<i>Objectives</i>. To investigate whether the incidence of acute appendicitis increases in summer and whether complicated cases present more in summer. <i>Methods</i>. 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. <i>Results</i>. 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&#x0025;). Gangrenous, perforated, and purulent appendices were regarded as complicated appendicitis. The highest number of cases were admitted in summer (234), comprising 36.2&#x0025; of cases. Complicated cases were equal to 65, of which 23 (35.4&#x0025;) were admitted in summer and 30 (46.2&#x0025;) 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&#xb0;C) and second lowest (19.8&#xb0;C), respectively. Moderate positive correlation (Pearson&#x2019;s R 0.5183) between the monthly incidence of appendicitis and the mean temperature is noted. <i>Conclusion</i>. 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.

Rawan A. Rahman AlHarmi

Sayed Ali Almahari

Jasim AlAradi

Asma Alqaseer

Noof Sami AlJirdabi

Fatema Ali Ahmed

Seasonal Variation in Cases of Acute Appendicitis

<i>Background</i>. 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. <i>Methods</i>. 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. <i>Results</i>. Independent preoperative predictors of mortality were the albumin-bilirubin (ALBI) grade 3 (OR: 21.7; CI 95: 2.1–226.9; <span class="inline_break"><svg xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg" width="18.973pt" style="vertical-align:-3.42938pt" id="M1" height="11.7782pt" version="1.1" viewBox="-0.0498162 -8.34882 18.973 11.7782"><g transform="matrix(.013,0,0,-0.013,0,0)"><path id="g113-113" d="M570 304C570 398 525 448 414 448C385 448 343 445 312 434L329 511L321 518C297 504 262 482 244 460L233 411C195 397 159 381 128 358L135 332C160 347 189 360 224 373L111 -147C97 -210 84 -218 17 -231L13 -257L254 -247L259 -218L233 -216C183 -212 177 -202 189 -142L218 -1C238 -10 266 -12 283 -12C351 3 429 48 483 105C543 168 570 242 570 304ZM482 289C482 161 380 33 304 33C278 33 248 51 233 69L303 396C326 400 352 403 369 403C428 403 482 380 482 289Z"/></g><g transform="matrix(.013,0,0,-0.013,11.342,0)"><path id="g117-34" d="M535 323V373H52V323H535ZM535 138V188H52V138H535Z"/></g></svg><span class="irelop"/><span class="nowrap"><svg xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg" width="21.921pt" style="vertical-align:-3.42938pt" height="11.7782pt" version="1.1" viewBox="22.555183800000002 -8.34882 21.921 11.7782"><g transform="matrix(.013,0,0,-0.013,22.605,0)"><path id="g113-49" d="M241 635C89 635 35 457 35 312C35 153 89 -12 240 -12C390 -12 443 166 443 312C443 466 390 635 241 635ZM238 602C329 602 354 454 354 312C354 172 330 22 240 22C152 22 124 173 124 313S148 602 238 602Z"/></g><g transform="matrix(.013,0,0,-0.013,28.845,0)"><path id="g113-47" d="M113 -12C146 -12 170 11 170 46C170 78 146 103 114 103S58 78 58 46C58 11 82 -12 113 -12Z"/></g><g transform="matrix(.013,0,0,-0.013,31.809,0)"><use xlink:href="#g113-49"/></g><g transform="matrix(.013,0,0,-0.013,38.049,0)"><path id="g113-50" d="M384 0V27C293 34 287 42 287 114V635C232 613 172 594 109 583V559L157 557C201 555 205 550 205 499V114C205 42 199 34 109 27V0H384Z"/></g></svg>)</span></span> and the estimated glomerular filtration rate (eGFR) &lt;90 mL/min/1.73 m<sup>2</sup> (OR: 17.7; CI 95: 1.8–172.6; <span class="inline_break"><svg xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg" width="18.973pt" style="vertical-align:-3.42938pt" id="M2" height="11.7782pt" version="1.1" viewBox="-0.0498162 -8.34882 18.973 11.7782"><g transform="matrix(.013,0,0,-0.013,0,0)"><use xlink:href="#g113-113"/></g><g transform="matrix(.013,0,0,-0.013,11.342,0)"><use xlink:href="#g117-34"/></g></svg><span