Management of acute appendicitis during the COVID-19 pandemic: a retrospective cohort study.

BACKGROUND: The Coronavirus Disease 2019 (COVID-19) pandemic profoundly impacted delivery of health care. South Western Sydney Local Health District (SWSLHD) experienced some of the highest cases, admissions and deaths during the Delta and Omicron waves in New South Wales. This study aims to determine the impact of the pandemic on emergency surgery services for adults presenting with acute appendicitis. METHODS: A retrospective review of patient records was performed of adults presenting with acute appendicitis between 1st March 2021 and 31st March 2022, which was compared to a pre-COVID control period of the same dates in 2019-2020. Patients managed operatively or conservatively were included. RESULTS: 1556 patients were included in the operative arm; 723 and 833 respectively in the study and control groups, which were comparable at baseline. 1.66% were COVID positive. During the pandemic, patients were significantly more likely to be investigated with computered tomography (CT) scan (p ≤ 0.001), present with complicated appendicitis (p = 0.03), and require caecectomy (p = 0.005). They had higher American Society of Anaesthesiology (ASA) scores (p = 0.001) and significantly lower negative appendectomy rates (p = 0.001). Fifty-two patients were included in the conservative arm; 29 and 23 respectively in the pandemic and control groups. Patients were comparable at baseline. There were two COVID positive patients. During the pandemic, there was a significant reduction in complications (p = 0.033), readmissions (0.044) and interval appendicectomy (p = 0.0044). CONCLUSION: We identified higher rates of complicated appendicitis, caecectomies and greater reliance on CT imaging preoperatively during the pandemic in SWSLHD.

Determinants of survival and attempted resection in patients with non-metastatic pancreatic cancer: An Australian population-based study.

BACKGROUND: There are indications that pancreatic cancer survival may differ according to sociodemographic factors, such as residential location. This may be due to differential access to curative resection. Understanding factors associated with the decision to offer a resection might enable strategies to increase the proportion of patients undergoing potentially curative surgery. METHODS: Data were extracted from medical records and cancer registries for patients diagnosed with pancreatic cancer between July 2009 and June 2011, living in one of two Australian states. Among patients clinically staged with non-metastatic disease we examined factors associated with survival using Cox proportional hazards models. To investigate survival differences we examined determinants of: 1) attempted surgical resection overall; 2) whether patients with locally advanced disease were classified as having resectable disease; and 3) attempted resection among those considered resectable. RESULTS: Data were collected for 786 eligible patients. Disease was considered locally advanced for 561 (71%) patients, 510 (65%) were classified as having potentially resectable disease and 365 (72%) of these had an attempted resection. Along with age, comorbidities and tumour stage, increasing remoteness of residence was associated with poorer survival. Remoteness of residence and review by a hepatobiliary surgeon were factors influencing the decision to offer surgery. CONCLUSIONS: This study indicated disparity in survival dependent on patients' residential location and access to a specialist hepatobiliary surgeon. Accurate clinical staging is a critical element in assessing surgical resectability and it is therefore crucial that all patients have access to specialised clinical services.

Meta-analysis of radical resection rates and margin assessment in pancreatic cancer.

BACKGROUND: R0 resection rates (complete tumour removal with negative resection margins) in pancreatic cancer are 70-80 per cent when a 0-mm margin is used, declining to 15-24 per cent with a 1-mm margin. This review evaluated the R0 resection rates according to different margin definitions and techniques. METHODS: Three databases (MEDLINE from 1946, PubMed from 1946 and Embase from 1949) were searched to mid-October 2014. The search terms included 'pancreatectomy OR pancreaticoduodenectomy' and 'margin'. A meta-analysis was performed with studies in three groups: group 1, axial slicing technique (minimum 1-mm margin); group 2, other slicing techniques (minimum 1-mm margin); and group 3, studies with minimum 0-mm margin. RESULTS: The R0 rates were 29 (95 per cent c.i. 26 to 32) per cent in group 1 (8 studies; 882 patients) and 49 (47 to 52) per cent in group 2 (6 studies; 1568 patients). The combined R0 rate (groups 1 and 2) was 41 (40 to 43) per cent. The R0 rate in group 3 (7 studies; 1926 patients) with a 0-mm margin was 72 (70 to 74) per cent The survival hazard ratios (R1 resection/R0 resection) revealed a reduction in the risk of death of at least 22 per cent in group 1, 12 per cent in group 2 and 23 per cent in group 3 with an R0 compared with an R1 resection. Local recurrence occurred more frequently with an R1 resection in most studies. CONCLUSION: Margin clearance definitions affect R0 resection rates in pancreatic cancer surgery. This review collates individual studies providing an estimate of achievable R0 rates, creating a benchmark for future trials.

