Postoperative complications and waiting time for surgical intervention after radiologically guided drainage of intra-abdominal abscess in patients with Crohn's disease.

BACKGROUND: In patients with active Crohn's disease (CD), treatment of intra-abdominal abscess usually comprises antibiotics and radiologically guided percutaneous drainage (PD) preceding surgery. The aim of this study was to investigate the risk of postoperative complications and identify the optimal time interval for surgical intervention after PD. METHODS: A multicentre, international, retrospective cohort study was carried out. Details of patients with diagnosis of CD who underwent ultrasonography- or CT-guided PD were retrieved from hospital records using international classification of disease (ICD-10) diagnosis code for CD combined with procedure code for PD. Clinical variables were retrieved and the following outcomes were measured: 30-day postoperative overall complications, intra-abdominal septic complications, unplanned intraoperative adverse events, surgical-site infections, sepsis and pathological postoperative ileus, in addition to abscess recurrence. Patients were categorized into three groups according to the length of the interval from PD to surgery (1-14 days, 15-30 days and more than 30 days) for comparison of outcomes. RESULTS: The cohort comprised 335 CD patients with PD followed by surgery. Median age was 33 (i.q.r. 24-44) years, 152 (45.4 per cent) were females, and median disease duration was 9 (i.q.r. 3.6-15) years. Overall, the 30-day postoperative complications rate was 32.2 per cent and the mortality rate was 1.5 per cent. After adjustment for co-variables, older age (odds ratio 1.03 (95 per cent c.i. 1.01 to 1.06), P < 0.012), residual abscess after PD (odds ratio 0.374 (95 per cent c.i. 0.19 to 0.74), P < 0.014), smoking (odds ratio 1.89 (95 per cent c.i. 1.01 to 3.53), P = 0.049) and low serum albumin concentration (odds ratio 0.921 (95 per cent c.i. 0.89 to 0.96), P < 0.001) were associated with higher rates of postoperative complications. A short waiting interval, less than 2 weeks after PD, was associated with a high incidence of abscess recurrence (odds ratio 0.59 (95 per cent c.i. 0.36 to 0.96), P = 0.042). CONCLUSION: Smoking, low serum albumin concentration and older age were significantly associated with postoperative complications. An interval of at least 2 weeks after successful PD correlated with reduced risk of abscess recurrence.

Delay to surgery does not influence the pathological outcome of acute appendicitis.

INTRODUCTION: Emergency surgery is performed on patients with appendicitis in the belief that inflammation of the appendix may progress to necrosis and perforation. Many cases of appendicitis, however, resolve with conservative treatment, and necrotic appendicitis may represent a different disease rather than the end result of inflammation of the appendix. We wished to explore the relationship between the interval to surgery after admission to hospital with appendicitis and the proportion of patients developing necrosis. METHODS: Appendicectomy operations performed between 2005 and 2010 were reviewed. End points included age, sex, interval from admission to surgery, and final pathological diagnosis. RESULTS: A total of 2403 evaluable patients were identified (1266 females). Necrotic appendicitis occurred more commonly in children (17.5%) and the elderly (25.4%) compared with adults (10.5%). The median interval to surgery of patients with normal histology (17.1 h) was longer than the time to removal of inflamed (13 h) or necrotic (13.5 h) appendices (p < 0.001).The ratio of necrotic to inflamed appendicitis in the entire cohort was 0.24. Multivariate analysis reveals that necrosis of the appendix is more common in children and the elderly and that the proportion of patients with necrosis does not change with increasing interval to surgery. DISCUSSION: Our observations show that appendicitis is not more likely to lead to perforation if a short delay prior to surgery is allowed. In addition, our findings add weight to the increasing volume of data showing that necrosis of the appendix is a disease different from simple inflammation.

Retraction techniques in laparoscopic colorectal surgery: a literature-based review.

AIM: To systematically review the published literature and describe the various techniques of bowel and mesentery retraction available for use in laparoscopic colorectal resection. METHOD: A comprehensive search of the literature was undertaken using MESH terms 'retraction', 'laparoscopic' and 'colorectal'. All articles describing methods of retraction in laparoscopic colorectal surgery were included. RESULTS: Twelve methods of retraction in laparoscopic colorectal surgery were described. Five case-based series and three case studies were reported on 108 patients. Techniques were classified into those offering retraction of the small or large bowel or according to the mode of retraction. CONCLUSION: Many retraction methods are available to the surgeon varying in cost, invasiveness and complexity. Adequate retraction remains a challenge for optimal exposure and dissection during laparoscopic colorectal surgery.

