Clinical relevance of the 3-cm threshold in sigmoid diverticulitis with abscess: consensus or quandary?

PURPOSE: Diverticular abscess is a common manifestation of acute complicated diverticulitis. We aimed to analyze the clinical course of patients with diverticular abscess initially treated conservatively. METHODS: All patients with diverticular abscess undergoing elective or urgent/emergency surgery from October 2004 to October 2022 were identified from our institutional database. Depending on the abscess size, patients were divided into group A (≤ 3 cm) and group B (> 3 cm). Conservative treatment failure was defined as clinical deterioration, persistent or recurrent abscess, or urgent/emergency surgery. Baseline characteristics and short-term perioperative outcomes were recorded and compared between both groups. Uni- and multivariate analyses were conducted to identify determinants of conservative treatment failure and overall ostomy formation. RESULTS: A total of 105 patients were enrolled into group A (n = 73) and group B (n = 32). Uni- and multivariate analyses revealed abscess size as the only significant factor of conservative therapy failure [OR 9.904; p < 0.0001], while overall ostomy formation was significantly affected by an increased body mass index (BMI) [OR 1.366; p = 0.026]. There were no significant differences in perioperative outcome with the exception of a longer total hospital stay in patients managed with abscess drainage compared to antibiotics alone prior surgery in group B (p = 0.045). CONCLUSION: Abscess diameter > 3 cm is not just an arbitrary chosen cut-off value for drainage placement but has a prognostic impact on medical treatment failure in patients with complicated acute diverticulitis. In this subgroup, the choice between primary drainage and antibiotics does not appear to influence outcome at the cost of prolonged hospital stay after drainage insertion.

Caffeine intake enhances bowel recovery after colorectal surgery: a meta-analysis of randomized and non-randomized studies.

Postoperative ileus (POI) after colorectal surgery is a major problem that affects both patient recovery and hospital costs highlighting the importance of preventive strategies. Therefore, we aimed to perform a systematic analysis of the effects of postoperative caffeine consumption on bowel recovery and surgical morbidity after colorectal surgery. A comprehensive literature search was conducted through September 2023 for randomized and non-randomized trials comparing the effect of caffeinated versus non-caffeinated drinks on POI by evaluating bowel movement resumption, time to first flatus and solid food intake, and length of hospital stay (LOS). Secondary outcome analysis included postoperative morbidity in both groups. After data extraction and inclusion in a meta-analysis, odds ratios (ORs) for dichotomous variables and standardized mean differences (SMDs) for continuous outcomes with 95% confidence intervals (CIs) were calculated. Subgroup analyses were performed in cases of substantial heterogeneity. Six randomized and two non-randomized trials with a total of 610 patients were included in the meta-analysis. Caffeine intake significantly reduced time to first bowel movement [SMD -0.39, (95% CI -0.66 to -0.12), p = 0.005] and time to first solid food intake [SMD -0.41, (95% CI -0.79 to -0.04), p = 0.03] in elective laparoscopic colorectal surgery, while time to first flatus, LOS, and the secondary outcomes did not differ significantly. Postoperative caffeine consumption may be a reasonable strategy to prevent POI after elective colorectal surgery. However, larger randomized controlled trials (RCTs) with homogeneous study protocols, especially regarding the dosage form of caffeine and coffee, are needed.

Routine closed-suction drainage reduces seromas following totally extraperitoneal (TEP) inguinal hernia repair: A meta-analysis.

BACKGROUND: The value of prophylactic closed-suction drainage in totally extraperitoneal inguinal hernia repair (TEP) is still a matter of controversy. We conducted a meta-analysis of studies examining postoperative seroma rates in patients with or without routine placement of closed-suction drainage tubes. METHODS: A systematic literature search was conducted for trials comparing the outcome of TEP with or without routine drainage placement. Data regarding postoperative outcomes were extracted and compared by meta-analysis. The odds ratio and standardized mean differences with 95% confidence intervals were calculated. RESULTS: Four studies were identified, involving a total of 1626 cases (Drain: n = 1251, no Drain: n = 375). There was a statistically significant difference noted between the 2 groups regarding postoperative seroma formation favoring the Drain group (odds ratio = 0.12; 95% confidence intervals [0.05, 0.29]; P < .001; 4 studies; I2 = 72%). For the remaining secondary endpoints postoperative urinary retention, recurrence, mesh infection and in-hospital length of stay no statistically significant difference was noted between the 2 study groups. CONCLUSION: Current evidence suggests that patients who underwent TEP with routine closed-suction drain placement developed significantly fewer seromas without any additional morbidity or prolongation of in-hospital stay.

