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).

Ten golden rules for optimal antibiotic use in hospital settings: the WARNING call to action

Antibiotics are recognized widely for their benefits when used appropriately. However, they are often used inappropriately despite the importance of responsible use within good clinical practice. Effective antibiotic treatment is an essential component of universal healthcare, and it is a global responsibility to ensure appropriate use. Currently, pharmaceutical companies have little incentive to develop new antibiotics due to scientific, regulatory, and financial barriers, further emphasizing the importance of appropriate antibiotic use. To address this issue, the Global Alliance for Infections in Surgery established an international multidisciplinary task force of 295 experts from 115 countries with different backgrounds. The task force developed a position statement called WARNING (Worldwide Antimicrobial Resistance National/International Network Group) aimed at raising awareness of antimicrobial resistance and improving antibiotic prescribing practices worldwide. The statement outlined is 10 axioms, or "golden rules," for the appropriate use of antibiotics that all healthcare workers should consistently adhere in clinical practice.

Six Long-Standing Questions about Antibiotic Prophylaxis in Surgery

Surgical site infections (SSIs) are the most common adverse event occurring in surgical patients. Optimal prevention of SSIs requires the bundled integration of a variety of measures before, during, and after surgery. Surgical antibiotic prophylaxis (SAP) is an effective measure for preventing SSIs. It aims to counteract the inevitable introduction of bacteria that colonize skin or mucosa into the surgical site during the intervention. This document aims to guide surgeons in appropriate administration of SAP by addressing six key questions. The expert panel identifies a list of principles in response to these questions that every surgeon around the world should always respect in administering SAP.

The unrestricted global effort to complete the COOL trial

BACKGROUND

Severe complicated intra-abdominal sepsis (SCIAS) has an increasing incidence with mortality rates over 80% in some settings. Mortality typically results from disruption of the gastrointestinal tract, progressive and self-perpetuating bio-mediator generation, systemic inflammation, and multiple organ failure. A further therapeutic option may be open abdomen (OA) management with negative peritoneal pressure therapy (NPPT) to remove inflammatory ascites and attenuate the systemic damage from SCIAS, although there are definite risks of leaving the abdomen open whenever it might possibly be closed. This potential therapeutic paradigm is the rationale being assessed in the Closed Or Open after Laparotomy (COOL trial) ( https://clinicaltrials.gov/ct2/show/NCT03163095 ). Initially, the COOL trial received Industry sponsorship; however, this funding mandated the use of a specific trademarked and expensive NPPT device in half of the patients allocated to the intervention (open) arm. In August 2022, the 3 M/Acelity Corporation without consultation but within the terms of the contract canceled the financial support of the trial. Although creating financial difficulty, there is now no restriction on specific NPPT devices and removing a cost-prohibitive intervention creates an opportunity to expand the COOL trial to a truly global basis. This document describes the evolution of the COOL trial, with a focus on future opportunities for global growth of the study.

METHODS

The COOL trial is the largest prospective randomized controlled trial examining the random allocation of SCIAS patients intra-operatively to either formal closure of the fascia or the use of the OA with an application of an NPPT dressing. Patients are eligible if they have free uncontained intraperitoneal contamination and physiologic derangements exemplified by septic shock OR severely adverse predicted clinical outcomes. The primary outcome is intended to definitively inform global practice by conclusively evaluating 90-day survival. Initial recruitment has been lower than hoped but satisfactory, and the COOL steering committee and trial investigators intend with increased global support to continue enrollment until recruitment ensures a definitive answer.

DISCUSSION

OA is mandated in many cases of SCIAS such as the risk of abdominal compartment syndrome associated with closure, or a planned second look as for example part of "damage control"; however, improved source control (locally and systemically) is the most uncertain indication for an OA. The COOL trial seeks to expand potential sites and proceed with the evaluation of NPPT agnostic to device, to properly examine the hypothesis that this treatment attenuates systemic damage and improves survival. This approach will not affect internal validity and should improve the external validity of any observed results of the intervention.

TRIAL REGISTRATION

National Institutes of Health ( https://clinicaltrials.gov/ct2/show/NCT03163095 ).

The ChoCO-W prospective observational global study: Does COVID-19 increase gangrenous cholecystitis?

