Úlcera péptica perforada durante el puerperio / Perforated peptic ulcer during the puerperium

RESUMEN La úlcera péptica es menos frecuente en las embarazadas que en las mujeres no gestantes. Aunque rara vez se perfora durante el embarazo y aún menos frecuentemente durante el puerperio, está asociada con mayor riesgo de muerte materna. El uso de analgésicos no esteroideos y la infección por Helicobacter pylori están relacionados con su patogénesis. Debido a sus características clínicas durante el embarazo, la sepsis puerperal e íleo paralítico pueden retrasar el diagnóstico. Luego del parto, signos clínicos como taquicardia de reciente aparición, dolor abdominal y el aumento de la distensión deben sugerir el diagnóstico. Dado que las complicaciones pueden provocar morbilidad y mortalidad significativas durante el puerperio, la detección precoz y el tratamiento rápido son imperativos. El tratamiento de la úlcera péptica perforada durante el puerperio es el mismo que el de una situación quirúrgica abdominal urgente. Una reparación satisfactoria con parche omental suele sellar el defecto y evitar nuevas perforaciones. Se presenta un caso de úlcera péptica perforada durante el puerperio.

ABSTRACT Peptic ulcer is less frequent in pregnant women than in non-pregnant women. Although it rarely perforates during pregnancy and even less frequently during the puerperium, it is associated with an increased risk of maternal death. The use of nonsteroidal analgesic and Helicobacter pylori infection are related to its pathogenesis. Due to its clinical features during pregnancy, puerperal sepsis and paralytic ileus may delay diagnosis. After delivery, clinical signs such as new-onset tachycardia, abdominal pain, and increased distension should suggest the diagnosis. Since complications can cause significant morbidity and mortality during the puerperium, early detection and prompt treatment are imperative. Treatment of perforated peptic ulcer during the puerperium is the same as for an urgent abdominal surgical situation. Successful repair with omental patching usually seals the defect and prevents additional perforations. A case of perforated peptic ulcer during the puerperium is presented.

Prevalencia de neoplasia en úlceras gástrica perforada en el Servicio de Cirugía General- Hospital Central IPS, 2015-2020 / Prevalence of neoplasm in perforated gastric ulcers in the General Surgery Department - IPS Central Hospital, 2015-2020

Introducción: La úlcera gástrica perforada es la complicación ulcerativa más frecuente después del sangrado y la más grave de todas. A medida que se desarrolla el proceso inflamatorio la lesión gástrica evoluciona pasando por los siguientes estadíos: gastritis superficial, gastritis atrófica crónica, metaplasia intestinal, displasia y finalmente cáncer. En este proceso de evolución natural de la enfermedad radica la importancia de realizar una biopsia durante el abordaje quirúrgico de la úlcera gástrica perforada. Objetivos: Determinar la prevalencia de neoplasia en úlceras gástrica perforada en el servicio de Cirugía General del Hospital Central del Instituto de Previsión Social en el periodo 2015-2020. Materiales y métodos: Se llevó a cabo un estudio observacional descriptivo de corte transversal con datos retrospectivos. Resultados: Se incluyeron 50 pacientes sometidos a cirugía por úlcera gástrica perforada. El promedio de edad fue 67,1 ±17,1 años, el 60% correspondían al sexo masculino; en el 94% se realizó reavivamiento de bordes y en el 6% antrectomía. Con respecto al diagnóstico anatomopatológico, en el 90% se confirmó proceso infamatorio, la prevalencia de neoplasia fue del 6% y en el total de los pacientes postoperados por úlcera gástrica perforada se constató un 46% de mortalidad. Conclusión: La prevalencia de neoplasia fue mínima en los pacientes sometidos a cirugía por úlcera gástrica perforada. Se identificó un alto porcentaje de mortalidad en los pacientes postoperados por úlcera gástrica perforada. El promedio de edad fue 67,1 años y predominó el sexo masculino. El procedimiento quirúrgico más frecuente fue el reavivamiento de bordes y el diagnóstico anatomopatológico más prevalente fue proceso inflamatorio.

Introduction: Perforated gastric ulcer is the most frequent ulcerative complication after bleeding and the most serious of all; as inflammation progresses, gastric lesion evolves, beginning with superficial gastritis, then chronic atrophic gastritis, intestinal metaplasia, dysplasia, and finally cancer; hence the importance of performing a biopsy in the surgical approach of perforated gastric ulcer. Objectives: To determine the prevalence of neoplasia in perforated gastric ulcers in the General Surgery service of the Hospital Central del Instituto de Previsión Social in the period 2015-2020. Materials and methods: An observational descriptive cross-sectional study with retrospective data was carried out. Results: 50 patients who underwent surgery for perforated gastric ulcer were included. The average age was 67.1 ± 17.1 years, 60% were male; 94% underwent edge revival and 6% antrectomy. Regarding the anatomopathological diagnosis, 90% confirmed the inflammatory process, the prevalence of neoplasia was 6%, and in the total number of postoperative patients for perforated gastric ulcer, 46% mortality was confirmed. Conclusion: The average age was 67.1 years and the male sex predominated. The most frequent surgical procedure was edge revival and the most prevalent pathological diagnosis was inflammatory process. The prevalence of neoplasia was minimal in patients undergoing surgery for perforated gastric ulcer. A high percentage of mortality was identified in postoperative patients for perforated gastric ulcer.

Stomach versus heart: case report of a giant hiatal hernia with perforated gastric ulcer with obstructive shock

A giant paraesophageal hernia is defined when at least 30% of the stomach has moved to the thorax or the presence of another intra-abdominal organ. We describe the presentation of a clinical case of a giant hiatal hernia with perforated gastric ulcer in a 52-year-old man who presented to the emergency department with pain in the inguinal region developing obstructive shock. Presentation of hiatal hernias is usually asymptomatic and in some cases with atypical signs and symptoms involving cardiovascular and respiratory disorders. In patients with a history of gastroesophageal reflux disease/ with atypical thoracic symptoms, hiatal hernia and its complications should be ruled out.