FDG-PET nodal staging does not correlate with histopathological nodal stage for oesophageal cancers.

OBJECTIVE: To investigate whether pre-operative N-stage (nodal stage) based on FDG-PET for oesophageal cancers, correlates with final histopathology. Additionally, we assessed if N-stage differs for squamous cell cancers compared with adenocarcinomas and if neoadjuvant therapy alters these results. BACKGROUND: Our current understanding of oesophageal cancer biology means that personalisation of multimodality therapy is based on accurate clinical staging, allied with patient co morbidities and patient preference. METHODS: We conducted a retrospective review of consecutive oesophagectomy cases performed over a ten year period (between 2002 and 2013) from a single tertiary centre. A total of 161 patients were identified in the study period. RESULTS: Overall, 103 specimens with 1402 lymph nodes were included. For both Adenocarcinomas (AC) and Squamous Cell Carcinomas (SCC), there was no significant difference between the N-stage determined by CT vs. FDG-PET (p > 0.05). For AC, there was statistically significant under-reporting of the N-stage by PET compared with the final histopathology (p < 0.01). Subgroup analysis showed that neoadjuvant therapy vs. adjuvant therapy alone did not alter the bias for under-reporting of the N-stage for adenocarcinoma by PET-CT (Bland-Altman bias 0.76 vs. bias 0.75). CONCLUSION: There is little doubt that PET-CT provides useful information in determining metastatic disease however its use in evaluating nodal burden is limited. Theoretically, this should not preclude patients from receiving definitive surgical management but the decision regarding neoadjuvant treatment based on locoregional disease may be affected.

The prognostic and predictive value of serum CA19.9 in pancreatic cancer.

BACKGROUND: Current staging methods for pancreatic cancer (PC) are inadequate, and biomarkers to aid clinical decision making are lacking. Despite the availability of the serum marker carbohydrate antigen 19.9 (CA19.9) for over two decades, its precise role in the management of PC is yet to be defined, and as a consequence, it is not widely used. METHODS: We assessed the relationship between perioperative serum CA19.9 levels, survival and adjuvant chemotherapeutic responsiveness in a cohort of 260 patients who underwent operative resection for PC. RESULTS: By specifically assessing the subgroup of patients with detectable CA19.9, we identified potential utility at key clinical decision points. Low postoperative CA19.9 at 3 months (median survival 25.6 vs 14.8 months, P=0.0052) and before adjuvant chemotherapy were independent prognostic factors. Patients with postoperative CA 19.9 levels>90 U/ml did not benefit from adjuvant chemotherapy (P=0.7194) compared with those with a CA19.9 of ≤90 U/ml (median 26.0 vs 16.7 months, P=0.0108). Normalization of CA19.9 within 6 months of resection was also an independent favorable prognostic factor (median 29.9 vs 14.8 months, P=0.0004) and normal perioperative CA19.9 levels identified a good prognostic group, which was associated with a 5-year survival of 42%. CONCLUSIONS: Perioperative serum CA19.9 measurements are informative in patients with detectable CA19.9 (defined by serum levels of >5 U/ml) and have potential clinical utility in predicting outcome and response to adjuvant chemotherapy. Future clinical trials should prioritize incorporation of CA19.9 measurement at key decision points to prospectively validate these findings and facilitate implementation.