BACKGROUND

The incidence of the highly morbid and potentially lethal gangrenous cholecystitis was reportedly increased during the COVID-19 pandemic. The aim of the ChoCO-W study was to compare the clinical findings and outcomes of acute cholecystitis in patients who had COVID-19 disease with those who did not.

METHODS

Data were prospectively collected over 6 months (October 1, 2020, to April 30, 2021) with 1-month follow-up. In October 2020, Delta variant of SARS CoV-2 was isolated for the first time. Demographic and clinical data were analyzed and reported according to the STROBE guidelines. Baseline characteristics and clinical outcomes of patients who had COVID-19 were compared with those who did not.

RESULTS

A total of 2893 patients, from 42 countries, 218 centers, involved, with a median age of 61.3 (SD: 17.39) years were prospectively enrolled in this study; 1481 (51%) patients were males. One hundred and eighty (6.9%) patients were COVID-19 positive, while 2412 (93.1%) were negative. Concomitant preexisting diseases including cardiovascular diseases (p < 0.0001), diabetes (p < 0.0001), and severe chronic obstructive airway disease (p = 0.005) were significantly more frequent in the COVID-19 group. Markers of sepsis severity including ARDS (p < 0.0001), PIPAS score (p < 0.0001), WSES sepsis score (p < 0.0001), qSOFA (p < 0.0001), and Tokyo classification of severity of acute cholecystitis (p < 0.0001) were significantly higher in the COVID-19 group. The COVID-19 group had significantly higher postoperative complications (32.2% compared with 11.7%, p < 0.0001), longer mean hospital stay (13.21 compared with 6.51 days, p < 0.0001), and mortality rate (13.4% compared with 1.7%, p < 0.0001). The incidence of gangrenous cholecystitis was doubled in the COVID-19 group (40.7% compared with 22.3%). The mean wall thickness of the gallbladder was significantly higher in the COVID-19 group [6.32 (SD: 2.44) mm compared with 5.4 (SD: 3.45) mm; p < 0.0001].

CONCLUSIONS

The incidence of gangrenous cholecystitis is higher in COVID patients compared with non-COVID patients admitted to the emergency department with acute cholecystitis. Gangrenous cholecystitis in COVID patients is associated with high-grade Clavien-Dindo postoperative complications, longer hospital stay and higher mortality rate. The open cholecystectomy rate is higher in COVID compared with non -COVID patients. It is recommended to delay the surgical treatment in COVID patients, when it is possible, to decrease morbidity and mortality rates. COVID-19 infection and gangrenous cholecystistis are not absolute contraindications to perform laparoscopic cholecystectomy, in a case by case evaluation, in expert hands.

It is time to define an organizational model for the prevention and management of infections along the surgical pathway: a worldwide cross-sectional survey

BACKGROUND

The objectives of the study were to investigate the organizational characteristics of acute care facilities worldwide in preventing and managing infections in surgery; assess participants' perception regarding infection prevention and control (IPC) measures, antibiotic prescribing practices, and source control; describe awareness about the global burden of antimicrobial resistance (AMR) and IPC measures; and determine the role of the Coronavirus Disease 2019 pandemic on said awareness.

METHODS

A cross-sectional web-based survey was conducted contacting 1432 health care workers (HCWs) belonging to a mailing list provided by the Global Alliance for Infections in Surgery. The self-administered questionnaire was developed by a multidisciplinary team. The survey was open from May 22, 2021, and June 22, 2021. Three reminders were sent, after 7, 14, and 21 days.

RESULTS

Three hundred four respondents from 72 countries returned a questionnaire, with an overall response rate of 21.2%. Respectively, 90.4% and 68.8% of participants stated their hospital had a multidisciplinary IPC team or a multidisciplinary antimicrobial stewardship team. Local protocols for antimicrobial therapy of surgical infections and protocols for surgical antibiotic prophylaxis were present in 76.6% and 90.8% of hospitals, respectively. In 23.4% and 24.0% of hospitals no surveillance systems for surgical site infections and no monitoring systems of used antimicrobials were implemented. Patient and family involvement in IPC management was considered to be slightly or not important in their hospital by the majority of respondents (65.1%). Awareness of the global burden of AMR among HCWs was considered very important or important by 54.6% of participants. The COVID-19 pandemic was considered by 80.3% of respondents as a very important or important factor in raising HCWs awareness of the IPC programs in their hospital. Based on the survey results, the authors developed 15 statements for several questions regarding the prevention and management of infections in surgery. The statements may be the starting point for designing future evidence-based recommendations.