A Revised Version of the TNM Classification Leads to Optimized Predictive Performance in Patients with Adrenocortical Carcinoma.

The prognostic stratification of the current AJCC/UICC TNM classification for adrenocortical carcinoma (ACC) has been validated in only a few studies. In this study, it was hypothesized that redefining the T category cut-off would result in a significant improvement in estimated stage-related survival. In 935 patients with ACC from the SEER database, optimal cut-off values based on tumor size were first determined to redefine T1 and T2 categories. Cox proportional hazards regression analysis and receiver operating characteristics (ROC) were then used to determine the prognostic value of the revised version. A new cut-off value of 9.5 cm tumor size was established to differentiate between T1 and T2 tumors, leading to a revised TNM classification. As a result, a more homogeneous distribution of patients with ACC across all stages was observed. Notably, the predictive value of the newly proposed TNM classification in the ROC analysis exceeded that of the 7th and 8th editions of the AJCC/UICC classification system. Finally, the prognostic superiority of the revised TNM classification was confirmed in a multivariate Cox proportional hazards regression model. In conclusion, the present study demonstrates that updating the current staging system with revised T1 and T2 categories significantly improves the prediction of cancer-specific survival (CSS) in patients with ACC.

Jejunal Intussusception Due to Heterotopic Pancreas: A Case Report.

Intussusception in adults is rare. Even more unusual is jejunal intussusception secondary to a heterotopic pancreas. The presence of pancreatic tissue in an ectopic location and lacking contiguity with the main pancreatic gland is defined as pancreatic heterotopia. It is very rarely symptomatic and usually diagnosed incidentally during surgical intervention for other conditions. We report the case of a 78-year-old lady who presented with a history of constipation, abdominal pain, and vomiting. A CT scan revealed features of a proximal jejunojejunal intussusception secondary to a small soft tissue density lead point. After laparotomy and segmental jejunal resection, histopathology confirmed the diagnosis of ectopic pancreatic tissue as the lead point. Although uncommon, heterotopic pancreatic tissue should be included in the differential diagnosis for proximal small bowel intussusception.

Efficacy of universal preoperative decolonization with Polyhexanide in primary joint arthroplasty on surgical site infections. A multicenter before-and after-study.

BACKGROUND: Surgical site infections (SSI) are rare but severe complications after total joint arthroplasty (TJA). Decolonization measures prior to elective orthopedic surgeries have shown to reduce the risk of SSI with Staphylococcus aureus (S. aureus). OBJECTIVE: To determine the efficacy of universal decolonization with Polyhexanide on SSI rates with a focus on Staphylococcus aureus in patients with TJA. METHODS: Patients scheduled for elective hip or knee TJA in 5 participating certified orthopedic centers were included between 2015 and 2018 into this before and after study. Data on patients, surgeries and infections were prospectively collected. CDC-criteria were used to define and categorize Infections within 90 days after surgery. From January 2017 on, patients received decolonization sets containing Polyhexanide. Patients performed a 5 day decolonization regimen starting 4 days prior to surgery which included wipes, nasal decontamination and oral solution. RESULTS: Thirteen thousand, three hundred fifteen patients received TJA. During intervention 4437 decolonization sets were distributed among 7175 patients. Overall SSI rates increased from 0.68 /100 surgeries to 0.91/ 100 surgeries after implementation of the intervention (IRR 1.32; 95% CI 0.90-1.96). Time series analysis identified an increasing trend of SSI prior to the intervention. After implementation overall SSI rates plateaued. Regression analysis revealed surgery during intervention period to be an independent risk factor for developing a SSI (OR 1.34; 95%CI 1.18-1.53). Initial SSI rates due to S. aureus were 0.24/100 surgeries and decreased to 0.14/100 surgeries (IRR 0.57; 95% CI 0.25-1.22) after introduction of decolonization. Regression analysis revealed surgery during intervention period to be an independent protective factor for developing a SSI with S. aureus (OR 0.57, 95% CI: 0.33-0.99). Overall deep S. aureus SSI decreased significantly from 0.22/100 surgeries to 0.00/100 surgeries in patients adherent to protocol (IRR 0.00, 95% CI 0.00-.85). CONCLUSION: Universal decolonization with Polyhexanide did not reduce overall surgical site infections, but was effective in reducing Staphylococcus aureus - surgical site infections following elective joint arthroplasty. Polyhexanide could extend the list of alternatives to already established decolonization strategies. TRIAL REGISTRATION: The trial was registered at the German Registry for clinical studies www.drks.de ( DRKS00011505 ).