class="irelop"/><span class="nowrap"><svg xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg" width="28.184pt" style="vertical-align:-3.42938pt" height="11.7782pt" version="1.1" viewBox="22.555183800000002 -8.34882 28.184 11.7782"><g transform="matrix(.013,0,0,-0.013,22.605,0)"><use xlink:href="#g113-49"/></g><g transform="matrix(.013,0,0,-0.013,28.845,0)"><use xlink:href="#g113-47"/></g><g transform="matrix(.013,0,0,-0.013,31.809,0)"><use xlink:href="#g113-49"/></g><g transform="matrix(.013,0,0,-0.013,38.049,0)"><use xlink:href="#g113-50"/></g><g transform="matrix(.013,0,0,-0.013,44.289,0)"><path id="g113-52" d="M285 378C315 398 338 416 353 432C373 451 384 474 384 503C384 579 325 635 236 635H235C182 635 136 610 108 579L65 516L85 496C110 533 150 575 205 575C258 575 300 543 300 481C300 407 232 369 141 339L147 310C163 315 188 321 211 321C268 321 338 284 338 192C338 94 288 40 217 40C160 40 119 68 93 91C85 98 77 97 69 91C60 84 47 71 46 58C44 46 48 35 62 22C75 10 116 -12 162 -12C234 -12 424 62 424 224C424 297 373 359 285 376V378Z"/></g></svg>).</span></span> The eGFR &lt;90 mL/min/1.73 m<sup>2</sup> (OR = 6.6; CI 95: 1.9–23.4; <span class="inline_break"><svg xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg" width="18.973pt" style="vertical-align:-3.42938pt" id="M3" height="11.7782pt" version="1.1" viewBox="-0.0498162 -8.34882 18.973 11.7782"><g transform="matrix(.013,0,0,-0.013,0,0)"><use xlink:href="#g113-113"/></g><g transform="matrix(.013,0,0,-0.013,11.342,0)"><use xlink:href="#g117-34"/></g></svg><span class="irelop"/><span class="nowrap"><svg xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg" width="28.184pt" style="vertical-align:-3.42938pt" height="11.7782pt" version="1.1" viewBox="22.555183800000002 -8.34882 28.184 11.7782"><g transform="matrix(.013,0,0,-0.013,22.605,0)"><use xlink:href="#g113-49"/></g><g transform="matrix(.013,0,0,-0.013,28.845,0)"><use xlink:href="#g113-47"/></g><g transform="matrix(.013,0,0,-0.013,31.809,0)"><use xlink:href="#g113-49"/></g><g transform="matrix(.013,0,0,-0.013,38.049,0)"><use xlink:href="#g113-49"/></g><g transform="matrix(.013,0,0,-0.013,44.289,0)"><use xlink:href="#g113-52"/></g></svg>)</span></span> and prothrombin time (OR = 1.5; CI 95; 1.1–2.1; <span class="inline_break"><svg xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg" width="18.973pt" style="vertical-align:-3.42938pt" id="M4" height="11.7782pt" version="1.1" viewBox="-0.0498162 -8.34882 18.973 11.7782"><g transform="matrix(.013,0,0,-0.013,0,0)"><use xlink:href="#g113-113"/></g><g transform="matrix(.013,0,0,-0.013,11.342,0)"><use xlink:href="#g117-34"/></g></svg><span class="irelop"/><span class="nowrap"><svg xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg" width="28.184pt" style="vertical-align:-3.42938pt" height="11.7782pt" version="1.1" viewBox="22.555183800000002 -8.34882 28.184 11.7782"><g transform="matrix(.013,0,0,-0.013,22.605,0)"><use xlink:href="#g113-49"/></g><g transform="matrix(.013,0,0,-0.013,28.845,0)"><use xlink:href="#g113-47"/></g><g transform="matrix(.013,0,0,-0.013,31.809,0)"><use xlink:href="#g113-49"/></g><g transform="matrix(.013,0,0,-0.013,38.049,0)"><use xlink:href="#g113-49"/></g><g transform="matrix(.013,0,0,-0.013,44.289,0)"><path id="g113-54" d="M153 550H386L412 615L406 623H120L82 318C104 327 142 338 184 338C294 338 347 275 347 187C347 112 305 39 221 39C160 39 119 71 97 89C88 97 80 96 71 90C59 80 50 67 49 57C48 45 52 36 66 23C80 9 123 -12 169 -12C221 -11 288 15 342 59C403 109 431 165 431 225C431 308 366 395 238 395C212 395 165 379 127 364L153 550Z"/></g></svg>)</span></span> were independent predictors for severe morbidity. <i>Conclusion</i>. 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.

