A Fast and Reliable Method to Interpret Short-Term Mortality in Perforated Peptic Ulcer: Red Cell Distribution Width is Sensitive and SpecificRead the full article
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Proposal and Validation of a New Classification of Surgical Outcomes after Colorectal Resections within an Enhanced Recovery Programme
Background. Advantages of Enhanced Recovery (ER) programmes in colorectal surgery have already been demonstrated, but heterogeneity exists with respect to the choice of compared outcomes. A comprehensive classification aimed at standardizing the reporting of surgical outcomes has been proposed and validated. Method. Clinical variables of 231 patients who underwent colorectal resections within an ER programme from 2013–2018 were analysed. Their outcomes have been reported according to a new classification in 5 classes and 11 subclasses. Prognostic variables have been identified. Results. Seventy-nine patients (34.2%) had an optimal class 1 outcome. Almost half of the patients had an uneventful recovery after being discharged after day 4 (2a). Only two patients (0.9%) were discharged early and then readmitted for a minor ailment (2b). Total morbidity was 12.6% (3a–5). Perioperative mortality was 2.6% (5). Young age, laparoscopic resection, and years of experience with ER have been identified as independent prognostic factors towards a totally positive outcome. Conclusions. The proposed outcome classification is a simple and objective tool to report the surgical outcome in clinical studies. Its implementation seems to be appropriate, in particular, in the field of ER protocols in colorectal surgery, but it can have a wider application in any other surgical subspeciality.
Acute Generalized Peritonitis in a Peripheral Hospital Centre in Benin: Can It Be Managed by a Local General Practitioner?
Background. Acute generalized peritonitis in resource-poor countries is still a health challenge due to late diagnosis, surgical delay, and specialists’ unavailability. These are the foremost determinants of surgical morbidity and mortality. We report the experience of a peripheral hospital in Benin not equipped with specialized surgeons. Methods. This is an observational, retrospective, and descriptive study including patients operated for acute generalized peritonitis at the Atacora Departmental Hospital Centre, Benin, where unfortunately CT scan and intensive care unit are still not available. Most of surgical activities were performed by a general practitioner with previous surgical training (but no surgical specialization). Age, gender, cause of peritonitis, surgical procedures, and postoperative outcome were evaluated. Results. Sixty-three patients were included. The mean age was 23.2 years and sex ratio M/F 1.5. The mean surgical delay was 26 hours (range: 6–92 hours). An ileal typhoid perforation was found in 40 patients (63.5%), and 35 of them (87.5%) underwent a primary perforation repair without bowel resection. 73% of surgical procedures were performed by the general practitioner. Morbidity was 34.9% and mortality was 14.3%. The average postoperative hospital stay was 12 days (range: 11–82 days). These results were comparable to those observed in the subgroup of patients (17 cases) operated by the general surgeons (morbidity 32.6%, mortality 13.0%, and average postoperative hospital stay 11 days, range: 1–58 days). Conclusion. Acute generalized peritonitis requires urgent management, and it can be effectively carried out, in a context of limited resources, by a general practitioner with surgical skills.
Appendicectomy for Uncomplicated Simple Appendicitis: Is It Always Required?
Background. Although appendicectomy is still the classical and standard treatment for acute appendicitis, initial conservative antibiotic only treatment for simple uncomplicated cases has been proposed and tried as a feasible and effective approach. The objective of this study was to evaluate the efficacy and outcomes of antibiotics treatment for acute simple uncomplicated appendicitis. Methods. This is a prospective controlled nonrandomized study in which a total of 156 patients whose ages range from 16 to 54 years presenting with clinical diagnosis of acute uncomplicated appendicitis were assigned for conservative antibiotics treatment, which consists of ceftriaxone I gram twice daily and metronidazole infusions, 500 mg in 100 ml, 3 times daily for 48 to 72 hours to be converted on oral antibiotics after clinical improvement for 5 to 7 days. Patients who failed to initial conservative treatment and those who had recurring symptoms of appendicitis were presented for appendectomy. Results. Antibiotic treatment was successful and feasible in 138 (88.5%) patients. Progression of the signs and symptoms despite full medical treatment was observed in 11 (7%) patients during the same admission. Further 7 (4.5%) patients showed recurrence of the symptoms during follow-up period of 6–12 months after successful initial conservative treatment and also proceeded for appendicectomy. Conclusion. Nonoperative antibiotic treatment of acute simple appendicitis is safe, feasible, and effective for properly selected cases, thus avoiding unnecessary surgery with its possible complications.