Designer nuclease-mediated gene correction via homology-directed repair in an in vitro model of canine hemophilia B.

BACKGROUND: Gene correction at specific target loci provides a powerful strategy for overcoming genetic diseases. In the present study, we aimed to use an in vitro model for canine hemophilia B containing a single point mutation in the catalytic domain of the canine coagulation factor IX (cFIX) gene. To correct the defective gene via homology-directed repair (HDR), we designed transcription-activator like effector nucleases and clustered regularly interspaced short palindromic repeats including Cas9 (CRISPR/Cas9) for introduction of double-strand breaks at the mutation site. METHODS: To generate a stable cell line containing the mutated cFIX locus, a 2-kb genomic DNA fragment derived from a hemophilia B dog was amplified and integrated utilizing the phiC31 integrase system. Designer nucleases were assembled and cloned into vectors for constitutive and inducible expression. To detect mutations, insertions and deletions, and HDR events after nuclease treatment T7E1 assays, an amplification-refractory mutation system-quantitative polymerase chain reaction and pyrosequencing were performed. RESULTS: To perform HDR correction experiments, we established a cell line carrying the mutated cFIX locus. In HDR approaches we either explored a wild-type or an optimized cFIX sequence and we found that our modified HDR cassette showed higher gene correction efficiencies of up to 6.4%. Furthermore, we compared inducible and constitutive designer nuclease expression systems and found that the inducible system resulted in comparable HDR efficiencies. CONCLUSIONS: In conclusion, the present study demonstrates the potential of this strategy for gene therapeutic approaches in vitro and in a canine model for hemophilia B.

CRISPR/Cas9 delivery with one single adenoviral vector devoid of all viral genes.

The Clustered Regularly Interspaced Short Palindromic Repeats (CRISPR)/Cas9 system revolutionized the field of gene editing but viral delivery of the CRISPR/Cas9 system has not been fully explored. Here we adapted clinically relevant high-capacity adenoviral vectors (HCAdV) devoid of all viral genes for the delivery of the CRISPR/Cas9 machinery using a single viral vector. We present a platform enabling fast transfer of the Cas9 gene and gRNA expression units into the HCAdV genome including the option to choose between constitutive or inducible Cas9 expression and gRNA multiplexing. Efficacy and versatility of this pipeline was exemplified by producing different CRISPR/Cas9-HCAdV targeting the human papillomavirus (HPV) 18 oncogene E6, the dystrophin gene causing Duchenne muscular dystrophy (DMD) and the HIV co-receptor C-C chemokine receptor type 5 (CCR5). All CRISPR/Cas9-HCAdV proved to be efficient to deliver the respective CRISPR/Cas9 expression units and to introduce the desired DNA double strand breaks at their intended target sites in immortalized and primary cells.

In the line of fire--21st-century approach to an ancient war injury.

Authentic black-powder muzzle-loader weapons or replicas are used today primarily for re-enactments of historic battles. A lay actor playing the role of a Prussian infantryman sustained life-threatening gunshot injuries during a recent re-enactment of a historic battle of the Sixth Coalition. As only blank historic muzzle-loading weaponry was used, the origin of the missile causing the wounding was initially unclear. Further investigation revealed a ramrod that had been propelled out of the barrel of another gunner's smooth-bore gun as cause of injury. The ramrod was hurled on a trajectory of more than 20 m, breaking the victim's shouldered barrel and hitting the victim resulting in severe abdominal, thoracic, and upper limb injuries. The critical incidents while handling muzzle-loading weaponry leading to premature discharge are elucidated. Furthermore, this report demonstrates how actual diagnostics and subsequent surgical treatment enabled this infantryman to survive an injury to which his comrades-in-arms would have succumbed 200 years ago.