High Failure Rate Following Restorative Surgery for Rectal Prolapse in Systemic Sclerosis Patients.

INTRODUCTION: Systemic sclerosis (SSc) is a rare autoimmune connective tissue disorder. Colonic disorders are reported in 70% of patients. Only a few cases of rectal prolapse surgical repair in SSc patients were published, demonstrating high recurrence rate following any restorative surgery. The aim of this study is to present our surgical experience combined with the reported cases of SSc patients who underwent surgical interventions for rectal prolapse. METHODS: We reviewed our data and the published reports in the English literature of patients with SSc who underwent surgery for rectal prolapse. We located 6 case reports, in addition to 3 patients who were operated in our center. RESULTS: A total of 19 procedures (9 patients) were included, among them 17 restorative surgeries and 2 low anterior resections (LAR) with end-colostomy. All patients were female (mean age 70.3). Index surgery was perineal rectosigmoidectomy in 5, abdominal resection rectopexy in 3, and LAR with colostomy in 1 patient. All patients following restorative surgery suffered from fecal incontinence. 5 patients (62.5%) who underwent restorative surgery required at least 1 re-operation. The 2 patients who underwent LAR and colostomy reported a complete resolution of anorectal symptoms with a major improvement in their quality of life. CONCLUSION: High recurrence rate is expected in SSc patients with rectal prolapse who undergo a restorative procedure. Low anterior resection and permanent colostomy provide an alternative surgical option to patients with SSc and prolapse in contrast to restorative surgery. We believe that this surgical approach should be offered for these patients.

Small Bowel Obstruction in Patients without Prior Abdominal Surgery: To Operate or Not?

INTRODUCTION: Surgical exploration is still considered mandatory in the setting of small bowel obstruction (SBO) in patients without prior intra-abdominal surgery. However, recent studies have challenged this 'classic' approach describing success with conservative non-surgical treatment. The aim of this study is to identify clinical, radiological and biochemical variables that may be associated with the absence of intra-abdominal pathology in patients with SBO who have not undergone previous surgery. METHODS: This is a retrospective cohort study of prospectively recorded data. Patients with SBO without prior abdominal surgery who presented to a single tertiary referral medical center between 2009 and 2019 were included. RESULTS: Eighty-seven patients were included of whom 61(70.0%) were allocated to the 'therapeutic exploration' group and 26 (30.0%) to the 'non-therapeutic exploration' group. Forty-eight patients (55.0%) had adhesions, 17.2% had closed-loop obstruction, 10.0% had an internal hernia, 27.6% had bowel ischemia and 5.7% had bowel necrosis. Although multiple clinical, laboratory, radiological and preoperative factors were examined, none were significantly associated with pathological findings during surgical exploration. There was no statistically significant difference in the incidence of complications when comparing between those groups. CONCLUSIONS: In this series, no variables were associated with intra-abdominal pathology in patients who underwent surgery for SBO with no history of prior abdominal surgery. However, the fact that 27.0% had ischemic bowel upon surgical exploration suggests that this approach is still mandatory for this specific group of patients. Furthermore, clinicians and patients should be aware that negative exploration may be expected in up to 30.0%.

The Decreasing Incidence of Acute Appendicitis During COVID-19: A Retrospective Multi-centre Study.

BACKGROUND: As the novel coronavirus disease 19 (COVID-19) spreads, a decrease in the number of patients with acute appendicitis (AA) has been noted in our institutions. The aim of this study was to compare the incidence and severity of AA before and during the COVID-19 pandemic. METHODS: A retrospective cohort analysis was performed between December 2019 and April 2020 in the four high-volume centres that provide health care to the municipality of Jerusalem, Israel. Two groups were created. Group A consisted of patients who presented in the 7 weeks prior to COVID-19 first being diagnosed, whilst those in the 7 weeks after were allocated to Group B. A comparison was performed between the clinicopathological features of the patients in each group as was the changing incidence of AA. RESULTS: A total of 378 patients were identified, 237 in Group A and 141 in Group B (62.7% vs. 37.3%). Following the onset of COVID-19, the weekly incidence of AA decreased by 40.7% (p = 0.02). There was no significant difference between the groups in terms of the length of preoperative symptoms or surgery, need for postoperative peritoneal drainage or the distribution of complicated versus uncomplicated appendicitis. CONCLUSIONS: The significant decrease in the number of patients admitted with AA during the onset of COVID-19 possibly represents successful resolution of mild appendicitis treated symptomatically by patients at home. Further research is needed to corroborate this assumption and identify those patients who may benefit from this treatment pathway.

Antibiotic treatment for children hospitalized with community-acquired pneumonia after oral therapy.

OBJECTIVE: To compare the outcome of treatment with narrow spectrum versus broad spectrum antibiotics in children hospitalized with community-acquired pneumonia (CAP) who received oral antibiotic treatment prior to their hospitalization. DESIGN, SETTING, AND PATIENTS: A review of all previously healthy children from 3 months to 18 years with non-complicated CAP who received an oral antibiotic course in the community and were admitted from 2003 to 2008 to our pediatric departments. MAIN OUTCOME MEASURES: Clinical course and outcome parameters were compared for treatment with narrow and broad spectrum antibiotics. RESULTS: Of the 337 children admitted with non-complicated CAP after an oral antibiotic treatment course in the community, 235 were treated with broad spectrum, and 102 with narrow spectrum antibiotics. The two groups were similar regarding age, sex, days of fever prior to admission, type of preadmission oral antibiotic treatment, and laboratory indices at admission (P > 0.1). The broad spectrum-treated group had significantly better outcomes in terms of number of febrile days (1.2 ± 1.1 vs. 1.7 ± 1.6, P < 0.001), number of days treated with intravenous antibiotics (3.1 ± 1.3 vs. 3.9 ± 2.0, P < 0.001), and days of hospitalization (3.5 ± 1.5 vs. 4.2 ± 2.0, P < 0.001). The odds ratio for remaining hospitalized at 72 hr and 7 days was significantly higher for the narrow spectrum group (2.0 and 5.5 respectively, P < 0.05). CONCLUSIONS: In previously healthy children hospitalized with CAP after oral antibiotic treatment in the community treatment with broad spectrum antibiotics showed better outcome. Prospective studies are needed for appropriate recommendation.