Goodbye Hartmann trial: a prospective, international, multicenter, observational study on the current use of a surgical procedure developed a century ago

BACKGROUND

Literature suggests colonic resection and primary anastomosis (RPA) instead of Hartmann's procedure (HP) for the treatment of left-sided colonic emergencies. We aim to evaluate the surgical options globally used to treat patients with acute left-sided colonic emergencies and the factors that leading to the choice of treatment, comparing HP and RPA.

METHODS

This is a prospective, international, multicenter, observational study registered on ClinicalTrials.gov. A total 1215 patients with left-sided colonic emergencies who required surgery were included from 204 centers during the period of March 1, 2020, to May 31, 2020. with a 1-year follow-up.

RESULTS

564 patients (43.1%) were females. The mean age was 65.9 ± 15.6 years. HP was performed in 697 (57.3%) patients and RPA in 384 (31.6%) cases. Complicated acute diverticulitis was the most common cause of left-sided colonic emergencies (40.2%), followed by colorectal malignancy (36.6%). Severe complications (Clavien-Dindo ≥ 3b) were higher in the HP group (P < 0.001). 30-day mortality was higher in HP patients (13.7%), especially in case of bowel perforation and diffused peritonitis. 1-year follow-up showed no differences on ostomy reversal rate between HP and RPA. (P = 0.127). A backward likelihood logistic regression model showed that RPA was preferred in younger patients, having low ASA score (≤ 3), in case of large bowel obstruction, absence of colonic ischemia, longer time from admission to surgery, operating early at the day working hours, by a surgeon who performed more than 50 colorectal resections.

CONCLUSIONS

After 100 years since the first Hartmann's procedure, HP remains the most common treatment for left-sided colorectal emergencies. Treatment's choice depends on patient characteristics, the time of surgery and the experience of the surgeon. RPA should be considered as the gold standard for surgery, with HP being an exception.

Axillary Cystic Lymphangioma in an Adult: A Case Report

Lymphangioma is a congenital malformation of the lymphatic system most often reported in children. Its occurrence in adults is rare. It usually develops in the head, neck, and axillary region. It mimics other conditions, such as cold abscess, simple cyst, hydatid cyst, and hemangioma, on clinical examination. Here, we report a case of cystic lymphangioma in the axillary region of a 32-year-old male. The patient underwent surgical excision and histopathology confirmed cystic lymphangioma. Although it is very rare in adults, cystic lymphangioma should be considered in the differential diagnosis of an axillary mass.

Evaluation of a quality improvement intervention to reduce anastomotic leak following right colectomy (EAGLE): pragmatic, batched stepped-wedge, cluster-randomized trial in 64 countries

BACKGROUND

Anastomotic leak affects 8 per cent of patients after right colectomy with a 10-fold increased risk of postoperative death. The EAGLE study aimed to develop and test whether an international, standardized quality improvement intervention could reduce anastomotic leaks.

METHODS

The internationally intended protocol, iteratively co-developed by a multistage Delphi process, comprised an online educational module introducing risk stratification, an intraoperative checklist, and harmonized surgical techniques. Clusters (hospital teams) were randomized to one of three arms with varied sequences of intervention/data collection by a derived stepped-wedge batch design (at least 18 hospital teams per batch). Patients were blinded to the study allocation. Low- and middle-income country enrolment was encouraged. The primary outcome (assessed by intention to treat) was anastomotic leak rate, and subgroup analyses by module completion (at least 80 per cent of surgeons, high engagement; less than 50 per cent, low engagement) were preplanned.

RESULTS

A total 355 hospital teams registered, with 332 from 64 countries (39.2 per cent low and middle income) included in the final analysis. The online modules were completed by half of the surgeons (2143 of 4411). The primary analysis included 3039 of the 3268 patients recruited (206 patients had no anastomosis and 23 were lost to follow-up), with anastomotic leaks arising before and after the intervention in 10.1 and 9.6 per cent respectively (adjusted OR 0.87, 95 per cent c.i. 0.59 to 1.30; P = 0.498). The proportion of surgeons completing the educational modules was an influence: the leak rate decreased from 12.2 per cent (61 of 500) before intervention to 5.1 per cent (24 of 473) after intervention in high-engagement centres (adjusted OR 0.36, 0.20 to 0.64; P < 0.001), but this was not observed in low-engagement hospitals (8.3 per cent (59 of 714) and 13.8 per cent (61 of 443) respectively; adjusted OR 2.09, 1.31 to 3.31).

