Adhesive small bowel adhesions obstruction: Evolutions in diagnosis, management and prevention

Intra-abdominal adhesions following abdominal surgery represent a major unsolved problem. They are the first cause of small bowel obstruction. Diagnosis is based on clinical evaluation, water-soluble contrast followthrough and computed tomography scan. For patients presenting no signs of strangulation, peritonitis or severe intestinal impairment there is good evidence to support non-operative management. Open surgery is the preferred method for the surgical treatment of adhesive small bowel obstruction, in case of suspected strangulation or after failed conservative management, but laparoscopy is gaining widespread acceptance especially in selected group of patients. "Good" surgical technique and anti-adhesive barriers are the main current concepts of adhesion prevention. We discuss current knowledge in modern diagnosis and evolving strategies for management and prevention that are leading to stratified care for patients.

What paradigm shifts occurred in the management of acute diverticulitis during the COVID-19 pandemic?A scoping review

BACKGROUND Acute colonic diverticulitis(ACD)is common in Western countries,with its prevalence increasing throughout the world.As a result of the coronavirus disease 2019(COVID-19),elective surgery and in-patients’visits have been cancelled or postponed worldwide.AIM To systematically explore the impact of the pandemic in the management of ACD.METHODS MEDLINE,Embase,Scopus,MedxRiv,and the Cochrane Library databases were searched to 22 December 2020.Studies which reported on the management of patients with ACD during the COVID-19 pandemic were eligible.For cross sectional studies,outcomes of interest included the number of hospital admission for ACD,as well as key features of disease severity(complicated or not)across two time periods(pre-and during lockdown).RESULTS A total of 69 papers were inspected,and 21 were eligible for inclusion.Ten papers were cross sectional studies from seven world countries;six were case reports;three were qualitative studies,and two review articles.A 56%overall decrease in admissions for ACD was observed during lockdown,peaking 67%in the largest series.A 4%-8%decrease in the rate of uncomplicated diverticulitis was also noted during the lockdown phase.An initial non-operative management was recommended for complicated diverticulitis,and encouraged to an out-of-hospital regimen.Despite initial concerns on the use of laparoscopy for Hinchey 3 and 4 patients to avoid aerosolized contamination,societal bodies have progressively mitigated their initial recommendations as actual risks are yet to be ascertained.CONCLUSION During the COVID-19 pandemic,fewer patients presented and were diagnosed with ACD.Such decline may have likely affected the spectrum of uncomplicated disease.Established outpatient management and follow up for selected cases may unburden healthcare resources in time of crisis.

Endoscopic ultrasound-guided biliary drainage after failed endoscopic retrograde cholangiopancreatography: The road is open for almighty biliopancreatic endoscopists!

Commentary on the article written and published by Peng et al,investigating the role of endoscopic ultrasound(EUS)-guided biliary drainage for palliation of malignant biliary obstruction after failed endoscopic retrograde cholangiopan-creatography(ERCP).For 40 years endoscopic biliary drainage was synonymous with ERCP,and EUS was used mainly for diagnostic purposes.The advent of therapeutic EUS has revolutionized the field,especially with the development of a novel device such as electrocautery-enhanced lumen-apposing metal stents.Complete biliopancreatic endoscopists with both skills in ERCP and in interven-tional EUS,would be ideally suited to ensure patients the best drainage technique according to each individual situation.

Advances in laparoscopy for acute care surgery and trauma

The greatest advantages of laparoscopy when compared to open surgery include the faster recovery times, shorter hospital stays, decreased postoperative pain, earlier return to work and resumption of normal daily activity as well as cosmetic benefits. Laparoscopy today is considered the gold standard of care in the treatment of cholecystitis and appendicitis worldwide. Laparoscopy has even been adopted in colorectal surgery with good results. The technological improvements in this surgical field along with the development of modern techniques and the acquisition of specific laparoscopic skills have allowed for its utilization in operations with fully intracorporeal anastomoses. Further progress in laparoscopy has included single-incision laparoscopic surgery and natural orifice trans-luminal endoscopic surgery. Nevertheless, laparoscopy for emergency surgery is still considered challenging and is usually not recommended due to the lack of adequate experience in this area. The technical difficulties of operating in the presence of diffuse peritonitis or large purulent collections and diffuse adhesions are also given as reasons. However, the potential advantages of laparoscopy, both in terms of diagnosis and therapy, are clear. Major advantages may be observed in cases with diffuse peritonitis secondary to perforated peptic ulcers,for example, where laparoscopy allows the confirmation of the diagnosis, the identification of the position of the ulcer and a laparoscopic repair with effective peritoneal washout. Laparoscopy has also revolutionized the approach to complicated diverticulitis even when intestinal perforation is present. Many other emergency conditions can be effectively managed laparoscopically, including trauma in select hemodynamically-stable patients. We have therefore reviewed the most recent scientific literature on advances in laparoscopy for acute care surgery and trauma in order to demonstrate the current indications and outcomes associated with a laparoscopic approach to the treatment of the most common emergency surgical conditions.