Role of Peptic Ulcer Perforation (PULP) score to Predict the Outcome in Patients with Perforated Peptic Ulcer

Background: Peptic ulcer disease is a global burden of disease associated with potentially life-threatening complications, including bleeding, perforation and obstruction. Perforated peptic ulcer (PPU) is a frequent emergency condition worldwide with associated morbidity and mortality. Variations in the clinical presentation, as well as delay in diagnosis and work-up at admission to the hospital, may potentially cause a worsening of symptoms and a deterioration of the clinical condition, with a detrimental outcome. Therefore, accurate and early identification of high-risk surgical patients with perforated peptic ulcers (PPUs) is important for triage and risk stratification. Currently, the ASA score and the Boey score are the most frequently used prognostic scoring systems in patients with PPU. Yet, the ASA score is a general surgical risk score not intended for PPU patients in particular. Moreover, the external validation of the Boey score is uncertain. PULP score appears to have the greatest predictability of the outcome of perforated PUD. Aim of the study: The objective of the study was to evaluate the role of the PULP score in the prediction of outcomes in patients with a perforated ulcer.Material & Methods:It is an observational cross-sectional study, carried out in the Department of Surgery, Dhaka Medical College Hospital, Dhaka. Ethical approval was obtained from the Dhaka Medical College ethical review board. Patients aged 18 to 60 years admitted to the emergency department with a clinical diagnosis of perforated peptic ulcer disease, confirmed by different investigation modalities, e.g, imaging, sonography, laboratory test, etc were enrolled in the study. The data regarding sociodemographic, clinical, biochemical, radiological and surgical profiles were recorded. The operation was done by upper midline incision under general anesthesia. A modified Graham’s patch technique was used to repair the duodenal ulcer. Postoperative follow up was conducted meticulously. Patient outcome was assessed during their hospital stay and then OPD follow-up or by telephone interviews up to 30 days after the intervention. All the information is recorded in the data collection sheet. All collected questionnaires were checked very carefully to identify the error in the data. Data processing work consisted of registration schedules, editing computerization, preparation of dummy tables, and analyzing and matching data. Data was processed and analysed with the help of the computer program SPSS and Microsoft excel. Quantitative data are expressed as mean and standard deviation and qualitative data as frequency and percentage. The comparison was done by tabulation and graphical presentation in the form of tables, pie charts, graphs, bar diagrams, histograms &charts etc.Results:Present study demonstrates that the maximum number of patients (43.0%) was between 51-60 years of age group, mean age of the patient was 49.35 ± 11.7 years. The male and female ratio was 3.54:1. Maximum (57%) patients came from urban, (36%) rural and (7%) urban non-slum areas. In this study, the most common signs were tachycardia (100%), abdominal tenderness (100%), abdominal rigidity (100%), absence of vowel sound (86.2%), and obliteration of liver dullness (78.7%), dehydration (67.5%). The time lapse between the onset of symptoms and admission to the hospital varied from 4 hours to 4 days. Most of the patients (76.0%) were admitted after 24 hours. In this study, PULP score was assessed according to the operational definition of optimal cut-off point 7, below this considered as low-risk patients. in this study 85% were 0-7 PULP scores and 15% were PULP scores 8-18. Patients’ condition after proper treatment, symptoms, degree of abnormalities or dependence on the daily physiological activity and the clinical outcome had evaluated and measured by follow up and close monitoring. The study shows that 69.0% of the patients recovered completely, but 24.0% of patients had developed complications. The mortality rate in this study was 7.0%. Finally, a correlation of the PULP score with mortality of perforated PUD was carried out. Among the 7 expired cases the, PULP score was correlated with 6 cases like high risk. In 93 cases of recovered, the PULP score was predicted in 84 cases as low risk. So the effectiveness of PULP has proven significant in the prediction of mortality in perforated PUD patients. The Sensitivity and Specificity of the Peptic Ulcer Perforation (PULP) score was 85.7% and 90.3% respectively. Similarly, the positive predictive value and accuracy rate for the same was 40.0% and 90.0% respectively.Conclusion: Patients with perforated peptic ulcer (PPU) often present with acute, severe illness that carries a high risk for morbidity and mortality. Several prognostic scoring systems have been suggested to identify high-risk surgical patients with perforated peptic ulcers accurately and early. The present study demonstrates that the PULP score can be used to predict 30-day mortality accurately in patients operated for PPU. The prognostic predictors included in the PULP score can be readily identified prior to surgery. The PULP score can assist in the accurate and early identification of high-risk patients with PPU.

A safer alternative approach to penetrating keratoplasty in opaque corneas

Background: This video demonstrates a useful technique of keratoplasty which can be routinely undertaken by all surgeons when imaging modalities such as anterior segment optical coherence tomography are not available and prior patient history is not forthcoming. Purpose: To demonstrate a technique of lamellar separation and layer by layer removal of host cornea when dealing with keratoplasty in perforated corneal ulcers, adherent leucomas, dense corneal opacities, which obscure visualization of the iris and anterior chamber details. Synopsis: In this video, we demonstrate penetrating keratoplasty in a failed opacified graft with iridocorneal adhesions, with no visualization of anterior chamber details. Lamellar dissection of the host cornea is done starting at its periphery and moving centrally, with gentle peeling of the superficial layers, the epithelium and bulk of stroma, following which, the deeper portion of the cornea is dissected and separated from underlying adherent iris tissue. Layer by layer separation allows better visualization through the remaining thin layers of the cornea. This permits fine dissection and layered removal of the cornea, thereby avoiding injury to iris and lens. Debulking of the host cornea decreases the force that is needed to be applied to separate adherent iris tissue from the host cornea, and reduces the chances of sudden entry into the anterior chamber and subsequent damage to the iris or lens. This also reduces the chance of iris tears, iridodialysis and bleeding from the iris and helps maintain iris integrity, which is essential intraoperatively for protection of lens and anterior chamber formation, and to avoid glare and photophobia postoperatively. Preventing iris damage also reduces the chances of formation of peripheral anterior synechiae (PAS), which can predispose to graft rejection, graft failure and secondary glaucoma. Highlights: Layer by layer corneal separation beginning inside the graft host junction, careful separation of iridocorneal adhesions and PAS is a helpful technique to optimally preserve the anterior segment anatomy during difficult cases of penetrating keratoplasty.