CONCLUSION

Adequacy of prevention and management of infections in acute care facilities depends on HCWs behaviours and on the organizational characteristics of acute health care facilities to support best practices and promote behavioural change. Patient involvement in the implementation of IPC is still little considered. A debate on how operationalising a fundamental change to IPC, from being solely the HCWs responsibility to one that involves a collaborative relationship between HCWs and patients, should be opened.

WSES/GAIS/WSIS/SIS-E/AAST global clinical pathways for patients with skin and soft tissue infections

Skin and soft-tissue infections (SSTIs) encompass a variety of pathological conditions that involve the skin and underlying subcutaneous tissue, fascia, or muscle, ranging from simple superficial infections to severe necrotizing infections.

Together, the World Society of Emergency Surgery, the Global Alliance for Infections in Surgery, the Surgical Infection Society-Europe, The World Surgical Infection Society, and the American Association for the Surgery of Trauma have jointly completed an international multi-society document to promote global standards of care in SSTIs guiding clinicians by describing reasonable approaches to the management of SSTIs.

An extensive non-systematic review was conducted using the PubMed and MEDLINE databases, limited to the English language. The resulting evidence was shared by an international task force with different clinical backgrounds.

ANALYSIS THEORICO-PRACTICA DE VIRIBUS VIRUS FEBRIFERI, PESTIFERI, ATQUE SERPENTIN – THE FIRST MEDICAL ARTICLE BY AN AUTHOR FROM BOSNIA AND HERZEGOVINA

This review describes the first medical article written by an author from Bosnia and Herzegovina. The article was published by Fr. Franjo Gracić (1740-1799), in Latin, under the title: "Analysis theorico-practica de viribus virus febriferi, pestiferi, atque serpentin", and printed in Padua in 1795, translated as: "A Theoretical and Practical Presentation of the Effects of Fevers, Infectious Diseases, and Snake Poison". From today's standpoint, it may be said that it was a review article about some of the most frequent diseases of that time. The paper is of exceptional importance for the history of medicine in Bosnia and Herzegovina because it is the first documented medical article whose author was from Bosnia and Herzegovina. The paper contains observations of the course of diseases and treatment, in line with the medical insights of the time. The author refers to the authorities of that time, such as Samuel Auguste André Tissot, the Swiss physicist and doctor, Georg Bauer, the German doctor, and Lodovico Antonio Muratori, the Italian scholar, which makes this article a link between Bosnia and Herzegovina and the knowledge of the Europe of that time. This paper represents the beginning of medical writing in Bosnia and Herzegovina and has a very important place in the history of medicine in this country.

WSES/GAIS/SIS-E/WSIS/AAST global clinical pathways for patients with intra-abdominal infections

Intra-abdominal infections (IAIs) are common surgical emergencies and have been reported as major contributors to non-trauma deaths in hospitals worldwide. The cornerstones of effective treatment of IAIs include early recognition, adequate source control, appropriate antimicrobial therapy, and prompt physiologic stabilization using a critical care environment, combined with an optimal surgical approach. Together, the World Society of Emergency Surgery (WSES), the Global Alliance for Infections in Surgery (GAIS), the Surgical Infection Society-Europe (SIS-E), the World Surgical Infection Society (WSIS), and the American Association for the Surgery of Trauma (AAST) have jointly completed an international multi-society document in order to facilitate clinical management of patients with IAIs worldwide building evidence-based clinical pathways for the most common IAIs. An extensive non-systematic review was conducted using the PubMed and MEDLINE databases, limited to the English language. The resulting information was shared by an international task force from 46 countries with different clinical backgrounds. The aim of the document is to promote global standards of care in IAIs providing guidance to clinicians by describing reasonable approaches to the management of IAIs.

