Perforated marginal ulcer after gastric bypass for obesity: a systematic review.

Marginal ulcers are a recognized complication of gastric bypass procedures for obesity. Perforated marginal ulcer (PMU) is a life-threatening complication of marginal ulcers. We performed a systematic review to understand the presentation, management, and outcomes of PMUs. PubMed, Google Scholar, and Embase databases were searched to identify all studies on PMUs after gastric bypass procedures. A total of 610 patients were identified from 26 articles. The mean age was 39.8±2.59 years, and females represented most of the cohort (67%). The mean body mass index was 43.2±5.67 kg/m2. Most of the patients had undergone a Roux-en-Y gastric bypass (98%). The time gap between the primary bariatric surgery and the diagnosis of PMU was 27.5±8.56 months. The most common presenting symptom was abdominal pain (99.5%) and a computed tomography scan was the diagnostic modality used in 72% of the patients. Only 15% of patients were on prophylactic proton pump inhibitors or H2 blockers at the time of perforation, and 41% of patients were smoking at the time. Twenty-three percent of patients were on nonsteroidal anti-inflammatory drugs. Laparoscopic omental patch repair of the perforation (59%) was the most used technique; 18% of patients underwent open surgery, and 20% were managed non-surgically. Thirty-day mortality was 0.97%; it was 1.21% (n=5) and 0% (n=0) in those who were managed surgically and nonsurgically, respectively. Ulcers recurred in 5% of patients. In conclusion, PMU is a surgical emergency after gastric bypass that can result in significant morbidity and even mortality. This is the first systematic review in scientific literature characterizing this condition.

WSES/GAIS/WSIS/SIS-E/AAST global clinical pathways for patients with skin and soft tissue infections.

Skin and soft-tissue infections (SSTIs) encompass a variety of pathological conditions that involve the skin and underlying subcutaneous tissue, fascia, or muscle, ranging from simple superficial infections to severe necrotizing infections.Together, the World Society of Emergency Surgery, the Global Alliance for Infections in Surgery, the Surgical Infection Society-Europe, The World Surgical Infection Society, and the American Association for the Surgery of Trauma have jointly completed an international multi-society document to promote global standards of care in SSTIs guiding clinicians by describing reasonable approaches to the management of SSTIs.An extensive non-systematic review was conducted using the PubMed and MEDLINE databases, limited to the English language. The resulting evidence was shared by an international task force with different clinical backgrounds.

Anastomotic stricture after Ivor Lewis esophagectomy: An evaluation of incidence, risk factors, and treatment.

BACKGROUND: Anastomotic stricture is a recognized complication after esophagectomy. It can impact the patient's quality of life and may require recurrent dilatations. Thus, the aim of this study was to evaluate the frequency of strictures, contributing factors, and long-term outcomes of management in patients undergoing esophagectomy with thoracic anastomosis using a standardized circular stapled technique. METHODS: All patients who underwent a 2-stage transthoracic esophagectomy with curative intent between January 2010 and December 2019 at NOGU, Newcastle upon Tyne, UK were included. All patients who underwent a stapled (circular) intrathoracic anastomosis using gastric conduits were included. Stricture incidence, number of dilatations to resolve strictures, and refractory stricture rate were recorded. RESULTS: Overall, 705 patients were included with 192 (27.2%) developing strictures. Refractory strictures occurred in 38 patients (5.4%). One, 2, and 3 dilatations were needed for resolution of symptoms in 46 (37.4%), 23 (18.7%), and 20 (16.3%) patients, respectively. Multivariable analysis identified the occurrence of an anastomotic leak (odds ratio 1.906, 95% confidence interval 1.088-3.341, P = .024) and circular staple size <28 mm (odds ratio 1.462, 95% confidence interval 1.033-2.070, P = .032) as independent predictors of stricture occurrence. Patients with anastomotic leaks were more likely to develop refractory strictures (13.1% vs 4.7%, odds ratio 3.089, 95% confidence interval 1.349-7.077, P = .008). CONCLUSION: This study highlights that nearly 30% of patients having a circular stapled anastomosis will require dilatation after surgery. Although the majority will completely resolve after 2 dilatations, 5% will have longer-term problems with refractory strictures.

Physiological parameters for Prognosis in Abdominal Sepsis (PIPAS) Study: a WSES observational study.

