Frequency of colorectal surveillance colonoscopies for adenomatous polyps: systematic review and meta-analysis.

BACKGROUND AND AIM: The purpose of this study was to assess evidence on the frequency of polyp surveillance colonoscopies performed earlier than the recommended follow-up intervals in clinical practice guidelines. METHODS: A systematic review was performed based on electronic searches in PubMed and Embase. Research articles, letters to the editors, and review articles, published before April 2022, were included. Studies that focused on the intervals of polyp surveillance in adult populations were selected. The Risk Of Bias In Non-randomized Studies of Exposure (ROBINS-E) was used to assess the risk of bias. A meta-analysis was performed with Forest plots to illustrate the results. RESULTS: In total, 16 studies, comprising 11 172 patients from Australia, Europe, and North America, were included for analysis. The quality of the studies was moderate. Overall, 38% (95% CI: 30-47%) of colonoscopies were undertaken earlier than their respective national clinical guidelines. In risk-stratified surveillance, 10 studies contained data relating to low-risk polyp surveillance intervals and 30% (95% CI: 29-31%) of colonoscopies were performed earlier than recommended. Eight studies contained data relating to intermediate-risk polyp surveillance and 15% (95% CI: 14-17%) of colonoscopies were performed earlier than recommended. One study showed that 6% (95% CI: 4-10%) of colonoscopies performed for high-risk polyp surveillance were performed earlier than recommended. CONCLUSIONS: A significant proportion of polyp surveillance was performed earlier than the guidelines suggested. This provides evidence of the potential overuse of healthcare resources and the opportunity to improve hospital efficiency.

Extraperitoneal parastomal metastasis of malignant peritoneal mesothelioma.

A 75-year-old man was referred to surgical outpatient department with what was thought to be a parastomal hernia. Through further investigations with CT and biopsy, it was identified that the parastomal mass was metastatic peritoneal mesothelioma in the abdominal wall and subcutaneous tissue. The patient had a significant surgical history including a previous abdominoperineal resection with end colostomy 9 years prior and a right hemicolectomy for small bowel obstruction the previous year which diagnosed peritoneal mesothelioma. Peritoneal mesothelioma often spreads throughout the abdominal cavity and rarely spreads outside the peritoneum, with this being the first case describing parastomal metastasis. Given the patient's surgical background, this is possible to have contributed to seeding the spread of peritoneal mesothelioma.

Systematic use of the serum C-reactive protein concentration and computed tomography for the detection of intestinal anastomotic leaks.

BACKGROUND: This study aimed to characterize the time-dependent relationship between serum C-reactive protein (CRP) and anastomotic integrity in the early post-operative period and to develop a systematic use of CRP and computed tomography. METHODS: Patients aged 18 years or over who had the formation of a left-sided colonic or a colorectal anastomosis, in Royal Sussex County Hospital, were included. The post-operative day (POD) CRP cut-off values were calculated according to receiver operating characteristic analysis to evaluate the sensitivities and specificities of the proposed cut-off parameters. RESULTS: A total of 125 left-sided colonic and colorectal anastomoses were recruited and analysed. When comparing to POD1 CRP cut-off, the calculated CRP ratio cut-off values of all the rest of PODs (2-5) were highly significant in the laparoscopic group and the overall group (P < 0.001). This statistically significant ratio was also demonstrated in the open group at POD2 (P < 0.0001). CONCLUSION: CRP and CRP ratios cut-off values were sensitive to detect an anastomotic leak in the early post-operative period. The cut-off values could facilitate the development of systematic use of CRP and computed tomography.

Benchmarking against the National Emergency Laparotomy Audit recommendations.