Ramiro Fernandez-Placencia

Francisco Berrospi-Espinoza

Karla Uribe-Rivera

Jose Medina-Cana

Ivan Chavez-Passiuri

Nestor Sanchez-Bartra

Kori Paredes-Galvez

Carlos Luque-Vasquez Vasquez

Juan Celis-Zapata

Eloy Ruiz-Figueroa

Preoperative Predictors for 90-Day Mortality after Pancreaticoduodenectomy in Patients with Adenocarcinoma of the Ampulla of Vater: A Single-Centre Retrospective Cohort Study

<i>Background</i>. 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. <i>Aim</i>. &#x2009;The aim of this study is to ascertain the perception and attitude of future surgeons towards trauma care in Nigeria. <i>Materials and methods</i>. 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. <i>Results</i>. One hundred and fifty-seven questionnaires were adequately completed with a male-to-female ratio of 18&#x2009;:&#x2009;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&#x0025; of the respondents believe that the Nigerian trauma system is poorly planned, about 19&#x0025; think it is nonexistent. 81 (53.7&#x0025;) agree or strongly agree that managing trauma patients is too stressful. A good number, 116 (74.4&#x0025;), strongly agree that having a separate dedicated trauma unit will improve care and outcome. While 82&#x0025; of the surgical trainees support post fellowship training in trauma, only 62.2&#x0025; 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. <i>Conclusion</i>. Surgical trainees in Nigeria have good perception and positive attitude towards trauma care<i>.</i> Primary prevention measures must be emphasized during surgical trainees&#x2019; training in trauma.

Onyedika Okoye

Emmanuel Ameh

Emmanuel Ojo

Perception and Attitude of Surgical Trainees in Nigeria to Trauma Care

<i>Introduction</i>. Upper gastrointestinal (GI) bleeding is associated with increased morbidity and mortality. Tranexamic acid (TXA) is an antifibrinolytic agent which is licensed in the management of haemorrhage associated with trauma. It has been suggested that tranexamic acid may be able to play a role in upper GI bleeding. However, there is currently no recommendation to support this. <i>Aim</i>. The aim of this study was to synthesise available evidence of the effect of TXA on upper GI bleeding. <i>Methods and Materials</i>. A systematic review was conducted. PubMed, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL) were searched for relevant studies. A random effects meta-analysis was performed to determine the risk ratio of primary and secondary outcomes pertaining to the use of TXA in upper GI bleeding. <i>Results</i>. A total of 8 studies were included in this systematic review. The total number of patients in all studies was 12994 including 4550 females (35&#x0025;) and 8444 males (65&#x0025;). The mean age of participants in 6 of the studies was 59.3; however the mean age for either intervention or placebo group was not reported in two of the studies. All studies reported on the effect of TXA on mortality, and the risk ratio was 0.95; however, with the 95&#x0025; CI ranging from 0.80 to 1.13, this was not statistically significant. 6 of the studies reported on rebleeding rate, the risk ratio was 0.64, and with a 95&#x0025; CI ranging from 0.47 to 0.86, this was statistically significant. 3 of the studies reported on the risk of adverse thromboembolic events, and the risk ratio was 0.93; however, the 95&#x0025; CI extended from 0.62 to 1.39 and so was not statistically significant. 7 of the studies reported on the need for surgery, and the risk ratio was 0.59 and was statistically significant with a 95&#x0025; CI ranging from 0.38 to 0.94. <i>Conclusion</i>. In conclusion, the use of TXA in upper GI bleeding appears to have a beneficial effect in terms of decreasing the risk of re-bleeding and decreasing the need for surgery. However, we could not find a statistically significant effect on need for blood transfusions, risk of thromboembolic events, or effect on mortality. Future randomised controlled trials may elucidate these outcomes.

Eoghan Burke

Patricia Harkins

Ibrahim Ahmed

Is There a Role for Tranexamic Acid in Upper GI Bleeding? A Systematic Review and Meta-Analysis