Superior mesenteric artery syndrome: diagnosis and treatment strategies.

INTRODUCTION: Superior mesenteric artery (SMA) syndrome is an unusual cause of vomiting and weight loss resulting from the compression of the third part of the duodenum by the SMA. Various medical and psychiatric conditions may result in the initial rapid weight loss which causes narrowing of the aortomesenteric angle. The vomiting and obstructive syndrome is then self-perpetuated regardless of the initiating factors. The young age and nonspecific symptoms often lead to a delay in diagnosis. DISCUSSION: A series of eight cases is presented reviewing the presentation, investigations, surgical treatment by division of duodenum and duodenojejunostomy, and outcomes. CONCLUSION: SMA syndrome is a well-described entity which must be considered as a cause of vomiting associated with significant weight loss in young adults. Surgical treatment should be allied with psychological assessment to treat any underlying psychosocial abnormality.

Skills acquired on virtual reality laparoscopic simulators transfer into the operating room in a blinded, randomised, controlled trial.

Virtual reality surgical simulators have proven value in the acquisition and assessment of laparoscopic skills. In this study, we investigated skill transfer from a virtual reality laparoscopic simulator into the operating room, using a blinded, randomised, controlled trial design. Surgical trainees using the LapSim System performed significantly better at their first real-world attempt at a laparoscopic task than their colleagues who had not received similar training, as measured independently by a number of expert surgical observers using four criteria.

Desmoplastic reaction in pancreatic cancer: role of pancreatic stellate cells.

OBJECTIVES: Pancreatic cancer has a very poor prognosis, largely due to its propensity for early local and distant spread. Histopathologically, most pancreatic cancers are characterized by a prominent stromal/fibrous reaction in and around tumor tissue. The aims of this study were to determine whether (1) the cells responsible for the formation of the stromal reaction in human pancreatic cancers are activated pancreatic stellate cells (PSCs) and (2) an interaction exists between pancreatic cancer cells and PSCs that may facilitate local and distant invasion of tumor. METHODS: Serial sections of human pancreatic cancer tissue were stained for desmin and glial fibrillary acidic protein (stellate cell selective markers) and alpha-smooth muscle actin (alphaSMA), a marker of activated PSC activation, by immunohistochemistry, and for collagen using Sirius Red. Correlation between the extent of positive staining for collagen and alphaSMA was assessed by morphometry. The cellular source of collagen in stromal areas was identified using dual staining methodology, ie, immunostaining for alphaSMA and in situ hybridization for procollagen alpha1I mRNA. The possible interaction between pancreatic cancer cells and PSCs was assessed in vitro by exposing cultured rat PSCs to control medium or conditioned medium from 2 pancreatic cancer cell lines (PANC-1 and MiaPaCa-2) for 24 hours. PSC activation was assessed by cell proliferation and alphaSMA expression. RESULTS: Stromal areas of human pancreatic cancer stained strongly positive for the stellate cell selective markers desmin and GFAP (indicating the presence of PSCs), for alphaSMA (suggesting that the PSCs were in their activated state) and for collagen. Morphometric analysis demonstrated a close correlation (r = 0.77; P < 0.04; 8 paired sections) between the extent of PSC activation and collagen deposition. Procollagen mRNA expression was localized to alphaSMA-positive cells in stromal areas indicating that activated PSCs were the predominant source of collagen in stromal areas. Exposure of PSCs to pancreatic cancer cell secretions in vitro resulted in PSC activation as indicated by significantly increased cell proliferation and alphaSMA expression. CONCLUSIONS: Activated PSCs are present in the stromal reaction in pancreatic cancers and are responsible for the production of stromal collagen. PSC function is influenced by pancreatic cancer cells. Interactions between tumor cells and stromal cells (PSCs) may play an important role in the pathobiology of pancreatic cancer.

Use of the Hasson cannula producing major vascular injury at laparoscopy.