Hyperbilirubinemia, a Predictor of the Severity of Acute Appendicitis

Introduction: Appendicitis is a challenging diagnosis to make especially in children/elderly and the diagnosis is mostly made on clinical grounds. To operate upon a case of suspected acute appendicitis is a double challenge for a budding surgeon and can be a nightmare if it turns out to be a complicated appendicitis (e.g., Gangrenous or Perforated) especially when the surgeon is on their own as the findings are relatively unexpected. The surgeon can perform better with planning if they are knowledgeable or have a high index of suspicion about the complexity of the situation. Raised serum bilirubin in acute complicated appendicitis can help in better understanding the severity of the situation, especially the complicated cases like perforated and/or gangrenous appendix. Aim: This retrospective study抯 aim was to assess high bilirubin levels in acutely inflamed appendicitis and to look for its value in severity of acute inflammation of appendix. b: In this study, serum bilirubin was raised in 60% of cases of perforated/gangrenous appendicitis. Conclusion: Therefore, a simple, cheap, and readily available blood test like Serum Bilirubin can be of great value and importance in the management of complicated appendicitis.

Resultados de la cirugía de urgencia en pacientes con cáncer de colon perforado / Results of emergency surgery in patients with perforated colon cancer

RESUMEN: Gran parte de los pacientes con cáncer de colon (CC), son diagnosticados y tratados de forma electiva. Sin embargo, aproximadamente un 20 % de ellos debutará como una emergencia (obstrucción o perforación). El objetivo de este estudio fue determinar morbilidad postoperatoria (MPO) y supervivencia global (SVG) en pacientes resecados por CC perforado (CCP). Serie de casos retrospectiva de pacientes con CCP, sometidos a colectomía y linfadenectomía, de forma consecutiva, en Clínica RedSalud Mayor y Hospital de Temuco, Chile, entre 2010 y 2019. Las variables resultados fueron SVG y MPO. Otras variables de interés fueron: tiempo quirúrgico, resecabilidad, número de linfonodos resecados, estancia hospitalaria, mortalidad operatoria, recurrencia y supervivencia libre de enfermedad (SLE). Los pacientes fueron seguidos de forma clínica. Se utilizó estadística descriptiva, con medidas de tendencia central y dispersión; y análisis de SV con curvas de Kaplan Meier. Se intervinieron 15 pacientes (60 % mujeres), con una mediana de edad de 62 años. La localización más frecuente fue sigmoides (6 casos; 40,0 %). La resecabilidad de la serie fue 100 %. La medianas del tiempo quirúrgico, número de linfonodos resecados y estancia hospitalaria; fueron 80 min, 20 y 5 días respectivamente. La MPO fue 26,7 % (4 casos). Con una mediana de seguimiento de 36 meses, se verificó una recurrencia de 40,0 %. Por otra parte, la SVG y SLE a 5 años fue 46,7 % y 33,3 % respectivamente. Los resultados obtenidos, en términos de MPO y SVG, fueron similares a series internacionales.

SUMMARY: Most patients with colon cancer (CC) are diagnosed and treated electively. However, a fifth of them will debut as an emergency (obstruction or perforation). The aim of this study was to determine postoperative morbidity (POM) and overall survival (OS) in patients resected by perforated CC (PCC). Retrospective case series of patients with PCC undergoing colectomy and lymphadenectomy, consecutively, at RedSalud Mayor Clinic and Temuco hospital, Chile, between 2010 and 2019. The outcome variable were POM and OS. Other variables of interest were surgical time, resectability, number of resected lymph nodes, hospital stay, mortality, recurrence, and disease-free survival (DFS). Patients were followed clinically. Descriptive statistics was used (measures of central tendency and dispersion), and OS analysis was applying Kaplan Meier curves.15 patients (60 % women) were intervened, with a median age of 62 years. The most frequent location was the sigmoid colon (6 cases, 40.0 %). Resectability of the series was 100 %. Median surgical time, number of lymph nodes resected, and hospital stay; they were 80 min, 20 and 5 days respectively. POM was 26.7 % (4 cases). With a median follow-up of 36 months, recurrence was 40.0 %. On the other hand, OS and DFS at 5 years were 46.7 % and 33.3 %, respectively. The observed results, in terms of POM and OS, were like international series.

