Bilirubin is a specific marker for the diagnosis of acute appendicitis.

Total serum bilirubin and other biochemical parameters have been associated with acute appendicitis, mainly in complicated cases. The present study aimed to evaluate the role of biochemical parameters in the diagnosis of acute appendicitis, and to further investigate the role of bilirubin as a diagnostic marker irrespective of the severity of the pathology. All recorded cases of appendicectomies in a 1-year period in a single institution were reviewed. The median values of white cell count, C-reactive protein and total serum bilirubin on admission were associated with final histology, and their respective rates of abnormal and normal values were compared between patients who were proven to have negative histology and patients who were proven to have acute appendicitis. A total of 300 patients were studied. Median total serum bilirubin, white cell count and C-reactive protein on admission were significantly associated with acute appendicitis (P<0.001). Respective rates of normal and abnormal values were significantly associated with final histology (P<0.001). Total serum bilirubin demonstrated higher specificity (0.88) but lower sensitivity (0.26) and diagnostic accuracy (0.40) for acute appendicitis. In conclusion, total serum bilirubin on admission should be considered in the diagnostic workup to confirm rather than exclude appendicitis, without focusing on subgroups of specific severity of the disease. White cell count and C-reactive protein may also contribute to the diagnostic work-up, although with limited accuracy.

Laparostomy and temporary abdominal closure outcomes in emergency non-trauma surgery and parameters affecting early definite primary fascial closure.

BACKGROUND: The open abdomen or laparostomy is a great advance of surgery based on the concept of damage control surgery. Aim of the study is to review the laparostomy outcomes of non-trauma emergency surgery patients in a district general hospital and identify parameters affecting early definite primary fascial closure. METHODS: The records of all non-trauma emergency surgical patients who underwent laparostomy in a three-year period in a single institute were studied retrospectively. Outcomes included length of stay, morbidity, mortality, readmission rates, number of re-look operations, rate of definite primary fascial closure and time to closure. RESULTS: Thirty-two patients were included. Morbidity was 84.4% and mortality rates were 21.9% (in-hospital), 18.8% (30-day) and 46.9% (overall). Median length of hospital stay was 22 days. Rate of primary fascial closure was 87.5% and median time to closure was two days. The number of relook operations was the only independent prognostic factor of definite early primary fascial closure, with higher rates of closure in patients with 1-2 relooks. CONCLUSIONS: Although the open abdomen has been demonstrated to improve survival, the precise role in abdominal sepsis has not been elucidated. Current consensus does not support use of open abdomen routinely, however in selected situations it becomes unavoidable. Laparostomy is a valid option in non-trauma emergency surgery and can be managed safely in a district hospital. High closure rates can be achieved if one or two re-look operations are performed with an early attempt for closure.

Single Port Laparoscopic Total and Subtotal Colectomies for Inflammatory Bowel Disease in a District General Hospital.

Background: Single incision laparoscopic surgery (SILS) is expanding, enhancing the advantages of multi-port laparoscopic surgery (MLS). Limited literature exists regarding SILS total/subtotal colectomies for inflammatory bowel disease (IBD). Aim of the study was to present the initial experience with this type of approach in a district general hospital and extrapolate its feasibility and safety in this specific context based on gold standard outcomes reported in literature. Materials and Methods: Preoperative parameters, operative details and surgical outcomes of consecutive patients who underwent colonic SILS for IBD in a 5-year period were reviewed retrospectively. Median length of follow-up was 26 months. Results: Fourteen patients underwent SILS subtotal/total colectomy. Median body mass index was 25 (18.1-35). Two patients had previous abdominal surgeries. Median operating time was 202.5 minutes. Two cases were converted to open. Median length of stay was 5 days. Three patients presented complications. Three patients developed parastomal hernias (21.4%). Five out of 12 patients with ulcerative colitis declined further surgery, 3 are awaiting laparoscopic/SILS pouch formation, 1 underwent SILS pouch formation, 1 SILS ileo-rectal anastomosis and 1 patient had SILS completion proctectomy. One patient was not followed up. Conclusions: Despite literature data heterogeneity, these results provide support to the feasibility and applicability of SILS in the subgroup of patients who undergo subtotal/total colectomies for IBD, offering the option for subsequent SILS completion or restorative procedures. Further studies are required to explore the benefit of SILS over MLS (including cosmesis and quality of life) and non-inferiority of SILS regarding the parastomal hernia issue and the operative duration.

Adjuvant radiotherapy in oesophageal cancer with positive circumferential resection margins-recurrence and survival outcomes.

BACKGROUND: The role of adjuvant radiotherapy in patients with microscopically positive circumferential resection margins (CRM), R1 specimen, in oesophageal resections for cancer with curative intent remains unclear. However, R1 specimens are associated with poorer survival outcomes. The aim was to assess the benefit of adjuvant radiotherapy on recurrence and survival in these patients. METHODS: Patients were identified in a single centre between July 2000 and December 2016. Patient demographics, tumour characteristics and survival outcomes were assimilated and compared between those who received adjuvant therapy and those who did not. RESULTS: Sixty-eight patients were included in the study; 57 (83.8%) male and 11 (16.2%) female with a median age of 67 years. The adjuvant radiotherapy regimen used was 40-50 Gy in 25 fractions over 5 weeks. Median follow-up was 13 months (interquartile range, 6-27 months). Twenty-five (36.8%) patients received adjuvant radiotherapy. There was no statistically significant correlation between administration of adjuvant radiotherapy and local recurrence (P=0.148), distant metastases (P=0.605), overall disease progression (P=0.561), progression-free survival (P=0.663) and overall survival (P=0.538). CONCLUSIONS: This study detects no benefit to oncological outcomes with the use of adjuvant radiotherapy in patients with microscopically positive CRM. Larger randomized studies are needed to further confirm these results.

