Rectal prolapse as the initial presentation of rectal cancer-A case report.

Herein we report the case of a 63-year-old female tourist who presented to our Emergency Department with complete rectal prolapse. She had complained of diarrhea with traces of blood and mucus and had experienced fatigue after hiking. After the initial evaluation, it became clear that prolapse bares a large rectal tumor as a leading point. The prolapse was reduced under general anesthesia, along with a tumor biopsy. Further workup confirmed locally advanced adenocarcinoma of the rectum, which was treated with neoadjuvant chemoradiation followed by curative surgery in another hospital after repatriation. Rectal prolapse affects people of all ages, but it is more common in older adults, particularly women. Treatment options vary depending on the severity of the prolapse and can range from conservative measures to surgical interventions. This case report highlights the importance of early recognition and appropriate management of rectal prolapse in the emergency setting and the possibility of an underlying malignancy.

Hyperbilirubinemia as an Indicator of Perforated Acute Appendicitis in Pediatric Population: A Prospective Study.

Background: This prospective cohort study aimed to investigate the association of hyperbilirubinemia with perforated appendicitis in the pediatric population. Patients and Methods: A total of 284 children in whom the diagnosis of acute appendicitis was established were included in this study. The patients were allocated in study groups in regard to operative findings. The first study group included patients who had perforated appendicitis (n = 64; 22.5%) whereas the patients in the second group had simple appendicitis (n = 220; 77.5%). Blood samples for serum bilirubin levels and acute inflammatory markers were taken before the patients underwent surgery. The primary outcome of the study was to investigate whether the level of serum bilirubin should be used to distinguish between simple and perforated appendicitis. Results: The median level of serum bilirubin in children with perforated appendicitis was 27 mcmol/L whereas the patients with simple appendicitis had lower median levels of serum bilirubin (10 µmol/L; p < 0.001). An area under the receiver operating characteristic (ROC) curve for total serum bilirubin was 0.876 (95% confidence interval [CI], 0.820-0.929) in the patients who had a perforated appendicitis. An ROC analysis showed the best sensitivity (92%) and specificity (77.3%) for a cutoff value of 15.5 mcmol/L for total serum bilirubin (p < 0.001). Hyperbilirubinemia at admission was found in 35 patients (54.7%) with complicated appendicitis and in 14 patients (6.4%) with non-perforated appendicitis (p < 0.001). The modeling of collected data by multivariable logistic regression identified serum bilirubin concentration (odss ratio [OR] = 1.12; 95% CI, 1.07-1.18; p < 0.001), serum sodium concentration (OR = 0.64; 95% CI, 0.51-0.81; p < 0.001), body temperature (OR = 2.48; 95% CI, 1.05-0.84; p < 0.001), and duration of symptoms (OR = 1.06; 95% CI, 1.02-1.09; p < 0.001) as risk factors for perforated appendicitis. Conclusion: Elevateds level of total serum bilirubin may be useful as an indicator of perforated appendicitis in children. Levels of bilirubin in serum is an inexpensive, simple, and available laboratory marker and should therefore be recommended in the initial evaluation for acute appendicitis in pediatric patients.

Extensive clostridial myonecrosis after gluteal intramuscular injection in immunocompromised patient treated with surgical debridement and negative-pressure wound therapy.

Gas gangrene is infectious disease caused by Clostridium perfringens infection. We are presenting extremely rare case of gluteal clostridial myonecrosis after intramuscular injection of diclofenac in immunocompromised young patient on a long-standing corticosteroid therapy presented with sepsis and initially absent clinical signs of severe anaerobic infection. After delayed diagnosis, she was treated with aggressive surgical removal of necrosed tissue and targeted antibiotic therapy which led to a rapid improvement allowing application of a negative-pressure wound therapy device with favorable outcome. This report shows the importance of timely diagnosis with pitfalls of imaging. It confirms that surgical debridement along with specific antibiotic therapy is the mainstay of treatment, but also promotes negative-pressure wound therapy which has proved convenient for accelerated closure of large incisions with tissue loss without any adverse effects or the need for complex reconstructive procedures.

Validity of Appendicitis Inflammatory Response Score in Distinguishing Perforated from Non-Perforated Appendicitis in Children.

BACKGROUND: This prospective observational study aimed to evaluate the validity of appendicitis inflammatory response (AIR) score in differentiating advanced (perforated) from simple (non-perforated) appendicitis in pediatric patients. METHODS: A single-center prospective cross-sectional study was conducted between 1 January 2019 until 1 May 2020 including 184 pediatric patients who underwent appendectomy. Based on the intraoperative finding of advanced (n = 38) or simple (n = 146) appendicitis the patients were divided into two groups. Recipient-operator curve (ROC), with calculation of sensitivity and specificity of best cutoff and the area under the curve (AUC), were used to measure the diagnostic value and the potential for risk stratification of the AIR score, among the patients with simple or advanced acute appendicitis. RESULTS: The median value of the AIR score in the perforated and non-perforated groups was 10 (interquartile range, IQR 9, 11), and was 7 (IQR 6, 9), respectively (p < 0.001). Based on the calculated value of AIR score, the patients were classified with a high precision into low, indeterminate and high risk groups for acute appendicitis (p < 0.001). A cutoff value of ≥9 was demonstrated to serve as a reliable indicator of perforated appendicitis with a sensitivity and a specificity of 89.5% and 71.9%, respectively (AUC = 0.80; 95% CI: 0.719-0.871; p < 0.001). CONCLUSIONS: Acute appendicitis can be detected with a high level of sensitivity and specificity using the AIR score. Also, the AIR score may differentiate perforated from non-perforated appendicitis in pediatric patients with a high level of accuracy.