A study to determine the value of pre operative hyperbilirubinemia as a predictor of complicated appendicitis

Background: Acute appendicitis is a common acute abdominal condition that all surgeons confront. The early detection of patients who could go in for complication is critical so that appropriate treatment can be initiated to reduce mortality. There is no pre-operative investigation which accurately point out the patients who are going to develop severe disease. Hence this prospective study was done to identify whether preoperative bilirubin level can predict the severity of the disease.Methods: The study was conducted in the Department of General Surgery, Sree Gokulam Medical College and Research Foundation, Venjaramoodu, Trivandrum on 100 consecutive patients who were clinically diagnosed as acute appendicitis. These patients were evaluated with Alvarado score. In addition, preoperative bilirubin level and liver enzymes were estimated. Ultrasound abdomen was done preoperatively routinely. After surgery histopathology was studied. The parameters which showed statistically significant results for predicting complications were analyzed.Results: In this prospective study on 100 consecutive patients, acute appendicitis was found more commonly in males, 57 (57%) cases than in females, 43 (43%) cases. Among the cases 56 were acute appendicitis, 13 perforated, 11 gangrenous and 20 suppurative appendicitis. In our study, there was significant correlation of preoperative hyperbilirubinemia with complications of appendicitis.Conclusions: Patients with appendicitis with elevated bilirubin levels have more chance for complications like perforation, gangrene and suppuration.

Impacto de la subespecialización en los resultados de la sigmoidectomía laparoscópica por diverticulitis perforada Hinchey III / Outcomes of emergent laparoscopic sigmoid resection for Hinchey III diverticulitis: Does specialization matter?

Introducción: La sigmoidectomía por diverticulitis perforada es una cirugía de urgencia comúnmente realizada por cirujanos generales. Está descripta la correlación positiva entre el volumen del cirujano y los mejores resultados postoperatorios. Sin embargo, existe escasa evidencia de la influencia de la especialización en cirugía colorrectal sobre los resultados de la sigmoidectomía laparoscópica por diverticulitis perforada. Objetivo: Evaluar el impacto de la especialización en cirugía colorrectal en los resultados postoperatorios de la sigmoidectomía laparoscópica por diverticulitis Hinchey III. Diseño: Estudio retrospectivo sobre una base de datos cargada de forma prospectiva. Material y métodos: Se incluyeron pacientes sometidos a sigmoidectomía laparoscópica por diverticulitis perforada Hinchey III. La muestra fue dividida en dos grupos: pacientes operados por un cirujano colorrectal (CC) y aquellos operados por un cirujano general (CG). Las variables demográficas, operatorias y postoperatorias fueron comparadas entre los grupos. El objetivo primario fue determinar si existían diferencias en la proporción de anastomosis primaria, morbilidad y mortalidad a 30 días entre los grupos. Resultados: Se incluyeron 101 pacientes en el análisis; 58 operados por CC y 43 por CG. Los pacientes operados por CC presentaron una mayor proporción de anastomosis primaria (CC: 98,3% vs. CG: 67,4%, p<0,001). Los CG realizaron más estomas (CC: 13,8% vs. CG: 46,5%, p<0,001), presentaron un mayor índice de conversión (CC: 20,6% vs. CG: 39,5%, p=0,03) y una mayor estadía hospitalaria (CC: 6,2 vs. CG: 10,8 días, p<0,001). La morbilidad global (CC: 34,4% vs. CG: 46,5%, p=0.22), dehiscencia anastomótica (CC: 3,5% vs. CG: 6,8%, p=0.48) y la mortalidad (CC: 1,7% vs. CG: 9,3 %, p=0,08) fueron similares entre ambos grupos. Conclusión: La sigmoidectomía laparoscópica de urgencia realizada por CG presenta similar morbilidad y mortalidad postoperatoria que la realizada por CC. Sin embargo, la participación del especialista se asoció a una mayor frecuencia de anastomosis primarias, menos estomas y una estadía hospitalaria más corta.

Background: Sigmoid resection for perforated diverticulitis is one of the most common emergency surgeries and often performed by general surgeons. Relationship between high-volume surgeons and improved postoperative outcomes is well established. However, the influence of colorectal specialization on outcomes after emergency laparoscopic sigmoidectomy for perforated diverticulitis is not well described. Aim: Evaluate the impact of colorectal surgery training on the outcomes after emergency laparoscopic sigmoid resection for Hinchey III diverticulitis. Design: Retrospective analysis of prospectively collected database.Method: Patients undergoing emergent laparoscopic sigmoid resection for perforated (Hinchey III) diverticulitis were identified and stratified by involvement of colorectal or general surgeon. This study was conducted from 2000 to 2018 at a teaching hospital. Primary outcome measures were primary anastomosis, postoperative morbidity and mortality.Results: A total of 101 patients were identified; 58 by colorectal and 43 by general surgeons. Patients in the colorectal surgeon group had higher rates of primary anastomosis (CS: 98, 2% vs. GS: 67, 4%, p<0.001). General surgeons performed more ostomies (CS: 13, 8% vs. GS: 46, 5%, p<0.001), had a higher conversion rate (CS: 20, 6% vs. GS: 39, 5%, p=0.03) and longer mean length of hospital stay (CS: 6, 2 vs. GS: 10, 8 days, p<0.001). Overall morbidity (CS: 34, 4% vs. GS: 46, 5%, p=0.22), anastomotic leak rate (CC: 3,5% vs. CG: 6,8%, p=0.48) and mortality (CS: 1, 7% vs. GS: 9,3 %, p=0.08) were similar between groups. Conclusion: Emergency laparoscopic sigmoid resection by general surgeons wasn ́t associated with higher rates of postoperative morbidity, anastomotic leakage or mortality. However, patients operated by colorectal surgeons had higher rates of primary anastomosis, lower rates of ostomy, conversion and shorter length of hospital stay.