CONCLUSION

Completion of globally available digital training by engaged teams can alter anastomotic leak rates. Registration number: NCT04270721 (http://www.clinicaltrials.gov).

Defining Critical View of Safety During Laparoscopic Cholecystectomy: The Preoperative Predictors of Failure

Background Defining critical view of safety (CVS) is one of the most crucial steps during laparoscopic cholecystectomy (LC). This study aimed to determine the preoperative predictors of failure to achieve CVS during LC. Methods All patients undergoing LC from December 2020 to July 2022 were prospectively included. Results There were 180 females and 93 males. CVS was achieved during LC in 238 (87.2%) patients. Conversion to open surgery was performed for 11 patients. Bile leak occurred in three patients which resolved spontaneously. No patient developed bile duct injury. On univariate analysis, age, male sex, American Society of Anaesthesiologists (ASA) grading, Murphy's sign, emergency surgery, neutrophil percentage, lymphocyte percentage, gallbladder wall thickness > 3mm, and impacted gallstone on abdominal ultrasound were predictors of failure to achieve CVS. On multivariate analysis, neutrophil and lymphocyte percentages were independent predictors of failure to achieve CVS. Patients in whom CVS could not be achieved had significantly longer operative time, higher blood loss, complications, and hospital stays. Discussion Inability to achieve CVS during LC can be predicted preoperatively using various parameters including neutrophil and lymphocyte percentages. Such cases must be operated by senior surgeons or referred to experienced general or hepatobiliary surgeons for cholecystectomy to avoid bile duct injury. The proposed algorithm can help in intraoperative decision-making in difficult cases.

Nontuberculous Mycobacterial Infection After Cholecystectomy: A Case Series and Literature Review

Nontuberculous mycobacteria (NTM) are ubiquitous micro-organisms that can cause skin, soft tissue, and respiratory infections. Some of these bacteria are resistant to the commonly used disinfectants in hospitals and lead to wound infections after surgery. The diagnosis of NTM infections requires a high index of clinical suspicion as their clinical presentation often overlaps with other bacterial infections. Moreover, the isolation of NTM from clinical samples is difficult and time-consuming. Also, there is a lack of standardized treatment protocols for NTM infections. We report four cases of delayed wound infections after cholecystectomy probably due to NTM which were successfully treated by a combination of clarithromycin, ciprofloxacin, and amikacin.

Pancreatoduodenal Tuberculosis: A Rare Site of a Common Disease

The most common site of abdominal tuberculosis (TB) is the ileocecal region. The duodenum and pancreas are rare sites of abdominal TB. It is usually observed in immunocompromised patients with miliary or disseminated TB. Pancreatoduodenal TB is often misdiagnosed as malignancy due to a lack of specific symptoms. Here, we present a case of a 55-year-old immunocompetent man having abdominal pain, bilious vomiting, weight loss, and high-grade fever for three months. Contrast-enhanced computed tomography of the abdomen showed a localized abscess with air foci in the pancreatic head and duodenopancreatic groove. Additionally, there was retroperitoneal lymphadenopathy and mild ascites. Upper gastrointestinal endoscopy revealed an ulceroproliferative lesion in the second part of the duodenum suspicious of a malignant tumor. However, the endoscopic biopsy showed epitheloid-like histiocytes, Langerhans type of giant cells, and granuloma formation suggestive of TB. The patient responded to antitubercular treatment and became symptom-free. 

Laparoscopic Removal of Retained Surgical Sponge After Caesarean Section: A Case Report

Gossypiboma or textiloma denotes the formation of a mass lesion due to the development of foreign body reactions around the retained surgical item in the body. Most of the cases are asymptomatic in the initial postoperative period. Due to the dense adhesions, most of the cases of intra-abdominal gossypiboma are treated by an open approach. Here we present a case of a 38-year-old lady with left iliac fossa pain one month after caesarean section. Contrast-enhanced computed tomography of the abdomen revealed gossypiboma. The patient was successfully treated with laparoscopic removal of the gossypiboma.