Suture mesh fixation versus glue mesh fixation in open inguinal hernia repair: a systematic review and meta-analysis.

OBJECTIVE: To systematically analyse the trials comparing suture mesh fixation (SMF) versus glue mesh fixation (GMF) in open inguinal hernia repair (OIHR). METHODS: Trials comparing the SMF versus GMF in OIHR were analysed systematically using RevMan(®), and combined outcomes were expressed as risk ratio (RR) and standardised mean difference (SMD). RESULTS: Seven randomised controlled trials encompassing 1259 patients were retrieved from the electronic databases. There were 628 patients in the SMF group and 653 patients in the GMF group. In the meta-analysis, postoperative complications (RR, 1.07; 95% CI, 0.72, 1.58; z = 0.34; p = 0.74), postoperative pain (SMD, 0.31; 95% CI, -0.03, 0.64; z = 1.81; p = 0.07), chronic groin pain (RR, 1.60; 95% CI, 0.78, 3.28; z = 1.28; p = 0.20) and length of hospital stay (SMD, 0.06; 95% CI, -0.08, 0.20; z = 0.82; p = 0.41) were statistically comparable between two techniques of mesh fixation in OIHR. However, GMF was associated with a reduced operating time (SMD, 0.15; 95% CI, 0.03, 0.26; z = 2.38; p = 0.02). CONCLUSION: GMF is comparable to SMF in terms of postoperative complications, postoperative pain, chronic groin pain and length of hospital stay. GMF is associated with a reduced operative time compared with SMF. Based on the results of this review the GMF approach may be considered as an alternative for mesh fixation in OIHR. Results should be interpreted cautiously due to relatively short follow up time in studies. A major, multicentre randomised, controlled trial is required to validate these findings.

A meta-analysis examining the use of tacker fixation versus no-fixation of mesh in laparoscopic inguinal hernia repair.

OBJECTIVE: The objective of this article is to systematically analyse the randomised, controlled trials comparing tacker mesh fixation (TMF) versus no-mesh fixation (NMF) in laparoscopic inguinal hernia repair (LIHR). METHODS: Randomised, controlled trials comparing TMF versus NMF in LIHR were analysed systematically using RevMan(®), and combined outcomes were expressed as risk ratio (RR) and standardised mean difference (SMD). RESULTS: Eight randomised, controlled trials encompassing 1386 patients were retrieved from the electronic databases. There were 691 patients in the TMF group and 695 patients in the NMF group. Statistically there was non-significant heterogeneity among trials. In random effects models, operating time (p = 0.15), post-operative pain (p = 0.45), post-operative complications (p = 0.55) and length of hospital stay (p = 0.11) were statistically comparable between two techniques of mesh fixation in LIHR. The risk of developing chronic groin pain (p = 0.67) and risk of hernia recurrence (p = 0.77) was also similar. CONCLUSION: NMF in LIHR does not increase the risk of hernia recurrence. It is comparable with TMF in terms of operation time, post-operative pain, post-operative complications, length of hospital stay and chronic groin pain. Therefore, based upon the results of this review NMF approach may be adopted routinely and safely in LIHR.

Preoperative neutrophil-to-lymphocyte ratio (NLR) is associated with reduced disease-free survival following curative resection of pancreatic adenocarcinoma.

BACKGROUND: Serological proinflammatory markers such as C-reactive protein (CRP), neutrophil-to-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR) have been associated with reduced survival for many different types of cancer. This study determined the prognostic value of the preoperative value of these markers in patients with resectable pancreatic adenocarcinoma. METHODS: Consecutive patients who underwent pancreaticoduodenectomy for pancreatic ductal adenocarcinoma were entered into our database from 2001 to the present day. CRP, NLR, and PLR at the time of presentation were recorded as well as overall and disease-free survival. RESULTS: Seventy-four patients were identified. Overall median survival was 35.0 months and median disease-free survival was 27.0 months. Follow-up ranged from 1 to 125.8 months. Preoperative NLR was significantly greater in those patients who developed recurrence in the follow-up period (4.5 vs. 3.1). CRP and PLR were not found to differ significantly between the two groups. Kaplan-Meier survival analysis of patients with NLR > 5 demonstrated a disease-free survival of 12 months compared with 52 months for those patients with NLR < 5 (p < 0.001). CONCLUSION: Preoperative NLR offers important prognostic information regarding disease-free survival following curative resection of pancreatic ductal adenocarcinoma.