<i>Background</i>. Laparoscopic reversal of Hartmann’s procedure (LHR) offers reduced morbidity compared with open Hartmann’s reversal (OHR). The aim of this study is to compare the outcome of laparoscopic versus open Hartmann reversal. <i>Materials and Methods</i>. Thirty-four patients who underwent Hartmann reversal between January 2017 and July 2019 were evaluated. Patients underwent either LHR (<i>n</i> = 17) or OHR (<i>n</i> = 17). Variables such as numbers of patients, patient’s age, sex, body mass index (BMI), comorbidities, ASA (American Society of Anesthesiology) score, indication for previous open sigmoid resection, mean operation time, rate of conversion to open surgery, length of hospital stay, mortality, and morbidity were retrospectively evaluated. <i>Results</i>. The two groups of patients were homogeneous for gender, age, body mass index, cause of primary surgery, time to reversal, and comorbidities. In 97% of the cases, HP was done by open surgery. Our data revealed no difference in mean operation time (LHR: 180.5 ± 35.1 vs. OHR: 225.2 ± 48.4) and morbidity rate, although, in OHR group, there were more severe complications. Less intraoperative blood loss (LHR: 100 ± 40 mL vs. OHR: 450 ± 125 mL; <svg xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg" style="vertical-align:-3.42943pt" id="M1" height="10.2124pt" version="1.1" viewBox="-0.0498162 -6.78297 7.83752 10.2124" width="7.83752pt"><g transform="matrix(.013,0,0,-0.013,0,0)"><path id="g113-113" d="M570 304C570 398 525 448 414 448C385 448 343 445 312 434L329 511L321 518C297 504 262 482 244 460L233 411C195 397 159 381 128 358L135 332C160 347 189 360 224 373L111 -147C97 -210 84 -218 17 -231L13 -257L254 -247L259 -218L233 -216C183 -212 177 -202 189 -142L218 -1C238 -10 266 -12 283 -12C351 3 429 48 483 105C543 168 570 242 570 304ZM482 289C482 161 380 33 304 33C278 33 248 51 233 69L303 396C326 400 352 403 369 403C428 403 482 380 482 289Z"/></g></svg> value &lt;0.001), shorter time to flatus (LHR: 2.4 days vs. OHR: 3.6 days; <svg xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg" style="vertical-align:-3.42943pt" id="M2" height="10.2124pt" version="1.1" viewBox="-0.0498162 -6.78297 7.83752 10.2124" width="7.83752pt"><g transform="matrix(.013,0,0,-0.013,0,0)"><use xlink:href="#g113-113"/></g></svg> value &lt;0.021), and shorter hospitalization (LHR: 4.4 vs. OHR: 11.2 days; <svg xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg" style="vertical-align:-3.42943pt" id="M3" height="10.2124pt" version="1.1" viewBox="-0.0498162 -6.78297 7.83752 10.2124" width="7.83752pt"><g transform="matrix(.013,0,0,-0.013,0,0)"><use xlink:href="#g113-113"/></g></svg> value &lt;0.001) were observed in the LHR group. Mortality rate was null in both groups. <i>Discussion</i>. LHR is feasible and safe even for patients who received a primary open Hartmann’s procedure. We suggest careful patient’s selection allowing LHR procedures to highly skilled laparoscopy surgeons.

Paolo Panaccio

Tommaso Grottola

Rossana Percario

Federico Selvaggi

Severino Cericola

Alfonso Lapergola

Maira Farrukh

Giuseppe Di Martino

Marco Ricciardiello

Pierluigi Di Sebastiano

Fabio Francesco Di Mola

Laparoscopic Versus Open Hartmann Reversal: A Case-Control Study

<i>Introduction</i>. Gastric Cancer (GC) is the fourth most common malignancy worldwide and the second leading cause of cancer-related mortality for both sexes. The gold standard for diagnosing GC is oesophagogastroduodenoscopy (OGD). Excess mucus on the gastric mucosa impairs the detection of early GC. <i>Aim</i>. To synthesize available evidence of the effect of premedication with a mucolytic agent among adults undergoing elective nontherapeutic OGD, compared to placebo or other mucolytic agents, on mucosal visibility during OGD. <i>Methods</i>. A systematic review was conducted. PubMed, EMBASE, CINAHL, Cochrane central register of controlled trials (CENTRAL), and Web of Science were searched for relevant studies. A random-effects meta-analysis was performed to determine the mean difference in total mucosal visibility score (TMVS) between the pooled mucolytic agents and control. Subgroup analyses were performed to determine the mean TMVS difference for simethicone versus control and the impact of different timings and doses of mucolytic premedication. <i>Results</i>. 13 studies, involving 11,086 patients, including 6178 females (55.7&#x0025;), with a mean age of 53.4 were identified and 6 of these were brought forward to meta-analysis. This revealed a mean difference of &#x2212;2.69 (95&#x0025; CI &#x2212;3.5, &#x2212;1.88) in total mucosal visibility scores (TMVS) between the pooled mucolytic agents and control. For simethicone, the mean difference was &#x2212;2.68 (95&#x0025; CI &#x2212;4.94, &#x2212;0.43). A simethicone dose of 133&#x2009;mg was most effective with a mean difference of &#x2212;4.22 (95&#x0025; CI &#x2212;5.11, &#x2212;3.33). Assessing timing of administration across all mucolytic agents revealed a mean difference for the &#x3e;20 minutes group of &#x2212;3.68 (95&#x0025; CI &#x2212;4.77, &#x2212;2.59). No adverse events were reported in any included trials. <i>Conclusions</i>. Regular use of premedication with mucolytic agents prior to routine OGD is associated with improved TMVS with no reported adverse events.

Frank Moriarty

Does Premedication with Mucolytic Agents Improve Mucosal Visualization during Oesophagogastroduodenoscopy: A Systematic Review and Meta-Analysis

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