Scalpel and strife: Assessing the impact of Sudan's ongoing civil war on surgical practice and healthcare delivery.

BACKGROUND: This study aims to shed light on the profound ramifications of the military conflict that started in April 2023 on surgical practice in Sudan. METHODS: This is a survey-based study. The survey link was disseminated to Sudanese medical practitioners via various social media (WhatsApp, Telegram, X (previously twitter) and Facebook) channels. We included only responses from medical practitioners working in the surgical specialities. RESULTS: A total of 90 responses have been collected. All participants were working in surgical service provision institutes. Sixty per cent of the responses were from the age group 25-35 years old, and two-thirds of the total cohort either left Sudan or was internally displaced because of the conflict. Moreover, 51% are no longer practising because they had to flee the conflict area (75%) or because the hospital is out of service (20%). There was a significant drop in the average number of emergency and elective lists. CONCLUSION: The military conflict affected Sudan's already strained health system. There was a significant drop in the average number of emergency and elective lists with surgeons out of practice because they had to flee the conflict area and hospitals were out of service.

Impact of COVID-19 on the Mode of Presentation and Stage at Diagnosis of Colorectal Cancer.

AIM: This study compares the stage at the presentation of patients with colorectal cancer (CRC) before and after introducing COVID-19 restrictions and the mode of presentation. METHODS: This is a retrospective cohort study comparing the incidence of CRC, TNM stage and mode of presentation in the pre-COVID and COVID cohorts at a single UK Trust. All patients discussed at the CRC multidisciplinary team (MDT) from March 2017 to March 2021 were included and split into two cohorts; the pre-COVID group from 01/03/2017 to 29/02/2020 and the COVID group from 01/03/2020 to 28/02/2021. Percentages were used for descriptive statistics. Student's t-test was used for the comparison of demographic variables. Chi-squared test was used for the difference analysis for the categorical data, such as TNM and mode of presentation. P value ≤0.05 was significant. RESULTS: In total, 1373 patients were diagnosed with CRC during the period from March 2017 to March 2021. The pre-COVID group (2017-2020) included 1104 CRC patients, compared to 269 patients in the COVID one (2020-2021). The mean age was higher in the pre-COVID group (p = 0.001). There was a statistically significant increase in the proportion of cases presenting with T4 disease (p = 0.023) and metastatic disease (p = 0.032) in the COVID group compared to the pre-COVID group. There was also a significant increase in the rate of emergency presentations (p < 0.0001). CONCLUSION: We observed a statistically significant increase in rates of locally advanced (T4) and metastatic (distant) CRC in patients presenting after introducing the COVID-19 lockdown. There was also an increase in emergency presentations. There was no observed difference in nodal status. This may reflect disruption to cancer diagnostic services and the reluctance of patients to access medical care during a pandemic, particularly the elderly.

Evaluation of Drain Insertion After Appendicectomy for Complicated Appendicitis: A Systematic Review and Meta-Analysis.

This meta-analysis aims to evaluate the comparative outcomes of drain insertion versus no drain after appendicectomy for complicated appendicitis. A systematic search of PubMed, Cochrane Library and Scopus was conducted, and all studies comparing drain versus no drain after appendicectomy for complicated appendicitis were included. Abdominal collection, surgical site infection (SSI), bowel obstruction, faecal fistula, paralytic ileus, length of hospital stay (LOS) and mortality were the evaluated outcome parameters for the meta-analysis. Seventeen studies reporting a total number of 4,255 patients who underwent appendicectomy for complicated appendicitis with (n=1,580) or without (n=2,657) drain were included. There was no significant difference between the two groups regarding abdominal collection (odds ratio (OR)=1.41, P=0.13). No-drain group was superior to the drain group regarding SSI (OR=1.93, P=0.0001), faecal fistula (OR=4.76, P=0.03), intestinal obstruction (OR=2.40, P=0.04) and paralytic ileus (OR=2.07, P=0.01). There was a difference regarding mortality rate between the two groups (3.4% in the drain group vs 0.5% in the no-drain group, risk difference (RD)=0.01, 95% CI (-0.01, 0.04), P=0.36). In conclusion, this meta-analysis has shown that drains have no effect on the development of intra-abdominal collections in complicated appendicitis, but it can significantly increase the risk of postoperative complications such as fistula, surgical site infection (SSI), bowel obstruction, ileus and length of hospital stay.