Multifocal Dedifferentiated Liposarcoma of the Jejunal Mesentery

Abdominal liposarcoma is most often located in the retroperitoneum. Small bowel mesentery is a rare site of liposarcoma. Dedifferentiated liposarcoma (DDLS) is a rare variant of mesenteric liposarcoma with only 12 cases reported in the literature. DDLS has a worse prognosis compared to a well-differentiated liposarcoma. Here, we present a case of giant liposarcoma located in the jejunal mesentery diagnosed on the contrast-enhanced computed tomography of the abdomen. The patient underwent complete surgical excision with uneventful postoperative recovery. DDLS was confirmed on histopathological examination of the resected specimen. The patient is currently receiving adjuvant therapy with doxorubicin and ifosfamide in view of close resection margin, mitotic rate and high rate of recurrence.

Essential Thrombocythemia Due to Janus Kinase 2 Mutation Unmasked After Splenectomy

Reactive thrombocytosis after splenectomy is common and often self-limiting. However, thrombocytosis can be multifactorial, especially extreme thrombocytosis (platelet count > 100 x 10⁴/cubic mm). It can lead to thrombotic or hemorrhagic complications. Hence, in patients with rising platelet count after splenectomy, detailed evaluation may be required to rule out other causes of thrombocytosis, such as infection, iron deficiency, and myeloproliferative disorders. Timely treatment of patients with thrombocytosis can prevent the development of life-threatening complications. The index case highlights the importance of regular follow-up of the patients after splenectomy to detect thrombocytosis and suspect other causes if the spleen was diseased or the platelet count fails to resolve spontaneously.

Colonic Gangrene: A Sequela of Coronavirus Disease 2019

Initially considered to be a respiratory disease, coronavirus disease 2019 (COVID-19) is now recognized as a multisystem disease known to affect all the major organs, including the gastrointestinal system. Based on recent studies, severe acute respiratory syndrome coronavirus 2 causes dysregulation of multiple biological pathways, triggers an exaggerated immune response, and affects multiple organs. The gastrointestinal symptoms in COVID-19 are common but often overlooked. We report the case of a 50-year-old female with a recent history of COVID-19 presenting with complaints of abdominal pain and constipation. Initially, the patient was treated for respiratory symptoms and discharged home. Subsequently, she was re-admitted and diagnosed with colonic obstruction on radiology. Laparotomy revealed descending and sigmoid colonic gangrene requiring left colectomy. This case highlights the uncommon but severe gastrointestinal manifestations of COVID-19.

Laparoscopic treatment of duplicate gallbladder with acute cholecystitis

Duplication of gallbladder is a rare congenital anomaly of the extrahepatic biliary tract. Patients with duplicate gallbladder who develop symptoms due to gallstones require surgery. Laparoscopic cholecystectomy in such cases is challenging due to altered biliary anatomy. We report a case of duplicate gallbladder with acute calculus cholecystitis successfully treated by laparoscopic removal of both the gallbladders.

Current spectrum of hepatobiliary disorders in northern India

OBJECTIVE

To evaluate the current spectrum of hepatobiliary disorders in children in Northern India.

SETTING

Tertiary level referral hospital.

METHODS

All children with hepatobiliary disorders presenting between January 1992 through July 1995 were evaluated by clinical assessment, liver function tests, viral and autoimmune markers, liver biopsy, copper studies and other relevant investigations.

RESULTS

Two hundred and thirty five children with hepatobiliary disorders were seen over three and a half years period (67 cases per year). Acute hepatitis (28%), chronic liver disease (36%) and neonatal cholestasis syndrome (NCS) (26%) were the most common patterns of liver diseases. Chronic liver diseases were constituted by ICC (2%), post-hepatitic etiology (13%), Wilson's disease (21%), autoimmune (4%), non-Wilsonian metabolic diseases (16%), hepatic venous outflow obstruction (2%) and non-cirrhotic portal fibrosis (1%). Cirrhosis was documented in 71% and chronic hepatitis in 12% of cases with chronic liver disease. Fulminant hepatic failure was the presentation in 4% of children with liver diseases.