Intraoperative use of indocyanine green fluorescence imaging in rectal cancer surgery: The state of the art

Indocyanine green(ICG)fluorescence imaging is widely used in abdominal surgery.The implementation of minimally invasive rectal surgery using new methods like robotics or a transanal approach required improvement of optical systems.In that setting,ICG fluorescence optimizes intraoperative vision of anatomical structures by improving blood and lymphatic flow.The purpose of this review was to summarize all potential applications of this upcoming technology in rectal cancer surgery.Each type of use has been separately addressed and the evidence was investigated.During rectal resection,ICG fluorescence angiography is mainly used to evaluate the perfusion of the colonic stump in order to reduce the risk of anastomotic leaks.In addition,ICG fluorescence imaging allows easy visualization of organs such as the ureter or urethra to protect them from injury.This intraoperative technology is a valuable tool for conducting lymph node dissection along the iliac lymphatic chain or to better identifying the rectal dissection planes when a transanal approach is performed.This is an overview of the applications of ICG fluorescence imaging in current surgical practice and a synthesis of the results obtained from the literature.Although further studies are need to investigate the real clinical benefits,these findings may enhance use of ICG fluorescence in current clinical practice and stimulate future research on new applications.

Laparoscopic management of intra-abdominal infections:Systematic review of the literature

AIM: To investigate the role of laparoscopy in diagnosis and treatment of intra abdominal infections.METHODS: A systematic review of the literature was performed including studies where intra abdominal infections were treated laparoscopically.RESULTS: Early laparoscopic approaches have become the standard surgical technique for treating acute cholecystitis. The laparoscopic appendectomy has been demonstrated to be superior to open surgery in acute appendicitis. In the event of diverticulitis, laparoscopic resections have proven to be safe and effective procedures for experienced laparoscopic surgeons and may be performed without adversely affecting morbidity and mortality rates. However laparoscopic resection has not been accepted by the medical community as the primary treatment of choice. In high-risk patients, laparoscopic approach may be used for exploration or peritoneal lavage and drainage. The successful laparoscopic repair of perforated peptic ulcers for experienced surgeons, is demonstrated to be safe and effective. Regarding small bowel perforations, comparative studies contrasting open and laparoscopic surgeries have not yet been conducted. Successful laparoscopic resections addressing iatrogenic colonic perforation have been reported despite a lack of literature-based evidence supporting such procedures. In post-operative infections, laparoscopic approaches may be useful in preventing diagnostic delay and controllingthe source.CONCLUSION: Laparoscopy has a good diagnostic accuracy and enables to better identify the causative pathology; laparoscopy may be recommended for the treatment of many intra-abdominal infections.

Prognostic criteria for postoperative mortality in 170 patients undergoing major right hepatectomy

BACKGROUND: Postoperative hepatic failure is a dreadful complication after major hepatectomy and carries high morbidity and mortality rates. In this study, we assessed the accuracy of the 50/50 criteria (bilirubin >2.9 mg/dL and international normalized ratio >1.7 on postoperative day 5) and the Mullen criteria (bilirubin peak >7 mg/dL on postoperative days 1-7) in predicting death from hepatic failure in patients undergoing right hepatectomy only. In addition, we identified prognostic factors linked to intra-hospital morbidity and mortality in these patients. METHODS: One hundred seventy consecutive patients underwent major right hepatectomy at a tertiary medical center from 2000 to 2008. Nineteen (11.2%) patients suffered from liver cirrhosis. Univariate and multivariate analyses were performed to identify predictors of intra-hospital mortality, morbidity and death from hepatic failure. RESULTS: The intra-hospital mortality was 6.5% (11/170). Of the six patients who died from hepatic failure, one was positive for the 50/50 criteria, but all six patients were positive for the Mullen criteria. Multivariate analysis showed that male gender, hepatitis C (HCV), hepatocellular carcinoma, postoperative bilirubin >7 mg/dL and ALT<188 U/L on postoperative day 1 were predictive of death from hepatic failure in the postoperative period. Age >65 years, HCV, reoperation, andrenal failure were significant predictors of overall intra-hospital mortality on multivariate analysis. CONCLUSIONS: The Mullen criteria were more accurate than the 50/50 criteria in predicting death from hepatic failure in patients undergoing right hepatectomy. A bilirubin peak >7 mg/dL in the postoperative period, HCV positivity, hepatocellular carcinoma, and an ALT level <188 U/L on postoperative day 1 were associated with death from hepatic failure in our patient population.

