Magnetic resonance imaging for acute appendicitis in pregnancy: can clinical scores predict when imaging is needed?

PURPOSE: Advanced imaging may augment the diagnostic milieux for presumed acute appendicitis (AA) during pregnancy, however it is not clear when such imaging modalities are indicated. The aim of this study was to assess the sensitivity and specificity of clinical scoring systems with the findings on magnetic resonance imaging (MRI) of AA in pregnant patients. METHODS: A retrospective cohort study between 2019 and 2021 was performed in two tertiary level centers. Pregnant patients presenting with suspected AA and non-diagnostic trans-abdominal ultrasound who underwent MRI as part of their evaluation were identified. Patient demographics, parity, gestation, presenting signs, and symptoms were documented. The Alvarado and Appendicitis Inflammatory Response (AIR) score for each patient were calculated and correlated with clinical and MRI findings. Univariate analysis was used to identify factors associated with AA on MRI. RESULTS: Of the 255 pregnant patients who underwent MRI, 33 (13%) had findings of AA. On univariate analysis, presentation during the second/third trimester, migration of pain, vomiting and RLQ tenderness correlated with MRI findings of AA. Whilst 5/77 (6.5%) of patients with an Alvarado score ≤4 had signs of AA on MRI, a score of ≥5 had a sensitivity, specificity, negative and positive predictive value of 84.8%, 36.6%, 94.0% and 17.2%. For an AIR score ≥ 5, this was 78.8%, 41.5%, 93.0%, and 16.7%, respectively. CONCLUSIONS: Whilst clinical scoring systems may be useful in identifying which pregnant patients require MRI to be performed when AA is suspected, the low sensitivity implies further research is needed to refine the use of this valuable resource.

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.

Decompressive Laparotomy for Veno-Venous Extracorporeal Membrane Oxygenation Failure due to Intra-Abdominal Hypertension in Critically Ill COVID-19 Patient.

The use of extracorporeal membrane oxygenation (ECMO) has increased over the course of the SARS-CoV-2 pandemic. Intra-abdominal hypertension resulting in abdominal compartment syndrome (ACS) during ECMO support is a rare but life-threatening complication, with previous case series describing mortality rates of 44%-100%. Bleeding complications, linked to both patient-related and device-related factors, also characterize prolonged ECMO support and have been reported in up to 60% of ECMO patients. We hereby describe a critically ill COVID-19 patient who underwent emergent bed-side decompressive laparotomy for acute ECMO failure related to the development of ACS. The discussion is focused on surgical considerations including the delicate balance between anticoagulation and thrombosis, as anticoagulation-free ECMO support may be required due to hemorrhagic complications.