Peritonitis diverticular: ¿Qué nos enseñó Ladies Trial? Análisis metodológico de su diseño, aplicación y resultados / Diverticular peritonitis: What did LADIES Trial teach us? Analysis of design, application and results

Contexto y Antecedentes: LADIES TRIAL es uno de los ensayos más importantes referidos a peritonitis diverticular. A pesar de este y otros ensayos publicados, aún se debate cuáles son los procedimientos adecuados para cada escenario de peritonitis diverticular, haciendo necesaria una revisión profunda de la metodología empleada en los ensayos para validar u objetar sus conclusiones. Objetivos: Analizar la metodología empleada en el diseño, aplicación, análisis de resultados y conclusiones de sus publicaciones. Secundariamente, colaborar en el mejoramiento de la investigación de la peritonitis diverticular y facilitar el análisis del tema por parte de los lectores. Métodos: Se analizaron las partes centrales de toda investigación, desde la pregunta de investigación, elaboración de hipótesis, operacionalización de variables y diseño del ensayo, análisis estadístico de resultados y conclusiones. Se buscaron errores, sesgos y debilidades que pudiesen objetar los hallazgos del estudio. Resultados: LADIES se trató de un estudio randomizado, abierto con análisis de superioridad según intención de tratar modificada en aquellos casos de incumplimiento de los criterios de inclusión y exclusión. Su diseño fue en general correcto, aunque en su aplicación se detectaron errores, debilidades y sesgos. En cuanto a resultados LOLA mostró que en Hinchey III el lavado laparoscópico tiene mayor morbimortalidad temprana que la sigmoidectomía, con un tiempo operatorio menor. Por su parte, DIVA mostró que en Hinchey III y IV la anastomosis primaria tiene mayor sobrevida libre de ostomía con menor morbilidad, combinando la cirugía inicial y cierre ostomía, respecto de la operación de Hartmann. Conclusiones: El no haber llegado al tamaño de muestra calculado hizo que solo grandes diferencias consiguieran significancia estadística. Las bajas frecuencias de eventos adversos acentuaron este problema metodológico. La especialización de los centros y cirujanos intervinientes, como la exclusión de pacientes hemodinámicamente inestables o bajo corticoterapia comprometieron su validación externa.

Background: LADIES TRIAL is considered one of the most important trials related to diverticular peritonitis. Its protocol and results were published in 2010, 2015, 2017, and 2019. Despite this one and other published trials, the proper procedures for each diverticular peritonitis scenario are still being debated, a thorough review of the methodology used in this trial is necessary to validate or reject their conclusions. Aim: To analyze the methodology used in the design, application, analysis of results, and conclusions of all LADIES TRIAL publications. Secondly, to collaborate in the improvement of the research about diverticular peritonitis and to facilitate its analysis by the readers. Methods: The central parts of a research trial were analyzed, from the research question, hypothesis development, operationalization of variables and trial design, statistical analysis of results, to conclusions. Errors, biases and weaknesses were searched for to try and challenge the trial's findings. Results: LADIES was a randomized, open-label, superiority trial analyzed according to intention to treat modified in cases of non-compliance with the inclusion-exclusion criteria. Its design was generally correct, although errors, weaknesses, and biases were detected in its application. Regarding results, LOLA showed that, in Hinchey 3, laparoscopic lavage has a higher rate in early morbidity and mortality than sigmoidectomy, but with a shorter operative time. For its part, DIVA showed that, in Hinchey 3 and 4, the primary anastomosis has higher ostomy-free survival with less morbidity, combining the initial surgery and ostomy closure, compared to the Hartmann procedure. Conclusions: Not having reached the sample size calculated in its design implies that only large effect differences achieved statistical significance. The low frequencies of adverse events accentuated this methodological problem. The specialization of the intervening centers and surgeons, the exclusion of hemodynamically unstable patients or patients undergoing steroid therapy, compromised the external validation of their findings.

Manejo conservador en diverticulitis aguda perforada con aire extraluminal / Conservative management of perforated diverticulitis with extraluminal air

Resumen Introducción: El tratamiento óptimo de la diverticulitis perforada con aire extraluminal (DPA) es materia de debate. El manejo conservador es controversial; en casos seleccionados puede ofrecer menor morbimortalidad y evitar una ostomía. Objetivo: Describir las características clínicas, imagenológicas, necesidad de intervención quirúrgica y morbimortalidad de pacientes con DPA tratados con manejo conservador. Materiales y Método: Estudio descriptivo retrospectivo de pacientes hospitalizados con diagnóstico de DPA hemodinámicamente estables sin evidencia de peritonitis entre los años 2009 y 2015. Resultados: Se hospitalizaron 162 pacientes con diagnóstico de diverticulitis aguda (DA), el 53,1% fueron diverticulitis agudas complicadas (DC), de las cuales el 43% (37 casos) eran DPA, la edad promedio fue 59,6 años, la mayoría eran mujeres (54,1%). Las manifestaciones clínicas más comunes fueron dolor abdominal (97,3%), signos peritoneales (59,5%) y fiebre (40,5%). La tomografía axial computada de abdomen y pelvis (TC AP) mostró burbujas extracolónicas en el 78,4% y neumoperitoneo en el 21,6%. El manejo conservador fue exitoso en el 87,8%. Durante el seguimiento de 71,2 meses la recurrencia fue 28,1% y el 31,3% se realizó sigmoidectomía electiva. La falla del tratamiento médico se presentó en 5 casos (12,2%), uno de los cuales fallece. Conclusión: el manejo conservador de la DPA es una alternativa válida de tratamiento con alto porcentaje de éxito en pacientes hospitalizados seleccionados. La decisión de cirugía de urgencia y de sigmoidectomía electiva posterior a una DPA tratada médicamente debe ser individualizada.