A pandemic recap: lessons we have learned

On January 2020, the WHO Director General declared that the outbreak constitutes a Public Health Emergency of International Concern. The world has faced a worldwide spread crisis and is still dealing with it. The present paper represents a white paper concerning the tough lessons we have learned from the COVID-19 pandemic. Thus, an international and heterogenous multidisciplinary panel of very differentiated people would like to share global experiences and lessons with all interested and especially those responsible for future healthcare decision making. With the present paper, international and heterogenous multidisciplinary panel of very differentiated people would like to share global experiences and lessons with all interested and especially those responsible for future healthcare decision making.

Tipp versus the Lichtenstein and Shouldice techniques in the repair of inguinal hernias - short-term results

OBJECTIVE

The Lichtenstein mesh technique is recommended as the standard surgical procedure for inguinal hernias. Shouldice is the best non-mesh technique. However, there are reports that the transinguinal preperitoneal technique (TIPP), which uses a preperitoneal mesh, has potential advantages in relation to the Lichtenstein and the Shouldice techniques.

PATIENTS AND METHODS

Three hundred patients with inguinal hernias were randomized into three groups of hundred patients each: Group 1 whose inguinal hernia repair was performed using the Lichtenstein technique; Group 2 using the Shouldice technique; and Group 3 using TIPP. The parameters for monitoring were: length of operation, blood loss, length of hospitalization, length of incision, post-operative pain, and the patient's satisfaction level.

RESULTS

The visual analog scale (VAS) score after 6, 12, 24 and 48 h, and 14 d was lower in TIPP than the Lichtenstein and Shouldice groups (p < .0001). The satisfaction level was higher in TIPP than in the Lichtenstein and Shouldice groups (p < .0001).

CONCLUSIONS

TIPP technique has advantages in comparison with the Lichtenstein and Shouldice techniques. This method takes a shorter time, the skin incision is smaller, the VAS score is lower and the patient satisfaction level is higher. These advantages are in balance with the higher costs of this procedure.

Minimising in minimally invasive surgery through the use of a novel and flexible super elastic titanium needle suitable for a 3.5- and 5-mm trocar

The use of smaller ports in surgery is the next step in the evolution of minimally invasive procedures. We present findings, using a novel flexible needle made from a super elastic titanium alloy, which demonstrate that it is possible for a 26- and 30-mm needle to pass through a 3.5- and 5-mm trocar. This new approach results in less trauma and improved cosmetic effect in comparison to the classical 10-mm port. Traditional steps such as handling of the needle holders, loading the needle and placing it at the correct angle and direction, inserting the needle into the tissue and finally safely tying a knot remain the same as with the standard procedure. We propose that this improved type of needle creates a refinement opportunity to replace the classic ones during both laparoscopic and robotic surgeries.

Tissue Reaction and the Formation of Adhesion after the Use of DS Clip in Laparoscopic Appendectomy

Background and Objectives:

Titanium DS clips are made to secure the appendiceal stump during laparoscopic appendectomy. The assumption is that they behave like stapler clips in the body, being made from titanium. However, the construction and weight of DS clips differs from staplers. Their biocompatibility may have implications for their clinical use.

Methods:

One hundred and twenty rats were randomized into four experimental groups: in the first group the appendiceal stump was secured by Vicryl® ligature, in the second by linear staplers, in the third by Hem-o-lok® plastic clips, and in the fourth by DS titanium clips. Ten animals from each group were sacrificed 7, 28, and 60 days post-surgery. Histopathological data and adhesion formation were assessed.

Results:

On postoperative day 7, a statistically significant difference was found in the occurrence of inflammation between the Hem-o-lok® and stapler groups. The adhesion score was significantly higher in the Vycril® and Hem-o-lok® in comparison to the DS and stapler groups. On postoperative day 28, a statistically significant difference was found in the occurrence of inflammation between the Vycril® and stapler groups. The adhesion score was significantly higher in the Vycril® than in the DS and stapler groups. On postoperative day 60, there were no statistical differences between any of the groups. The adhesion score was significantly higher in the Hem-o-lok® group in comparison to the DS and stapler groups.

Conclusion:

Staplers and DS clips have advantages over other methods of securing the appendiceal stump, because of their high biocompatibility and lower adhesion score.