Preoperative colonic stents vs emergency surgery for acute left-sided malignant colonic obstruction: meta-analysis with systematic review of the literature

AIM To investigate by meta-analytic study and systematic review, advantages of colonic stent placement in comparison with emergency surgery.METHODS We conducted an extensive literature search by PubMed, Google Scholar, Embase and the Cochrane Libraries. We searched for all the papers in English published till February 2016, by applying combinations of the following terms: Obstructive colon cancer, colon cancer in emergency, colorectal stenting, emergency surgery for colorectal cancer, guidelines for obstructive colorectal cancer, stenting vs emergency surgery in the treatment of obstructive colorectal cancer, selfexpanding metallic stents, stenting as bridge to surgery. The study was designed following the PrismaStatement. By our search, we identified 452 studies, and 57 potentially relevant studies in full-text were reviewed by 2 investigators; ultimately, 9 randomized controlled trials were considered for meta-analysis and all the others were considered for systematic review.RESULTS In the meta-analysis, by comparing colonic stenting(CS) as bridge to surgery and emergency surgery, the pooled analysis showed no significant difference between the two techniques in terms of mortality [odds ratio(oR) = 0.91], morbidity(oR = 2.38) or permanent stoma rate(oR = 1.67); primary anastomosis was more frequent in the stent group(oR = 0.45; P = 0.004) and stoma creation was more frequent in the emergency surgery group(oR = 2.36; P = 0.002). No statistical difference was found in disease-free survival and overall survival. The pooled analysis showed a significant difference between the colonic stent and emergency surgery groups(oR = 0.37), with a significantly higher 1-year recurrence rate in the stent group(P = 0.007).CONCLUSION CS improves primary anastomosis rate with significantly high 1-year follow-up recurrence and no statistical difference in terms of disease-free survival and overall survival.

Interventional treatment options for management of delayed arterial hemorrhage after major hepato-pancreatic-biliary surgery

Hilar cholangiocarcinoma is a biliary malignancy arising from the perihilar biliary tree,which is associated with poor oncological outcomes due to its aggressive biology,chemo-resistance and insidious onset[1].As stated by Di Martino et al.,the standard of care is radical resection,and during the last decades,there have been great efforts to improve survival of potentially resectable hilar cholangiocarcinoma,with surgery being the treatment associated with longer survival[2].However,radical resection still represents a challenging operation with high risk of intraoperative and postoperative complications.

Trauma-induced“Macklin effect”with pneumothorax and large pneumomediastinum,disguised by allergy

A 56-year-old man presented spontaneously to the Emergency Department complaining of facial and neck oedema after assumption of nonsteroidal anti-inflammatory drugs(NSAIDS).The triage nurse assigned the patient to Accident&Emergency(A&E)doctor as probable allergic reaction to NSAIDS.Chest X-ray(CXR),ordered after 24 hours,revealed a huge subcutaneous chest and neck emphysema without clearly visible pneumothorax.Subsequent chest CT scan showed a small left pneumothorax and a large amount of air in the mediastinum.The patient was conservatively treated since he was eupnoeic and hemodynamically stable.The pathophysiology of pneumomediastinum was first described by Macklin in 1939.The Macklin effect involves alveolar ruptures with air dissection along bronchovascular sheaths to the mediastinum.In this case the patient did not report in his history a recent blunt thoracic trauma and the initial suspicion of an allergic reaction has prevented physicians to immediately achieve the correct diagnosis.

Clinical outcomes of non-operative management and clinical observation in non-angioembolised hepatic trauma: A systematic review of the literature

Purpose: Liver is the most frequently injured organ in abdominal trauma. Today non-operative management (NOM) is considered as the standard of care in hemodynamically stable patients, with or without the adjunct of angioembolisation (AE). This systematic review assesses the incidence of complications in patients who sustained liver injuries and were treated with simple clinical observation. Given the differences in indications of treatment and severity of liver trauma and acknowledging the limitations of this study, an analysis of the results has been done in reference to the complications in patients who were treated with AE. Methods: A systematic literature review searched "liver trauma" , "hepatic trauma" , "conservative management" , "non operative management" on MEDLINE (via PubMed), Cochrane Central Register of Controlled Trials databases, EMBASE, and Google Scholar, to identify studies published on the conservative management of traumatic liver injuries between January 1990 and June 2020. Patients with traumatic liver injuries (blunt and penetrating) treated by NOM, described at least one outcome of interests and provided morbidity outcomes from NOM were included in this study. Studies reported the outcome of NOM without separating liver from other solid organs;studies reported NOM complications together with those post-intervention;case reports;studies including less than 5 cases;studies not written in English;and studies including patients who had NOM with AE as primary management were excluded. Efficacy of NOM and overall morbidity and mortality were assessed, the specific causes of morbidity were investigated, and the American Association for the Surgery of Trauma classification was used in all the studies analysed. Statistical significance has been calculated using the Chi-square test. Results: A total of 19 studies qualified for inclusion criteria were in this review. The NOM success rate ranged from 85% to 99%. The most commonly reported complications were hepatic collection (3.1%), followed by bile leak (1.5%), with variability between the studies. Other complications included hepatic haematoma, bleeding, fistula, pseudoaneurysm, compartment syndrome, peritonitis, and gallbladder ischemia, all with an incidence below 1%. Conclusion: NOM with simple clinical observation showed an overall low incidence of complications, but higher for bile leak and collections. In patients with grade III and above injuries, the incidence of bile leak, collections and compartment syndrome did not show a statistically significant difference with the AE group. However, the latter result is limited by the small number of studies available and it requires further investigations.