Background: The conservative management of perforated diverticulitis with extraluminal air (PDA) is controversial. In selected hospitalized patients may offer less morbidity and mortality and avoid an ostomy. Aim: To describe its clinical and imagenologic characteristics, the need for surgical procedure and morbimortality of patients with perforated diverticulitis with extraluminal air in conservative management. Materials and Methods: Retrospective descriptive study of hemodynamically stable hospitalized patients with a PDA diagnosis without evidence of peritonitis during the years 2009 and 2015. Results: 162 patients were admitted with the diagnosis of acute diverticulitis. 53.1% of cases were acute complicated diverticulitis, 43% (37 cases) were PDA. The average age was 59.6 years and most of them women (54.1%). The most common clinical manifestations were abdominal pain (97.3%), peritoneal signs (59.5%) and fever (40.5%). The abdomen and pelvic computerized axial tomography scan showed extra-colonic bubbles in 78.4% and pneumoperitoneum in 21.6%. The conservative management was successful in 87.8% of cases. After a 71.2-month follow-up, the recurrence was 28.1% and 31.3% had an elective sigmoidectomy. 5 cases did not respond to medical treatment, one of them resulting in death. Conclusion: The conservative management of PDA is a valid treatment option with a high degree of success in the selected sample of hospitalized patients. The decision of having emergency surgery and elective sigmoidectomy post DPA should be evaluated individually.

Hyperbilirubinemia as a diagnostic tool in patients with perforated appendicitis: a prospective study

Background: This study was conducted to determine the effectiveness of hyperbililrubinemia as diagnostic tool to predict perforated appendicitis.Methods: Patients presenting to department of general surgery of SS Medical College and Hospital during the period from June 2017 to June 2019 with features of appendicitis and liver function tests on admission undergoing laparoscopic or open appendectomy were included in this study. Age, duration of symptoms, temperature, white blood cell counts, bilirubin levels and histological data were collected. Culture and sensitivity of peritoneal fluid was done. Patients were grouped according to histological examination of appendectomy specimens and comparison was made between the groups.Results: The mean bilirubin level of all patients was 0.95 mg/dl (range, 0.1-4.3 mg/dl). The mean bilirubin levels were higher for patients with simple appendicitis compared to those with a non-inflamed appendix (0.8 mg/dl and o.5 mg/dl, p<0.001). Hyperbilirubinaemia had a specificity of 88% and a positive predictive value of 88.89% for acute appendicitis. Patients with appendiceal perforation, however, had a mean bilirubin level of 1.5 mg/dl and were more likely to have hyperbilirubinaemia (p<0.001). The specificity of hyperbilirubinaemia for perforation or gangrene was 70%.Conclusions: patients with hyperbilirubinemia and clinical symptoms of appendicitis should be identified as having a higher probability of appendiceal perforation than those with normal bilirubin levels. Hyperbilirubinemia alone is not a strong enough predictor, but might be more useful when integrated into a scoring system.

Open versus laparoscopic repair of perforated duodenal ulcer: a comparative study

Background: Surgery is the mainstay of the treatment for perforated duodenal ulcer by closing the perforation with or without omental patch. There are no controversies in the surgical treatment of perforated duodenal ulcer but the best approach to surgery is still debatable. Advances in minimal access surgery has made it possible to close the perforated duodenal ulcer laparoscopically. The present study was conducted to compare the results of open and laparoscopic repair of perforated duodenal ulcer in terms of operative time, postoperative pain, hospital stay, and post-operative complications etc.Methods: The study was conducted in Dr. V. M. Government Medical College and Hospital located in Solapur (Maharashtra) from December 2008 to December 2010. It was a prospective comparative study. Patients were randomly divided into 2 groups alternately where group A and B were operated by conventional and laparoscopic techniques respectively and their outcomes were compared.Results: Most commonly affected age in this study was 51 to 60 years with male preponderance. Post-operative pain, analgesic requirement, wound infection, hospital stay, was significantly less in laparoscopic group as compared to open group (p<0.05).Conclusions: Laparoscopic repair of perforated duodenal ulcer is safe and feasible in properly selected patients and has superior results as compared to open surgery.

An Analysis of Role of Computed Tomography Scan Abdomen in Differentiating Perforated from Non-perforated Appendicitis Accurately and Comparing with Histopathology Reports

Background: Acute appendicitis is one of the most common abdominal surgical emergencies requiring accurate diagnosis. Itis characterized by obstruction of its lumen, leading to inflammation and finally perforation. To define its prognosis, choose anappropriate surgical procedure and to decide non-surgical treatment, the pre-operative diagnosis of perforated or non-perforatedappendicitis is very important.Aim of the Study: This study aims to analyze the diagnostic accuracy of computed tomography (CT) scan abdomen indifferentiating perforated from non-perforated appendicitis using histopathology as the final diagnosis.Materials and Methods: Aprospective, cross-sectional analytical study, wherein 85 patients diagnosed with acute appendicitisreferred to the radiological department for CT scan abdomen were included in the study. Patients aged between 15 and 70 yearswere included in the study. CT scan abdomen with and without contrast was performed on a Toshiba 64 Multislice CT scanner(Toshiba Medical Systems Corp., Tokyo, Japan) which was used for all the patients. All the CT scans were interpreted by the sameconsultant radiologists with a minimum of 5 years of experience. The radiological features for the diagnosis of non-perforatedacute appendicitis by CT were based on swollen appendix, thickened enhancing wall, and smudging of surrounding fat planes,whereas the radiological features for perforated appendicitis used were, with abscess formation, phlegmon, extraluminal air,extraluminal appendicolith, and focal defect in the appendicular wall. Histopathology of the specimen collected following surgerywas undertaken by the hospital consultant pathologist of more than 5-year experience.Observations and Results: Among the 85 patients included in this study for the analysis of CT scan abdomen features, therewere 57 (67.05%) males and 28 (32.94%) females with a male-to-female ratio of 2.03:1. The mean age of the patients was38.90 ± 6.70 years. The incidence of non-perforated appendicitis was 66/85 (77.64%) including males 44/85 (51.76%) andfemales 22/85 (25.88%). The incidence of perforated appendicitis was 19/85 (22.35%) and males were 12/85 (14.11%) and 7/85(8.23%) were female. Patients aged 15–45 years of both genders constituted to 63/85 (74.11%) of the total patients. Amongthese patients, presenting with non-perforated appendicitis was 51/85 (60%) and perforated appendicitis was 12/85 (14.11%).Conclusions: Multislice CT scan abdomen was considered as the modality of choice for acute appendicitis not only to confirmthe diagnosis but also it plays an important role in assessment of appendicular complication, particularly in the detection ofperforated appendix. Using one or more of the five radiological signs of CT scan abdomen to identify appendicular perforationraised the sensitivity significantly reaching 94.12%.