Comparison of new versus reused Harmonic scalpel performance in laparoscopic appendectomy in patients with acute appendicitis-a randomized clinical trial.

BACKGROUND: The aim of this study was to compare lateral thermal damage of the appendix and clinical outcomes after laparoscopic appendectomy using new versus reused Harmonic scalpels. METHODS: A total of 100 consecutive patients with acute appendicitis who underwent laparoscopic appendectomy were enrolled in the two-center, randomized clinical trial. Using a computer random number generator, patients were allocated to new or reused group. Histopathological measurement of lateral thermal damage of the appendiceal base and mesoappendix, speed of transection of the appendiceal base, duration of surgery, subjective rating of device functionality, length of hospital stay, and complications were compared within groups. RESULTS: The median lateral thermal damage on the appendiceal base in the new group (N = 49) was 0.2 mm (IQR 0.1-0.2) and 0.1 mm (IQR 0.1-0.3) in the reused group (N = 51) (P = 0.644), while on the mesoappendix for both groups, thermal damage was 0.1 mm (IQR 0.1-0.2) (P = 0.418). The median time required for base transection in both groups was 8 s (IQR 7-9) (P = 0.776). The median duration of surgery was also comparable between the groups (22 min, IQR 20-30 vs 25 min, IQR 21-35; P = 0.233). Two postoperative complications in the new group and one in the reused group were recorded (4% vs 2%; P = 0.536). Surgeons' subjective assessment of the instrument did not reveal significant difference between the groups in all of the investigated categories. CONCLUSIONS: The results of our study support the reuse of Harmonic scalpels especially in the settings where economic constraints might hamper access to minimally invasive surgery to a larger number of patients. The results obtained on laparoscopic appendectomy might not be reproducible to other more demanding surgical procedures. TRIAL REGISTRATION: ClinicalTrials.gov registry under identifier NCT04226482.

Biomedical conferences' author instructions rarely mention guidelines for reporting abstracts of trials and systematic reviews.

Aim: To analyze whether instructions for authors of biomedical conference abstracts mention guidelines for writing randomized controlled trial and systematic review abstracts and to evaluate reasons for their absence from instructions. Materials & methods: We analyzed instructions for authors of biomedical conferences advertized in 2019 and assessed whether they mentioned Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Abstracts and Consolidated Standards of Reporting Trials for Abstracts guidelines. We surveyed contact persons from abstract/publication committees of selected conferences to analyze why relevant guidelines were missing. Results: Instructions for abstracts were available for 819 conferences. Only two (0.2%) had reporting instructions for randomized controlled trial/systematic review authors. Almost half of the contacted conference organizers whose response we received were not aware of Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Abstracts and Consolidated Standards of Reporting Trials for Abstracts guidelines. Conclusion: Conference organizers do not require and are not familiar enough with reporting guidelines.

Negative-pressure in treatment of persistent post-traumatic subcutaneous emphysema with respiratory failure: Case report and literature review.

Subcutaneous emphysema may aggravate traumatic pneumothorax treatment, especially when mechanical ventilation is required. Expectative management usually suffices, but when respiratory function is impaired surgical treatment might be indicated. Historically relevant methods are blowhole incisions and placement of various drains, often with related wound complications. Since the first report of negative pressure wound therapy for the treatment of severe subcutaneous emphysema in 2009, only few publications on use of commercially available sets were published. We report on patient injured in a motor vehicle accident who had serial rib fractures and bilateral pneumothorax managed initially in another hospital. Due to respiratory deterioration, haemodynamic instability and renal failure patient was transferred to our Intensive Care Unit. Massive and persistent subcutaneous emphysema despite adequate thoracic drainage with respiratory deterioration and potentially injurious mechanical ventilation with high airway pressures was the indication for active surgical treatment. Negative-pressure wound therapy dressing was applied on typical blowhole incisions which resulted in swift emphysema regression and respiratory improvement. Negative pressure wound therapy for decompression of severe subcutaneous emphysema represents simple, effective and relatively unknown technique that deserves wider attention.

Pneumoperitoneum in in-vitro Conceived Quadruplet Neonate: Rare Manifestation of Hirschsprung's Disease--Report of a Case.

INTRODUCTION: Hirschsprung's disease is a congenital colonic aganglionosis, usually presented as inability or difficulty in passing of meconium, chronic and persistent obstipation, maleficent feeding, vomiting, distension and lethargy. CASE PRESENTATION: We presented a case of an in-vitro conceived quadruplet premature neonate who presented with pneumoperitoneum caused by transverse colon spontaneous perforation and microcolon appearance of distal bowel, treated by resection and temporary colostomy turns to be a rare manifestation of Hirschsprung's disease. CONCLUSION: Assisted reproductive technologies increases chances for multiple pregnancies and may increase chance for major congenital anomalies. Rare manifestation of Hirschsprung's disease is spontaneous pneumoperitoneum which remains a surgical emergency. Delay in recognizing and treatment can significantly worsen prognosis. In neonate with intestinal perforation one should consider Hirschsprung's disease.