2020 update of the WSES guidelines for the management of acute colonic diverticulitis in the emergency setting

Acute colonic diverticulitis is one of the most common clinical conditions encountered by surgeons in the acute setting. An international multidisciplinary panel of experts from the World Society of Emergency Surgery (WSES) updated its guidelines for management of acute left-sided colonic diverticulitis (ALCD) according to the most recent available literature. The update includes recent changes introduced in the management of ALCD. The new update has been further integrated with advances in acute right-sided colonic diverticulitis (ARCD) that is more common than ALCD in select regions of the world.

Adrenocorticotropic Hormone (ACTH) and Cortisol Monitoring as Stress Markers During Laparoscopic Cholecystectomy: Standard and Low Intraabdominal Pressure and Open Cholecystectomy

Introduction

In this study we wanted to examine the hormonal responses due to stress exposure during laparoscopic cholecystectomy with standard (12-15 mm / Hg) (LCSP) and low (6-8 mm / Hg) (LCLP) intraabdominal pressure and open cholecystectomy (OC), with particular emphasis on stress hormone responses.

Aim

Determination of adrenocorticotropic hormone (ACTH) and cortisol stress hormones before and after laparoscopic cholecystectomy with standard and low insufflation pressure, determination of ACTH and cortisol values before and after open cholecystectomy and comparison of ACTH and cortisol values between the patient sub-groups.

Methods

In a prospective study conducted between July 2016 and February 2018, we involved 110 patients which were divided into two groups: 70 patients with laparoscopic cholecystectomy (LC) and 40 patients with open cholecystectomy (OC). The first group of patients was further divided into two subgroups of 35 patients, (subgroup LC with standard and subgroup LC with low intraabdominal pressure). All patients met the preset inclusion and exclusion criteria of the study. There were no statistically significant differences in the demographic characteristics of patients between the investigated groups. The stress hormones determined were adrenocorticotropic hormone (ACTH) and cortisol.

Results

During the first, second and seventh day postoperative day (POD),ACTH values were significantly lower (p <0.0001) in LCLP than in LCSP and OC groups. This was also the case for comparison in LCSP and OC groups. By comparing LC and OC groups during first, the second and seventh POD, there was a significant difference (p <0.0001) in the ACTH levels. The concentration of this hormone was higher in the OC group in all three cases. The first, second and seventh POD were also statistically significant (p <0.0001) in cortisol values and between LC and OC groups there was an increase in cortisol levels in patients operated by open method. There was also a significant difference (p <0.0001) in cortisol values measured between LCLP and LCSP groups in the investigated days. Cortisol levels were higher in patients in the LCSP group.

Conclusion

During open and laparoscopic cholecystectomy the response of the body to stress increased. The stress response of the organism during laparoscopic cholecystectomy was less than during open cholecystectomy. The stress response of the organism during laparoscopic cholecystectomy with low insufflation pressure ( 6-8mmHg) was less than during laparoscopic cholecystectomy with standard insufflation pressure (12-15mmHg).

Physiological parameters for Prognosis in Abdominal Sepsis (PIPAS) Study: a WSES observational study

BACKGROUND

Timing and adequacy of peritoneal source control are the most important pillars in the management of patients with acute peritonitis. Therefore, early prognostic evaluation of acute peritonitis is paramount to assess the severity and establish a prompt and appropriate treatment. The objectives of this study were to identify clinical and laboratory predictors for in-hospital mortality in patients with acute peritonitis and to develop a warning score system, based on easily recognizable and assessable variables, globally accepted.

METHODS

This worldwide multicentre observational study included 153 surgical departments across 56 countries over a 4-month study period between February 1, 2018, and May 31, 2018.

RESULTS

A total of 3137 patients were included, with 1815 (57.9%) men and 1322 (42.1%) women, with a median age of 47 years (interquartile range [IQR] 28-66). The overall in-hospital mortality rate was 8.9%, with a median length of stay of 6 days (IQR 4-10). Using multivariable logistic regression, independent variables associated with in-hospital mortality were identified: age > 80 years, malignancy, severe cardiovascular disease, severe chronic kidney disease, respiratory rate ≥ 22 breaths/min, systolic blood pressure < 100 mmHg, AVPU responsiveness scale (voice and unresponsive), blood oxygen saturation level (SpO₂) < 90% in air, platelet count < 50,000 cells/mm3, and lactate > 4 mmol/l. These variables were used to create the PIPAS Severity Score, a bedside early warning score for patients with acute peritonitis. The overall mortality was 2.9% for patients who had scores of 0-1, 22.7% for those who had scores of 2-3, 46.8% for those who had scores of 4-5, and 86.7% for those who have scores of 7-8.