Etomidate reduces excitability of the neurons and suppresses the function of nAChR ventral horn in the spinal cord of neonatal rats / 南方医科大学学报

OBJECTIVE@#To investigate the effects of etomidate on electrophysiological properties and nicotinic acetylcholine receptors (nAChRs) of ventral horn neurons in the spinal cord.@*METHODS@#The spinal cord containing lumbosacral enlargement was isolated from 19 neonatal SD rats aged 7-12 days. The spinal cord were sliced and digested with papain (0.18 g/30 mL artificial cerebrospinal fluid) and incubated for 40 min. At the ventral horn, acute mechanical separation of neurons was performed with fire-polished Pasteur pipettes, and perforated patch-clamp recordings combined with pharmacological methods were employed on the adherent healthy neurons. In current-clamp mode, the spontaneous action potential (AP) of the ventral horn neurons in the spinal cord was recorded. The effects of pretreatment with different concentrations of etomidate on AP recorded in the ventral horn neurons were examined. In the voltage-clamp mode, nicotine was applied to induce inward currents in the ventral horn neurons, and the effect of pretreatment with etomidate on the inward currents induced by nicotine were examined with different etomidate concentrations, different holding potentials and different use time.@*RESULTS@#The isolated ventral horn neurons were in good condition with large diverse somata and intact processes. The isolated spinal ventral horn neurons (=21) had spontaneous action potentials, and were continuously perfused for 2 min with 0.3, 3.0 and 30.0 μmol/L etomidate. Compared with those before administration, the AP amplitude, spike potential amplitude and overshoot were concentration-dependently suppressed ( < 0.01), and spontaneous discharge frequency was obviously reduced ( < 0.01, =12). The APs of the other 9 neurons were completely abolished by etomidate at 3.0 or 30 μmol/L. At the same holding potential (VH=-70 mV), pretreatment with 0.3, 3.0 or 30.0 μmol/L etomidate for 2 min concentration-dependently suppressed the current amplitude induced by 0.4 mmol/L nicotine ( < 0.01, =7). At the holding potentials of - 30, - 50, and - 70 mV, pretreatment with 30.0 μmol/L etomidate for 2 min voltage-dependently suppressed the current amplitude induced by 0.4 mmol/L nicotine ( < 0.01, =6 for each holding potential). During the 6 min of 30.0 μmol/L etomidate pretreatment, the clamped cells were exposed to 0.4 mmol/L nicotine for 4 times at 0, 2, 4, and 6 min (each exposure time was 2 s), and the nicotinic current amplitude decreased gradually as the number of exposures increased. But at the same concentration, two nicotine exposures (one at the beginning and the other at the end of the 6 min pretreatment) resulted in a significantly lower inhibition rate compared with 4 nicotine exposures ( < 0.01, =6).@*CONCLUSIONS@#etomidate reduces the excitability of the spinal ventral neurons in a concentration-dependent manner and suppresses the function of nAChR in a concentration-, voltage-, and use-dependent manner.

A Retrospective Comparative Study Of Outcomes In Patients Of Perforated Peptic Ulcer Applied With Cellan-jones Repair Versus Graham's Patch

Perforated Peptic ulcer is a complication of peptic ulcer disease (PUD) and is a surgical emergency with high morbidity and mortality. This study was undertaken to compare the outcome in patients treated with Cellan-Jones repair and Grahams patch for the perforation of peptic ulcer (PPU). It is a retrospective study done on 50 patients operated for perforated peptic ulcer in the District Hospital at Al Ameen Medical College Hospital Bijapur Karnataka from 2002 to 2005. Patients with acute and chronic peptic ulcer perforation selected for surgery, out of 50 patients 38 patients selected for Cellan-Jones repair and 12 patients selected for Graham's patch. Statistical analysis using Chi-square test was used to study the outcome in patients treated with two different surgical procedures for that particular age, sex, and occupation. Age related morbidity and mortality was also compared in the given study. A total of 50 patients with perforated peptic ulcer 38 patient treated with Cellan-Jones repair and 12 patients applied with Graham's patch. The overall mortality rate is 6% with p-value ˂0/05; 95% C.I . This study shows that the patients treated with Cellan-Jones repair and Graham's patch for the perforated peptic ulcer is having almost same result. This indicates that both the surgical methods have better survival outcome.

To study the role of hyperbilirubinemia as a marker of gangrenous/ perforated appendicitis