Despite the recent demonstration that vascular lesions occur significantly more frequently in patients having closed rather than "open" laparoscopy, there never has been a published case report of injury to the great vessels associated with the open technique of initial access to the peritoneal cavity at laparoscopy. We present the first two such cases reported, along with a brief review of the literature related to such major vascular injuries (MVI) sustained at laparoscopy. Lacking appreciation of aortic anatomy and intraoperative technical factors contribute to the occurrence of these injuries. Delayed diagnosis and management contribute to poor outcomes. Secondary injury frequently is associated with MVI at laparoscopy.

Bacteremia associated with operative decompression of a small bowel obstruction.

BACKGROUND: Intraoperative decompression of the small bowel has been advocated as a method of aiding recovery of both the patient and the intestine. However, the methods proposed (retrograde stripping or enterotomy) require vigorous handling of bacteria-laden small bowel, possibly giving rise to a bacteremia. STUDY DESIGN: A small bowel obstruction was created in 31 rats by means of a ligature. Twenty-four hours later, the obstruction was relieved, and the rats were divided into three groups: relief of obstruction alone, relief with retrograde stripping, and relief with enterotomy plus suction. Blood cultures were taken before and after manipulation of the bowel. RESULTS: In blood cultures taken before and after manipulation there was a significant increase of Escherichia coli bacteremia in the two manipulation groups compared with the relief of obstruction only group. CONCLUSIONS: Bacteremia may be an effect of operative decompression of obstructed bowel, which at times outweighs its supposed benefits.

Repair of giant inguinoscrotal inguinal hernia using marlex mesh and scrotal skin flaps.

A new technique for the repair of giant inguinoscrotal hernia is described. It consists of: reduction of the hernia; repair of the hernial orifices with marlex mesh; creation of a midline anterior wall defect to increase intra-abdominal capacity; covering this defect with marlex mesh; then covering the midline marlex mesh with a rotation flap of inguinoscrotal skin. This technique increases intra-abdominal capacity and allows reduction of the hernia without compromising respiratory function, in patients with chronic airflow limitation, by using skin that would otherwise be discarded.

Left lateral laparoscopic cholecystectomy and its relevance to choledocholithiasis.

One of the current challenges to the laparoscopic biliary surgeon is the management of bile duct stones. While laparoscopic bile duct exploration is in its infancy, pre- and postoperative endoscopic retrograde cholangiopancreatography with or without endoscopic papillotomy (ERCP/EP) currently plays a significant role. Intra-operative ERCP/EP has advantages over pre- and postoperative ERCP/EP; however it has not gained popularity due, partly, to the difficulties associated with ERCP/EP being performed with the patient in the supine position. This study prospectively assessed, in 10 consecutive patients, the feasibility of performing laparoscopic cholecystectomies in the left lateral position, a position amenable to intra-operative ERCP/EP if necessary. It is concluded that laparoscopic cholecystectomy in the left lateral position can be performed safely, with similar ease and results as in the supine position, increasing the options available to manage choledocholithiasis.

A totally diverting loop colostomy.

A technique is described where the distal limb of a loop colostomy is tied with nylon or polydioxanone. This ensures total faecal diversion and dispenses with the supporting rod, enabling early application of stoma appliances. The technique does not interfere with the traditional transverse closure of a loop colostomy.

Ischaemic complications of graduated compression stockings in the treatment of deep venous thrombosis.

Graduated compression stockings are frequently used in the prevention of deep venous thrombosis and the treatment of venous insufficiency. Two patients are discussed who sustained ischaemic complications after application of graduated compression stockings. Review of the literature demonstrates that low cutaneous pressures significantly decrease local blood flow and that the amount of pressure exerted by graduated compression stockings increases significantly with increases in leg girth. Ischaemic complications associated with the use of these stockings also appears to be more common than previously thought and any policy of routine prescription to patients should be questioned.

Torsion of the vermiform appendix: a case report and review of literature.

A case of torsion of the vermiform appendix is described. It is a rare cause of an acute abdomen with a clinical presentation that is indistinguishable from acute appendicitis.