CONCLUSION

Chronic liver diseases in Northern India are mainly constituted by post hepatitic, metabolic and cryptogenic etiology and ICC is rarely encountered. NCS is also one of the major subgroups of liver diseases in children.

Role of biliary scintigraphy in management of bile leak

BACKGROUND

Endoscopic biliary drainage is effective in the management of patients with postoperative bile leak. Evidently, it cannot be used in patients with completely tied-off common bile duct (CBD).

AIM

To ascertain whether biliary excretion scintigraphy could reliably detect patients with tied-off CBD so that endoscopic retrograde cholangiography (ERC), an invasive test, could be avoided.

METHODS

Twelve patients with active bile leak (11 postcholecystectomy, one posttraumatic), in whom the biliary system was imaged by both 99m technetium mebrofenin biliary scintigraphy and ERC, were evaluated.

RESULTS

Bile leak was demonstrated in all the 12 patients by scintigraphy. In six of these, there was no visualization of radionuclide activity in the intestines; in three of these six patients, ERC showed a patent CBD potentially amenable to endoscopic drainage, whereas in the remaining three, there was complete obstruction presumably due to CBD tie-off during surgery.

CONCLUSION

Biliary excretion scintigraphy is unreliable for detecting complete biliary obstruction in patients with bile leak.

Endoscopic sclerotherapy for esophageal varices in children with extrahepatic portal venous obstruction: a follow-up study

BACKGROUND

Results of treatment with endoscopic sclerotherapy for esophageal varices in children extrahepatic portal venous obstruction are limited.

METHODS

A prospective study was undertaken of fifty children (mean age, 7.4 +/- 3.8 years; range, 4 months to 14 years) with esophageal variceal bleeding caused by extrahepatic portal venous obstruction (EHPVO) treated by repeated intravariceal endoscopic sclerotherapy (EST) at intervals of 2-3 weeks until eradication (no varices on endoscopy).

RESULTS

Eradication of varices was achieved in 44 children (88%) with a mean of eight sessions per child. In six other cases, variceal grade decreased by 50% from the initial grades. Bleeding episodes at presentation were controlled in all of the children with first ET >. Over a mean follow-up period of 19 months (range, 12-36 months), a total of 15 episodes of rebleeding occurred in 13 children (26%) before the third session of EST and all were controlled with EST. Risk of rebleeding in children with eradicated varices (n = 44) significantly decreased from 0.2 episodes per month to nil after eradication. None of the children without eradicated varices had rebleeding. Thus, EST was successful in controlling rebleeding in all of the cases. Recurrence of varices was observed in five children (10%). None of our children either required surgery for EST failure or died.

CONCLUSIONS

EST is a safe and effective nonsurgical mode of therapy in controlling esophageal variceal bleeding in children with EHPVO. Significant variceal bleeding did not occur during the relatively short follow-up in this series.

Endoscopic, histologic and microbiologic evaluation of upper abdominal pain with special reference to Helicobacter pylori infection

OBJECTIVE

To study children with significant upper abdominal pain of unidentifiable etiology and evaluate: (a) the relationship of pain to inflammatory esophago-gastro-duodenal lesions and Helicobacter pylori (HP) infection, and (b) the response to specific therapy.

DESIGN

Prospective study.

SETTING

Pediatric section of a tertiary referral gastroenterology center.

SUBJECTS

Thirty three consecutive children with significant upper abdominal pain [mean age 9.9 +/- 2.7, range 4-15 years; 20 males] were subjected to upper gastrointestinal tract endoscopy and antral mucosal biopsies obtained for rapid urease test (RUT), Gram's staining of impression/crush smears and culture for HP and histologic examination. Patients with HP gastritis were treated with triple therapy, colloidal bismuth subcitrate, amoxycillin and metronidazole, for two weeks. At 8 weeks from the initiation of therapy, patients were re-evaluated for symptoms and HP eradication by repeat endoscopy and antral biopsies. Patients with esophagitis, gastritis and duodenitis without HP infection were treated with ranitidine for 6 weeks. All the patients were followed up for 6 months.