Seasonal Variation in Cases of Acute Appendicitis
Objectives. To investigate whether the incidence of acute appendicitis increases in summer and whether complicated cases present more in summer. Methods. A single-center cross-sectional, retrospective study on 697 cases of appendicitis admitted in the year 2018. Inclusion criteria: patients admitted with acute appendicitis who underwent appendectomy of all ages. Exclusion criteria: conservative management. Analysis was performed using Microsoft Excel. Pearson correlation coefficient was calculated to assess the correlation between monthly incidence of appendicitis and mean temperature in that month. Results. Fifty-one patients who were managed conservatively were excluded. Accordingly, 646 patients were included. Ages ranged from three to 77 years. Males comprised the majority (500, 77.4%). Gangrenous, perforated, and purulent appendices were regarded as complicated appendicitis. The highest number of cases were admitted in summer (234), comprising 36.2% of cases. Complicated cases were equal to 65, of which 23 (35.4%) were admitted in summer and 30 (46.2%) in winter. The highest number of cases was during the month of July (68), while the lowest (40) was during February. This corresponded to the highest recorded mean temperature (36.2°C) and second lowest (19.8°C), respectively. Moderate positive correlation (Pearson’s R 0.5183) between the monthly incidence of appendicitis and the mean temperature is noted. Conclusion. More cases of appendicitis were noted during summer. Monthly incidence correlated positively with the temperature. Larger numbers over several years are needed to draw better conclusions and reach the possible causes behind such variation.
Preoperative Predictors for 90-Day Mortality after Pancreaticoduodenectomy in Patients with Adenocarcinoma of the Ampulla of Vater: A Single-Centre Retrospective Cohort Study
Background. The standard treatment for ampullary adenocarcinoma is pancreaticoduodenectomy. Identification of preoperative risk factors might help the clinician to select patients fit for resection and potentially decrease morbidity and mortality after PD. We conducted a cohort study to determine the preoperative factors related to 90-day severe morbidity and mortality after PD. Methods. We conducted a retrospective cohort study in patients with a diagnosis of ampullary adenocarcinoma who underwent an open PD between January 2010 and December 2019 at our tertiary centre. Results. Independent preoperative predictors of mortality were the albumin-bilirubin (ALBI) grade 3 (OR: 21.7; CI 95: 2.1–226.9; ) and the estimated glomerular filtration rate (eGFR) <90 mL/min/1.73 m2 (OR: 17.7; CI 95: 1.8–172.6; ). The eGFR <90 mL/min/1.73 m2 (OR = 6.6; CI 95: 1.9–23.4; ) and prothrombin time (OR = 1.5; CI 95; 1.1–2.1; ) were independent predictors for severe morbidity. Conclusion. These findings suggest that baseline renal function measured by the eGFR and liver function categorized with the ALBI grading are predictors of severe morbidity and mortality. Thus, they should be considered when selecting patients for PD or the use of neoadjuvant treatments. Further research is warranted.
Perception and Attitude of Surgical Trainees in Nigeria to Trauma Care
Background. Trauma is still the leading cause of death in individuals between the ages of 1 and 44 years. Establishment of good trauma centres and systems has been shown to have a significant positive impact on outcomes. Surgical specialties, particularly trauma, are becoming less attractive in different parts of the world for a variety of reasons. Aim. The aim of this study is to ascertain the perception and attitude of future surgeons towards trauma care in Nigeria. Materials and methods. This is a cross-sectional study using a pretested, structured, paper-based questionnaire which was administered to consecutive surgical trainees at the annual revision course of West African College of Surgeons. Data were analyzed using SPSS version 12, and results are presented in tables and figures. Results. One hundred and fifty-seven questionnaires were adequately completed with a male-to-female ratio of 18 : 1 and median age of 30 years. There is a general agreement among the respondents that trauma incidence in Nigeria is high or very high. While about 70% of the respondents believe that the Nigerian trauma system is poorly planned, about 19% think it is nonexistent. 81 (53.7%) agree or strongly agree that managing trauma patients is too stressful. A good number, 116 (74.4%), strongly agree that having a separate dedicated trauma unit will improve care and outcome. While 82% of the surgical trainees support post fellowship training in trauma, only 62.2% will like to have the training. There is no significant difference between the proportion of males and females who would like to have the training. Conclusion. Surgical trainees in Nigeria have good perception and positive attitude towards trauma care. Primary prevention measures must be emphasized during surgical trainees’ training in trauma.