BACKGROUND: The Royal College of Anaesthetists published the National Emergency Laparotomy Audit (NELA) to describe and compare inpatient care and outcomes of major emergency abdominal surgery in England and Wales in 2015 and 2016. The purpose of this article is to compare emergency abdominal surgical care and mortality in a regional hospital (Logan Hospital, Queensland, Australia) with NELA results. METHODS: Data were extracted from two databases. All deaths from May 2010 to April 2015 were reviewed and patients who had an emergency abdominal operation within 30 days of death were identified. The health records of all patients who underwent abdominal surgery were extracted and those who had an emergency laparotomy were identified for analysis. RESULTS: Three hundred and fifty patients underwent emergency laparotomy and were included in the analysis. The total 30-day mortality during this 5-year period was 9.7%. Factors affecting mortality included age, Portsmouth-Physiological and Operative Severity Score (P-POSSUM) and admission source. Timing of antibiotic administration, use of perioperative medical service and frequency of intensive care admission were the same in patients who died and survived. CONCLUSION: Mortality in patients following emergency laparotomy at Logan Hospital compares favourably with 11.1% reported by NELA. This may be partly attributable to case mix distribution as for each P-POSSUM risk Logan Hospital mortality was at the upper end of that reported by NELA. Further Australia data are required. Improved compliance with NELA recommendations may improve outcomes.

An audit of characteristics and outcomes in adult intensive care patients following tracheostomy.

BACKGROUND: Tracheostomies are commonly performed on critically ill patients requiring prolonged mechanical ventilation. The purpose of this study was to review our experience with surgical and percutaneous tracheostomies and identify factors affecting outcome. MATERIALS AND METHODS: Patients who underwent tracheostomy between January 1999 and June 2008 were identified on the basis of Diagnostic Related Group coding and the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification procedural code. The primary endpoint was in-hospital mortality. Contingency tables were generated for clinical variables and a chi-squared test was used to determine significance. RESULTS: One hundred and sixty-eight patients underwent tracheostomy between January 1999 and 30 June 2008. In-hospital mortality was 22.6%. The probability of death was found to be independent of timing of tracheostomy, technique used (percutaneous vs. surgical), number of failed extubations and obesity. On univariate analysis, the null hypothesis of independence was rejected for age on admission (P = 0.014), diagnosis of sepsis (P = 0.0008) or cardiac arrest (P = 0.0016), Acute Physiology and Chronic Health Evaluation II score (P = 0.0319) and the Australasian Outcomes Research Tool for Intensive Care calculated risk of death (P = 0.0432). CONCLUSION: Although a number of patient factors are associated with worse outcome, tracheostomy appears to be a relatively safe technique in the Intensive Care Unit population.

Grade 4 renal injury: current trend of management and future directions.

The management of blunt renal trauma has been evolving. The past management largely based on American Association for Surgery of Trauma (AAST) grading system, i.e. necessitated a computed tomography (CT) scan. Although the CT scan use is increasing and becomes the standardized mode of investigation, AAST grading no longer plays the sole role in the decision of surgical interventions. Two case reports of blunt renal trauma managed successfully by conservative methods are presented. Case one was an 18 year-old boy who had a fall when riding a motorbike at 20 km/h with a helmet and full protective equipments. He was landed by his left flank onto a rock. Contrast abdominal CT revealed a 4 cm, grade III splenic tear and a grade IV left kidney injury with large perirenal haematoma. His international severity score (ISS) was 34. He was managed conservatively with bed rest and frequent serum haemoglobin monitoring. Subsequent CT with delayed contrast revealed stable perirenal haematoma with urine extravasation which was consistent with a grade IV renal injury. Case two was a 40 year-old male who had a motor bike accident on a racetrack when he was driving at 80 to 100 km/h, wearing a helmet. He lost control and hit onto the sidewall of the racetrack. Contrast abdominal CT revealed a grade IV left renal injury with a large urine extravasation. His renal injury was managed conservatively with interval delayed phase CT of the abdomen. A repeat CT on abdomen was performed five months after the initial injury which revealed no residual urinoma. In this study, moreover, a review of the literature to the management of blunt renal trauma was conducted to demonstrate the trend of increasing conservative management of such traumas. Extra radiological parameters may guide future decision making. However, the applicability of data may be limited until randomized trials are available.