Background: Timing and adequacy of peritoneal source control are the most important pillars in the management of patients with acute peritonitis. Therefore, early prognostic evaluation of acute peritonitis is paramount to assess the severity and establish a prompt and appropriate treatment. The objectives of this study were to identify clinical and laboratory predictors for in-hospital mortality in patients with acute peritonitis and to develop a warning score system, based on easily recognizable and assessable variables, globally accepted. Methods: This worldwide multicentre observational study included 153 surgical departments across 56 countries over a 4-month study period between February 1, 2018, and May 31, 2018. Results: A total of 3137 patients were included, with 1815 (57.9%) men and 1322 (42.1%) women, with a median age of 47 years (interquartile range [IQR] 28-66). The overall in-hospital mortality rate was 8.9%, with a median length of stay of 6 days (IQR 4-10). Using multivariable logistic regression, independent variables associated with in-hospital mortality were identified: age > 80 years, malignancy, severe cardiovascular disease, severe chronic kidney disease, respiratory rate ≥ 22 breaths/min, systolic blood pressure < 100 mmHg, AVPU responsiveness scale (voice and unresponsive), blood oxygen saturation level (SpO2) < 90% in air, platelet count < 50,000 cells/mm3, and lactate > 4 mmol/l. These variables were used to create the PIPAS Severity Score, a bedside early warning score for patients with acute peritonitis. The overall mortality was 2.9% for patients who had scores of 0-1, 22.7% for those who had scores of 2-3, 46.8% for those who had scores of 4-5, and 86.7% for those who have scores of 7-8. Conclusions: The simple PIPAS Severity Score can be used on a global level and can help clinicians to identify patients at high risk for treatment failure and mortality.

An Unusual Presentation of Gallstone Ileus: A Red-Herring or Missed Diagnosis.

BACKGROUND: Gallstone ileus is a rare complication of chronic calcular cholecystitis and an uncommon etiological entity responsible for mechanical intestinal obstruction. The most common obstructed part is the narrow terminal ileum, whereas the jejunum is rarely affected. The gallstone is postulated to reach the small bowel by gradual erosion from the gall bladder, most commonly into the duodenum, forming a cholecysto-duodenal fistula. CASE REPORT: Herein, we report a 72-year-old male who presented with intestinal obstruction of a 5-day duration, with a clinical diagnosis of an irreducible inguinal hernia. However, the patient continued to be symptomatic following an uncomplicated hernioplasty. A computerized tomography (CT) scan of the abdomen revealed a small bowel lesion, which intra-operatively was confirmed to be an impacted gallstone in the jejunum with a cholecysto-duodenal fistula. CONCLUSIONS: Despite gallstone is uncommon cause of intestinal obstruction, a high index of suspicion with a careful CT scan interpretation is the key to the diagnosis, especially when there is a red-herring distracting the attention, like irreducible hernia in this case.

Intraoperative diagnosis of solitary cecal diverticulum not requiring surgery: is appendectomy indicated?

AIM: To compare experience with solitary cecal diverticulum (SCD) with literature on the indication for appendectomy in cases of solitary cecal diverticulitis. METHODS: We retrospectively reviewed all cases of SCD in our institution from September 2011 to March 2013. Data on sex, age, ethnic origin, presence of pain in the right iliac fossa, duration of symptoms, diagnosis, management, intraoperative findings, histologic examination, hospital stay, complications, and follow-up were reviewed and analyzed. We compared this to related literature reported between 2000 and 2015. RESULTS: In the study period, 10 patients presented with an SCD. Male sex and Asian origin were predominant. All patients had pain in the right iliac fossa, with a duration of 2-5 days. In nine cases the diagnosis was made by clinical examination and laboratory testing. One patient who had undergone a previous appendectomy was diagnosed with SCD by computed tomography. This last patient was treated conservatively, four patients were treated with resection of the cecum "en bloc" with the last jejunal loop and appendix, and the other five patients were treated with appendectomies. Two patients had minor complications. All patients were followed up for a minimum of 12 to a maximum of 24 months. No recurrence was recorded in either the case treated conservatively or the cases treated by appendectomies. CONCLUSIONS: In cases of operative but conservative treatment for SCD, appendectomy could be justified to avoid misdiagnosis in case of future episodes of solitary cecal diverticulitis.