RESULTS

Histology revealed antral gastritis in 28/33 (85%) patients. HP infection was present in 12/28 (43%) patients with antral gastritis. Symptomatic improvement with triple therapy was observed in 10/12 (83%) patients with HP gastritis and eradication of HP in 5/7. Improvement on ranitidine therapy was observed in 12/16 (75%) patients with HP negative gastritis. On follow-up, no patient with initial improvement with therapy had relapse of symptoms.

CONCLUSION

Symptomatic children with HP related gastritis should be treated with triple therapy and HP negative gastritis with H2-receptor antagonist.

Gastrointestinal bleeding in children

We prospectively evaluated 139 consecutive children presenting to the Sanjay Gandhi Postgraduate Institute of Medical Sciences (Lucknow, India) with gastrointestinal (GI) bleeding from January 1991 to November 1994. Our aims were to find out whether the causes of GI bleeding in a developing country differed from developed countries and how the application of newer diagnostic techniques would help in the diagnosis of GI bleeding. Barium studies, endoscopy, technetium-99m-labelled (erythrocytes and pertechnetate) scans, selective abdominal angiography using a digital subtraction technique and rectal endoscopic ultrasonography were performed. Upper GI bleeding (n = 75) was variceal in 71 (95%) children (extrahepatic portal venous obstruction in 65, cirrhosis in six) and non-variceal in four (5%) cases (Henoch-Schonlein purpura, idiopathic thrombocytopenic purpura, drug-induced gastric erosions and pseudoaneurysm of the gastroduodenal artery due to idiopathic chronic calcific pancreatitis). Causes of lower GI bleeding (n = 64) were colitis (27 cases; 42%), colorectal polyps (26 cases; 41%), enteric fever (n = 3), solitary rectal ulcer (n = 3), portal hypertensive colopathy (n = 2), colonic arteriovenous malformation (n = 1) and internal haemorrhoids (n = 1). One patient remained undiagnosed. Angiography performed in four children was diagnostic in two. In one child with massive lower GI bleeding from portal colopathy, the bleeding site (caecum) was localized by intra-operative colonoscopy, while in the other child with portal colopathy, rectal endoscopic ultrasonography was performed to substantiate the diagnosis. We conclude that the causes of upper GI bleeding in children in developing countries are different from those in developed countries (variceal bleeding due to extrahepatic portal venous obstruction is the most common cause, while peptic ulcer is rare). However, the spectrum of lower GI bleeding is similar to that of developed countries. Application of newer diagnostic techniques is helpful and safe in the identification of the cause of GI bleeding in children.

Therapeutic gastrointestinal endoscopy

The safety, efficacy and utility of various therapeutic gastrointestinal (GI) endoscopic procedures performed on children (January 1992 to July 1995) at a tertiary referral centre in India were studied. A total of 1,030 sessions (upper GI 972 and lower GI 58) of therapeutic GI endoscopy were performed in 162 children (mean age 7.4 +/- 4 years; upper GI 115, lower GI 47). Various upper GI endoscopic procedures done were injection sclerotherapy (EIS), endoscopic variceal ligation (EVL), bougie dilatation of oesophageal strictures, balloon dilatations of oesophageal stricture/pyloric obstruction and retrieval of foreign bodies in 75%, 6%, 9%, 4% and 12% of children respectively. Therapy for bleeding from oesophageal varices constituted the major group (75%). Repeated EIS (sessions total--876, mean 8, range 5-15) performed on 86 children resulted in control of bleeding in all and eradication of oesophageal varices in 85% of cases. Minor complications (oesophageal ulcers and oesophageal strictures) due to EIS were observed in 9% of children. EVL (10 sessions in 7 children) was effective in controlling bleeding and substantial decrease of varices in all without any complication. Oesophageal dilation either by bougie (61 sessions in 10 children) or balloon (6 sessions in 3 children) were performed for benign strictures. Balloon dilatation of pyloric obstruction was successfully done in 2 children. Foreign bodies (retained or sharp) were retrieved from upper GI tract in 14 children. No complications were observed with stricture dilatation/foreign body retrieval. Therapeutic lower GI endoscopies were performed in 47 children (colonoscopic polypectomy in 92%, anal dilatation and piles banding in 4% each). One child with juvenile polyposis coli developed sigmoid colon performation following colonoscopic polypectomy which required surgical correction. We conclude that upper and lower GI endoscopic therapeutic procedures in children are highly effective and safe. The risk of major complication is very small in experienced hands and occasional minor complications, can be managed conservatively.