Systematic review and meta-analyses of cholecystectomy as a treatment of biliary hyperkinesia.

Biliary hyperkinesia is typically diagnosed in patients with biliary-like pain and no evidence of gall stones on imaging modalities but who have had biliary scintigraphy scan (HIDA) that shows ejection fraction ≥ 80%. This study aims to identify whether the removal of the gall bladder can alleviate the symptoms associated with biliary hyperkinesia. Systematic search following PRISMA guidelines was done from inception to January 2020 using PubMed/Medline, OVID, Embase, Cochrane database of systemic reviews, Cochrane central register of controlled trials, The Database of Abstracts of Reviews of Effects (DARE) and Cochrane library databases. Results were expressed as risk ratios (RR) for dichotomous outcomes together with 95% confidence intervals (CI) or mean differences (MD) or standardized MD (SMD) for continuous outcomes. A meta-analysis was done using random-effect model in RevMan 5.4® software. Thirteen studies met the inclusion criteria and were included in the review. A total of 332 patients diagnosed with biliary hyperkinesia underwent cholecystectomy, of whom 303 (91.3%) reported symptomatic improvement RR 8.67 (95% CI 4.95, 15.16) P = 0.01. Six studies described abnormal histological features in 163/181 (90.05%) with high GB EF. RR 7.88 (95% CI 3.94, 15.75) P = 0.08. Chronic cholecystitis n = 155 (95%), cholesterolosis n = 7 (4.3%), and one showed features of acute cholecystitis. Patients with typical biliary colic symptoms without gallstones and markedly high ejection fraction might benefit from having cholecystectomy to alleviate their symptoms.

Management of Lower Limb Ischemia During Operative Repair of Acute Type A Aortic Dissection by Distal Crossover Grafts: a Case Series.

OBJECTIVE: To describe our experience of nine patients with extra-anatomical bypass for clinically ischemic distal limb during repair of acute Type A aortic dissection (ATAAD). METHODS: We retrospectively examined a series of nine patients who underwent surgery for ATAAD. We identified a subset of the patients who presented with concomitant radiographic and clinical signs of lower limb ischemia. All but one patient (axillobifemoral bypass) underwent femorofemoral crossover grafting by the cardiac surgeon during cooling. RESULTS: One hundred eighty-one cases of ATAAD underwent surgery during the study period with a mortality of 19.3%. Nine patients had persistent clinical evidence of lower limb ischemia (4.9%) and underwent extra-anatomical bypass during cooling. Two patients underwent additional fasciotomies. Mean delay from symptoms to surgery in these nine patients was 9.5 hours. Two patients had bilateral amputations despite revascularisation and, of note, had long delays in presentation for surgery (> 12 hours). There were no mortalities during these inpatient episodes. Outpatient radiographic follow-up at the first opportunity demonstrated 100% patency. CONCLUSION: Our experience suggests that, during complicated aortic dissection, limb ischemia may have a devastating outcome including amputation when diagnosis and referral are delayed. Early diagnosis and surgery are crucial in preventing this potentially devastating complication.

Management of lower limb ischemia during operative repair of acute type a aortic dissection by distal crossover grafts: a case series

Abstract Objective: To describe our experience of nine patients with extra-anatomical bypass for clinically ischemic distal limb during repair of acute Type A aortic dissection (ATAAD). Methods: We retrospectively examined a series of nine patients who underwent surgery for ATAAD. We identified a subset of the patients who presented with concomitant radiographic and clinical signs of lower limb ischemia. All but one patient (axillobifemoral bypass) underwent femorofemoral crossover grafting by the cardiac surgeon during cooling. Results: One hundred eighty-one cases of ATAAD underwent surgery during the study period with a mortality of 19.3%. Nine patients had persistent clinical evidence of lower limb ischemia (4.9%) and underwent extra-anatomical bypass during cooling. Two patients underwent additional fasciotomies. Mean delay from symptoms to surgery in these nine patients was 9.5 hours. Two patients had bilateral amputations despite revascularisation and, of note, had long delays in presentation for surgery (> 12 hours). There were no mortalities during these inpatient episodes. Outpatient radiographic follow-up at the first opportunity demonstrated 100% patency. Conclusion: Our experience suggests that, during complicated aortic dissection, limb ischemia may have a devastating outcome including amputation when diagnosis and referral are delayed. Early diagnosis and surgery are crucial in preventing this potentially devastating complication.