Incisional hernia following ileostomy closure: who's at risk? The Gold Coast experience.

BACKGROUND: Diverting ileostomy is utilized to protect high-risk anastomoses, though it is not shown to reduce the leak rate it may reduce the severe consequences of an anastamotic leak. In recent years mesh development has advanced to allow placement of meshes into potentially contaminated fields, such as an ostomy closure site. METHOD: A retrospective review of all ileostomy closure procedures in Gold Coast from 1st January 2011 until 31st December 2018 were included. Patient demographics and surgical outcomes and follow up reviewed to identify any cases of incisional hernia relating to ostomy closure. RESULTS: A total of 193 patients were identified, after exclusions 171 were suitable for analysis within the study, a total of 25 incisional hernia detected radiologically or clinically. Two independent risk factors were identified BMI >30 and ASA 3-4. Both had significant association with development of incisional hernia with a 3- and 2-fold RR increase, respectively. This was also reflected in a subset analysis of BMI ranges demonstrating increased risk in the obese and severely obese group. DISCUSSION: The high-risk group in our population was elevated BMI and ASA, these are the patients we would expect to benefit the most from targeted therapy to reduce the incidence of incisional hernia. Future studies to look at whether reducing BMI or prophylactic mesh placement are effective.

Increasing rate of colorectal cancer in younger patients: a review of colonoscopy findings in patients under 50 at a tertiary institution.

BACKGROUND: In Australia, colorectal cancer (CRC) is the third most common cancer and the second leading cause of cancer death. It is more common in patients over 50 years, with previous evidence showing patients under 50 years account for only 9% of CRC. However, recent Australian and International studies have shown an increase in CRC incidence in patients under 50 years of age. The main aim of this study was to analyse the incidence of CRC in patients under 50 and to determine if screening would be beneficial in this population. METHODS: A retrospective cohort study was performed on all patients under 50 years of age who underwent a colonoscopy, performed by a colorectal surgeon, at the Gold Coast Hospital and Health Service between January 2013 and December 2017. RESULTS: A total of 557 patients were included in the study; 120 (21.5%) colonoscopies had a significant finding (CRC or adenoma with malignant potential). 1.9% of patients were diagnosed with CRC, all were symptomatic at time of diagnosis, the majority were stage 3 or 4. CONCLUSION: A total of 1.9% of patients under 50 who underwent colonoscopy were diagnosed with CRC, whilst 21.5% of patients had significant findings. These rates are greater than previously quoted figures and data for patients under 50, and provides evidence to support lowering of the CRC faecal occult blood testing screening age.

Variation in anti-microbial prescription and complications post emergency appendicectomy in Australia: do we follow recommended guidelines?

BACKGROUND: This study aims to establish compliance levels to prescription guidelines among Australian surgeons in the use of antibiotics in the surgical management of appendicitis. The secondary outcomes are predictors of post-operative infective complications; surgical site infection (SSI) and intra-abdominal abscess (IAA) at 30 days. METHODS: A multi-centre, prospective, observational study was conducted over a period of 2 months with a 30-day follow-up. Patients were eligible for recruitment if they underwent appendicectomy for suspected appendicitis. Antibiotics prescription practices were recorded and compared to national guidelines. RESULTS: A total of 1189 patients were recruited across 27 centres; 1081 (92.1%) patients were given prophylactic antibiotics at the time of appendicectomy. Patients with gangrenous appendicitis were more likely to receive prophylactic antibiotics (98.9%); lower rates of use were seen in the non-appendicitis group (85.7%). A total of 619 (53.3%) patients received antibiotics in the post-operative period. Despite recommendations, 300 (44.3%) patients with simple appendicitis received post-operative antibiotics. Only six (2.9%) patients with complicated appendicitis did not receive antibiotics. Overall, SSI and IAA rates were 1.9% and 2.7%, respectively. Aboriginal and Torres Strait Islanders (P = 0.02) and patients with converted operations (P = 0.001) were more likely to have a SSI. Patients with complicated appendicitis and those operated on by a consultant were more likely to increase the odds of IAA (odds ratio 3.8 and 5.1, respectively). CONCLUSION: This broad-based study shows mixed compliance with antibiotic guidelines in the surgical management of appendicitis in Australia. The use of post-operative antibiotics in patients with simple appendicitis should be a target for antimicrobial stewardship programmes to prevent antibiotic over-utilization.

Can normal inflammatory markers rule out acute appendicitis? The reliability of biochemical investigations in diagnosis.

BACKGROUND: Acute appendicitis is a common general surgical condition where diagnosis is predominantly clinical, with the aid of adjunct investigations. This study reviews the relationship between normal and elevated biochemical inflammatory markers, duration of symptoms and proven appendicitis. METHODS: A multicentre prospective observational study was performed across 27 centres and included a total of 949 patients with clinical suspicion of appendicitis, who had both white cell count (WCC) and C-reactive protein (CRP) recorded and underwent appendicectomy. RESULTS: A total of 90.4% of patients with raised WCC and CRP had appendicitis with a positive predictive value (PPV) of 0.9 and negative predictive value (NPV) of 0.4. Sensitivity and specificity of elevated WCC (sensitivity 66.5%, specificity 66.0%) and elevated CRP (sensitivity 77.3%, specificity 52.0%) lie within ranges identified by previous studies. A total of 39.8% of patients with normal CRP and WCC had appendicitis. Sensitivity and PPV for patients with elevated inflammatory markers were high until 48 h of symptoms (sensitivity 94%, PPV 0.87). NPV was elevated after 24 h (NPV 0.65 in patients with 24-48 h of symptoms, and 0.61 after 48 h), whilst those with symptoms less than 24 h had a lower NPV of 0.52. CONCLUSION: Whilst elevated inflammatory markers are a helpful aid in the diagnosis of appendicitis, they should not be relied on by themselves. Nor can normal inflammatory markers be used to exclude appendicitis, even in those with prolonged duration of symptoms. The diagnosis of appendicitis should be guided by a combination of clinical judgement with the assistance of inflammatory markers.

Chemospecific Cyclizations of α-Carbonyl Sulfoxonium Ylides on Aryls and Heteroaryls.

The functionalization of aryl and heteroaryls using α-carbonyl sulfoxonium ylides without the help of a directing group has remained so far a neglected area, despite the advantageous safety profile of sulfoxonium ylides. Described herein are the cyclizations of α-carbonyl sulfoxonium ylides onto benzenes, benzofurans and N-p-toluenesulfonyl indoles in the presence of a base in HFIP, whereas pyrroles and N-methyl indoles undergo cyclization in the presence of an iridium catalyst. Significantly, these two sets of conditions are chemospecific for each groups of substrates.

Palladium-Catalyzed Synthesis of Bis-Substituted Sulfoxonium Ylides.

The lack of general access to bis-substituted sulfoxonium ylides is addressed by developing a palladium-catalyzed C-H cross-coupling of α-ester sulfoxonium ylides with (hetero)aryl iodides, bromides, and triflates. Three different catalysts have been evaluated. This method is amenable to the late-stage functionalization of active pharmaceutical ingredients.

Synthesis of the tricyclic core of manzamine A.

An efficient synthetic approach to the core structure of the manzamine alkaloids is reported, particularly in relation to incorporating a one-carbon unit in ring B from which the aldehyde in ircinal A or the beta-carboline unit in manzamine A could potentially be generated. The key steps involve a Johnson-Claisen rearrangement, enolate alkylation, dithiane alkylation and a stereoselective intramolecular dipolar cycloaddition of an azomethine ylide, which provided the desired tricyclic ABC core structure.