Background: Acute appendicitis is the most common cause of acute abdomen in young adults requiring Emergency Surgery. Diagnosing Acute Appendicitis clinically still remains a common surgical problem. Accurate diagnosis can be aided by additional testing or expectant management or both. These might delay surgery and lead to appendicular perforation with increased morbidity and hospital stay. The aim of the study: To study the incidence of hyperbilirubinemia in cases of acute appendicitis and its complications (Gangrenous/ Perforated). Materials and methods: This Prospective study was done in the Department of General Surgery, Madras Medical College and Rajiv Gandhi Government General Hospital in 2017. Patient admitted with clinical diagnosis of acute appendicitis or its complications (Perforated/ Gangrenous) in the Emergency. Final HPE was considered as a gold standard for diagnosing and categorizing patients as having Normal Appendix, Acute appendicitis and Acute appendicitis with Perforation/Gangrene. Results: Out of 246 cases of Acute appendicitis 42 Cases were Gangrenous/ Perforated Appendix (17.07%). Out of 42 cases of Gangrenous/ Perforated appendix maximum cases seen in the Age group 21-30 years (31%) and least seen in below 10 years (0.0%). Above 50 years no of cases of Gangrenous/ Perforated appendix were 3 (7.1%). Rebound tenderness predominantly present in cases of Gangrenous/ Perforated Appendicitis than Acute appendicitis cases and its statistically significant. Among 246 cases minimum age was 9 and the maximum age was 65 years and the mean age was 24 years. Mean Total leukocyte count was 12687 and Mean polymorph count was 75. Serum mean total T. Avvai, S. Nedunchezian. To study the role of hyperbilirubinemia as a marker of gangrenous/ perforated appendicitis. IAIM, 2019; 6(3): 272-277. Page 273 bilirubin was .92 and maximum was 2.4 Alvarado’s score maximum seen was 10 and least was 5 with mean about 7. Conclusion: Patients with clinical signs and symptoms of Acute appendicitis with raised serum bilirubin should be considered as having high predictive potential for Appendicular gangrene/ Perforation. Serum Bilirubin is an important adjunct in diagnosing the presence of Gangrenous/ Perforated Appendicitis along with other diagnostic aids.

Factors predicting difficulty of thyroidectomy preoperatively

Background: Today, thyroidectomy is a common operation used to treat various thyroid disorders. Nowadays, many high-volume thyroid surgeons are discharging patients on the same day of thyroidectomy. The incidence of complications following thyroidectomy is directly linked to the difficulty of the procedure. So, if we can predict the difficulty of thyroidectomy preoperatively, we can anticipate complications and decide on which patients will require in-patient care. Materials and methods: A thyroidectomy difficulty scale was developed by Schneider and colleagues. This scale was used in our study to classify patients in to difficult thyroidectomy group and non-difficult thyroidectomy group. The association between preoperative variables and difficulty of thyroidectomy was studied. Results: Statistical analysis revealed that there was a significant association between hyperthyroidism and difficult thyroidectomy. Similarly, there was a significant association between positive antithyroid peroxidase antibody (which defines Hashimoto’s thyroiditis) and difficult thyroidectomy. Also, there was a significant association between positive anti-thyroglobulin antibody and difficult thyroidectomy. Difficult thyroidectomy was found to have a significant association with postoperative hypocalcemia. Statistical analysis also showed duration of surgery to have a significant association with difficulty of thyroidectomy Conclusion: Patients with hyperthyroidism, positive anti-thyroid peroxidase antibodies, and positive anti-thyroglobulin antibodies have a high probability of a difficult thyroidectomy, associated with longer operative times and increased complications. This information can improve preoperative risk counseling and lead to more efficient scheduling of the operating room.

A Cross-Sectional Study of Neutrophilto- Lymphocyte Ratio in Diagnosing Acute Appendicitis in Hospital Melaka

@#Background: Acute appendicitis is one of the most common surgical emergencies. However, its proper diagnosis is complicated. This study aims to evaluate the ability of the neutrophil-to-lymphocyte ratio (NLR) to diagnose acute appendicitis in pre-operative state. Methods: Histopathological examination of appendicectomies conducted between 2016 and 2017 in Melaka Hospital, Malaysia were traced and categorised into three groups: i) G1 (normal appendix), ii) G2 (acute appendicitis) and iii) G3 (perforated appendicitis). The reports were randomised and a total of 338 samples were collected. NLR values were compared between the three different groups and analysed. Results: The median values of NLR for G1, G2 and G3 were 2.37, 5.25 and 9.27, respectively. We found a statistically significant difference in NLR between G1 and G2 (P < 0.001), and G2 and G3 (P < 0.001). The diagnostic values of NLR for acute appendicitis and perforated appendicitis were 3.11 (sensitivity: 75.23%, specificity: 68.70%) and 6.17 (sensitivity: 76.32%, specificity: 58.72%), respectively. There was a substantial correlation between NLR and disease severity, and a moderate correlation between NLR and duration of admission. Conclusion: NLR, with a sensitivity of 75.23% and specificity of 68.70%, is a useful and reliable adjunct in diagnosing acute appendicitis. Hence, it will help in reducing the rate of negative appendicectomies.

Hematocolpos por himen imperforado en una adolescente / Hematocolpus due to non-perforated hymen in an adolescent

Se describe el caso clínico de una adolescente de 12 años de edad, quien había estado ingresada 5 años atrás en el Servicio de Terapia Intensiva del Hospital Pediátrico Docente Sur Antonio María Béguez César de Santiago de Cuba por presentar enfermedad estafilocócica y amenorrea primaria. Esta vez acudió a consulta con dolor abdominal recurrente desde hacía 3 meses, localizado en hipogastrio, acompañado de náuseas y vómitos, que se aliviaba con los analgésicos habituales. Se le realizó la prueba de embarazo cuyo resultado fue negativo y las imágenes ecográficas sugirieron la presencia de hematocolpos. Se le realizó himenotomía y egresó de la institución 48 horas después con evolución favorable.

The case report of a 12 years-old adolescent is described who had been admitted 5 years ago in the Intensive Therapy Service of Antonio María Béguez Caesar Southern Teaching Pediatric Hospital in Santiago de Cuba staphylococcal disease and primary amenorrhoea. This time she attended the service with recurrent abdominal pain for 3 months, located in hypogastrium, accompanied by nauseas and vomits that were alleviated with the habitual analgesic ones. The pregnancy test was carried out with negative result and the echographic images suggested hematocolpus. The himenotomy was practiced and was discharged from the institution 48 hours later with favorable clinical course.