Neonatal cholestasis syndrome: an appraisal at a tertiary center

OBJECTIVE

To know the magnitude, etiology and clinical profile, the efficacy of various investigations and the outcome in patients with neonatal cholestasis syndrome (NCS).

DESIGN

Prospective evaluation of 60 consecutive infants with NCS (mean age 3.9 +/- 1.9 months; 49 males) over a period of 3.5 years.

SETTING

Tertiary level referral gastroenterology center in North India.

METHODS

Liver function tests, urine examination, serum antibodies against Cytomegalovirus (CMV), Rubella and Toxoplasma; abdominal ultrasonography, hepatobiliary scintigraphy and liver biopsy were done. In appropriate setting, laparotomy and surgical corrections were done for biliary tract disorders.

RESULTS

NCS constituted 19% of pediatric liver diseases. Considerable delay in presentation was observed [mean delay, extrahepatic biliary atresia (EHBA) = 4 +/- 2.0 months, neonatal hepatitis (NH) = 2.2 +/- 1.3 months]. Thirty three (55%) infants had EHBA, 14 (23%) NH (4 CMV, 2 galactosemia, 1 urinary tract infection and 7 idiopathic), 2 (3%) paucity of intralobular bile ducts and 11 (18%) were of indeterminate etiology. Liver biopsy was the most accurate (96.4%) investigation in discriminating between EHBA and NH. Of the 18 operated infants with EHBA (portoenterostomy-15 and hepatico-jejunostomy-3), 10 were alive (mean follow up = 22.8 +/- 8.6 months) of which 4 were completely asymptomatic.

CONCLUSIONS

(i) NCS is an important cause of liver disease in Indian children. (ii) It requires prompt referral, quick investigative approach and targeted management. (iii) Liver biopsy is highly accurate in differentiating EHBA and NH. (iv) infants with EHBA and compensated status of liver should undergo corrective surgery irrespective of age at presentation.

Falciparum malaria with acute liver failure

INTRODUCTION

Falciparum malaria occasionally presents with encephalopathy, jaundice and fever mimicking fulminant hepatic failure.

PATIENTS

We recently managed seven cases (mean age 34 years, range 20-45; all men) of acute falciparum malaria presenting with a short history [mean duration 8.1 (4-15) days] of fever, jaundice, altered sensorium and oliguria. Only one patient had splenomegaly. Investigations revealed jaundice (bilirubin 1.9-30.7 mg/dl), moderate to severe anaemia (Hb 4-8 gm/dl), increased liver enzymes (2-4 times normal) and azotaemia (serum creatinine 1.6-7.4 mg/dl). Coagulation parameters were deranged in 3 with clinical bleeding in two cases. One patient without a past history of diabetes had increased blood glucose values with ketonuria. HBsAg was negative in all cases. Patients received supportive therapy along with intravenous quinine. Peritoneal dialysis was done in one patient. Three patients showed rapid recovery and four succumbed to the disease. Post-mortem liver biopsy showed Kupffer cell hyperplasia, pigment deposition, foci of steatosis and necrosis along with submassive necrosis in one case.

CONCLUSIONS

In areas endemic for malaria, awareness of this entity is a must. In a patient with jaundice and altered sensorium, disproportionate anaemia, azotaemia and only mild elevation of liver enzymes should help differentiate these patients from cases of fulminant hepatic failure. The diagnosis can be confirmed by peripheral blood examination. Early institution of specific therapy may be the only life saving measure in these patients.

Biliary ascariasis associated with periampullary carcinoma

A 65 year old man presented with obstructive jaundice, biliary colics and recurrent cholangitis. Sonography revealed dilated intrahepatic biliary radicles and common bile duct. Bile duct also showed linear parallel intraluminal structures suggesting biliary ascariasis. The lower end of common bile duct and pancreatic region showed a mass which proved to be a coexistent periampullary carcinoma.