.21], paralytic ileus[p = 0.06], surgical site infections [p = 0.78], re-operation [p = 0.26], re-admission rate [p = 0.48], and 30-day mortality [p = 1.00] between thegroups. Length of hospital stay was shorter following a robotic sub-total colectomy compared with conventional laparoscopy [p = 0.03].Conclusion: Outcomes in the surgical management of IBD are comparable between traditional laparoscopic techniques and robotic-assistedminimally invasive surgery, demonstrating the safety and feasibility of robotic platforms. Larger studies investigating the use of robotic tech-nology in Crohn’s disease and ulcerative colitis separately may be of benefit with a specific focus on important IBD-related metrics.</p

Building a model for day case hiatal surgery - Lessons learnt over a 10 year period in a high volume unit: A case series.

BACKGROUND Laparoscopic anti-reflux surgery has become the standard treatment for symptomatic gastro-oesophageal reflux disease refractory to medical therapy. Successful anti-reflux surgery involves safe, minimally invasive surgery, resulting in symptom resolution with minimal side effects. This study aims to assess the feasibility and safety of day case anti-reflux surgery focussing on peri- and post-operative outcomes as a measure of success. METHODS Data was collected from the hospital database from 2003 to 2012. Data collection included demographics, surgeon, mode of admission, length of stay and complications. Electronic records were independently scrutinised for all patients with a length of stay of more than two nights. RESULTS 723 patients underwent laparoscopic fundoplication ± small hiatus hernia repair (<5 cm) with a day case rate of 67.1%. The 30 day readmission rate in these patients was 2.9% (21/723 patients). Nine patients had a failure of their initial laparoscopic fundoplication (defined as recurrence of symptoms). Three patients required a re-operation within 12 months of their initial procedure (re-operation rate = 0.41% (3/723 patients)). CONCLUSION Laparoscopic hiatal surgery can be performed safely as a day case in high volume specialist centres with good outcomes. Raising the national standard for day case fundoplication promotes good practice and should be the model for future commissioning