Postoperative outcomes in laparoscopic appendicectomies with histopathologically normal appendix.

AIM: Although still debatable, appendicectomy during laparoscopy in patients with abdominal pain is often performed even if the appendix seems normal. The study's aim is to compare the postoperative outcomes of laparoscopic appendicectomies with appendix proven to be histologically normal to those with proven appendicitis, adding evidence on whether a normal appendix should be removed. METHODS: All consecutive patients who underwent laparoscopic appendicectomy in a one-year period in a single centre were retrospectively studied. Comparison was attempted between patients with negative and positive histology with regards to their postoperative outcomes (length of stay and postoperative complications). RESULTS: Out of 134 patients included in the study, ten patients developed postoperative complications (7.5%), 42 patients had negative histology (31.3%), 92 patients had positive histology (68.7%) and six (14.3%) and four patients (4.3%) respectively from each group developed post-operative complications. No statistically significant difference was found regarding morbidity, length of stay and Clavien-Dindo grading of complications between the two groups. DISCUSSION: Morbidity and length of stay in laparoscopic appendicectomy with normal appendix are not inferior to those with histologically confirmed appendicitis and thus should not be disregarded when considering a routine appendicectomy. CONCLUSION: The final decision to remove a normal appendix in laparoscopy for abdominal pain should be based on the individual clinical scenario and surgeon's experience. KEY WORDS: Acute appendicitis, Histology, Length of Stay, Morbidity.

Is ultrasound a reliable diagnostic tool for acute appendicitis? A single centre experience.

AIM: Aim of the present study is to evaluate the utility of US as a diagnostic method for acute appendicitis (AA) in a district general hospital, by use of accurate quality indices. MATERIAL AND METHODS: The records of all patients who underwent an appendicectomy in a one year period in a single centre were reviewed. The patients who underwent a preoperative US scan were included in the study in accordance to specific criteria and the results were statistically compared to the final surgical histology. RESULTS: 137 patients who underwent an US were included in the study, with 69 patients (23%) presenting a negative histology result. Overall, the US results correlated statistically significantly with the final histology results, with a specificity of 0.87, a sensitivity of 0.34 and an overall diagnostic accuracy of 0.51. DISCUSSION: The results of the study are comparable with the reported literature, presenting high specificity but a relatively low sensitivity, although great variability exists in the literature. US seems useful in confirming rather than excluding AA. CONCLUSION: In view of its advantages, the incorporation of ultrasonography into routine clinical practice when performed by an expert is recommended, but only in support of other diagnostic elements. The issue of low sensitivity should be further addressed. KEY WORDS: Appendicectomy, Diagnostic accuracy, Histology.

Preoperative ultrasound guided percutaneous axillary biopsy in breast cancer patients: fine needle aspiration cytology versus core biopsy.

AIM: The aim of this study is to compare the diagnostic accuracy in detecting axillary node metastases between preoperative ultrasound with percutaneous core biopsy or fine needle aspiration cytology, in patients with breast cancer. MATERIAL AND METHODS: All cases with newly diagnosed ipsilateral primary breast cancer that underwent axillary ultrasound guided biopsies in a 2 year period were reviewed and the biopsy outcome was compared to the final histopathology from sentinel lymph node biopsy or axillary node dissection. Comparison was also attempted in a subgroup including only patients who underwent one method and in a second subgroup of patients who had both techniques performed. RESULTS: Within the total population results are in favor of core biopsy which correlates statistically significantly with the final histology after excluding neoadjuvant related false negatives. Within the single modality subgroup results are again in favor of core biopsy which again correlates statistically significantly with the final histology. Within the combined modality subgroup results demonstrate equal diagnostics but neither method demonstrates statistically significant diagnostic success. DISCUSSION: The results of the study are generally in favour of core biopsy which tends currently to override fine needle aspiration cytology. Only few studies have directly compared the two methods and a great variability exists in the results of the different studies. CONCLUSIONS: A case-match cohort study is advised to accurately compare the diagnostic value of the two methods. Until then the decision will be based on the radiologist's experience. KEY WORDS: Breast cancer, Diagnostic accuracy, Percutaneous axillary biopsy.

Managing Small Ureteral Stones: A Retrospective Study on Follow-Up, Clinical Outcomes and Cost-Effectiveness of Conservative Management vs. Early Surgery.

INTRODUCTION: The management of ureteral calculi has evolved over the past decades with the advent of new surgical and medical treatments. The current guidelines support conservative management as a possible approach for ureteral stones sized = 10 mm. OBJECTIVES: We purport to follow the natural history of ureteral stones managed conservatively in this retrospective study, and attempt to ascribe an estimated health-care and cost-effectiveness, from presentation to time of being stone-free. MATERIALS AND METHODS: 192 male and female patients with a single ureteral stone sized = 10 mm were included in this study. The clinical and cost-related outcome was analyzed for different stone sizes (0-4, 4-6 and 6-10 mm). The effectiveness of selected follow-up (FU) scans was also analyzed. RESULTS: Stone size was found to be related to the degree of hydronephrosis and to the likelihood of need for a surgical management. Conservative management was found to be clinically effective, as 88% of the patients did not require surgery for their stone. 96.1% of the patients with a stone 0-4mm managed to expel their ureteral stone. Bigger ureteral stones were found to be more costly. The cost-effectiveness of the single FU scans was found to be related to their efficiency, while the global cost-effectiveness of conservative management vs. early surgery was higher for smaller stones (26.8 vs. 17.32% for stones 0-4 vs. 6-10 mm). CONCLUSION: Conservative management is clinically effective with a significant cost-benefit, particularly for the subgroup of stones sized 0-4 mm, where a need for FU scans is in dispute.