CONCLUSIONS

The simple PIPAS Severity Score can be used on a global level and can help clinicians to identify patients at high risk for treatment failure and mortality.

Introduction to Total Mesorectal Excision

Colorectal cancer is the second leading cause of mortality in the West, and rectal cancer accounts for about 25% of the colon cancers. The concept of total mesothelial excision (TME) was the most important event in surgery for rectal cancer of the last two decades, because even without a curative approach, it reduced local recurrence and extended 5-year survival.

Knowledge, awareness, and attitude towards infection prevention and management among surgeons: identifying the surgeon champion

Despite evidence supporting the effectiveness of best practices of infection prevention and management, many surgeons worldwide fail to implement them. Evidence-based practices tend to be underused in routine practice. Surgeons with knowledge in surgical infections should provide feedback to prescribers and integrate best practices among surgeons and implement changes within their team. Identifying a local opinion leader to serve as a champion within the surgical department may be important. The “surgeon champion” can integrate best clinical practices of infection prevention and management, drive behavior change in their colleagues, and interact with both infection control teams in promoting antimicrobial stewardship.

The Quality of Life and Degree of Depression of Patients Suffering from Breast Cancer

INTRODUCTION

Breast cancer and its treatment change the perception of mastectomized women of their physical appearance, which leads to depression and has a negative effect on the overall quality of life of those woman.

AIM

We wanted to assess the quality of life and the degree of depression of patients suffering from breast cancer, on the basis of a standardised questionnaire to assess the patients' quality of life (QLQ-C-30 BR-23), and the degree of depression using Beck's Depression Inventory (BDI, II).

MATERIALS AND METHODS

The research was conducted on a sample of 160 patients, who were surveyed before and after the surgical procedure. The inclusion criteria for the research were: patients suffering from breast cancer aged between 18 and 70 years, cancer diagnosed by FNB or CORE biopsy. The patients were divided into two groups: patients having breast-conserving surgery and patients having radical surgical treatment.

RESULTS

There were 47 or 39.37% patients who underwent breast-conserving surgery and 113 or 70.62% patients who underwent radical surgery. The results of the survey conducted show that there was no difference in the quality of life of patients before and after surgery, regardless of the type of surgical procedure undertaken. However, there was a significant different in the degree of depression between patients subjected to different surgical procedures, where the patients surveyed post-surgery after radical mastectomy showed a higher degree of depression than the patients surveyed after breast-conserving surgery.

CONCLUSION

There is no difference in the quality of life before and after surgery, regardless of the type of operation. However, there is a significant difference in the degree of depression in patients after radical mastectomy, who showed a higher degree of depression than the surveyed patients who underwent breast-conserving surgery.

Prospective Observational Study on acute Appendicitis Worldwide (POSAW)

BACKGROUND

Acute appendicitis (AA) is the most common surgical disease, and appendectomy is the treatment of choice in the majority of cases. A correct diagnosis is key for decreasing the negative appendectomy rate. The management can become difficult in case of complicated appendicitis. The aim of this study is to describe the worldwide clinical and diagnostic work-up and management of AA in surgical departments.

METHODS

This prospective multicenter observational study was performed in 116 worldwide surgical departments from 44 countries over a 6-month period (April 1, 2016-September 30, 2016). All consecutive patients admitted to surgical departments with a clinical diagnosis of AA were included in the study.

RESULTS

A total of 4282 patients were enrolled in the POSAW study, 1928 (45%) women and 2354 (55%) men, with a median age of 29 years. Nine hundred and seven (21.2%) patients underwent an abdominal CT scan, 1856 (43.3%) patients an US, and 285 (6.7%) patients both CT scan and US. A total of 4097 (95.7%) patients underwent surgery; 1809 (42.2%) underwent open appendectomy and 2215 (51.7%) had laparoscopic appendectomy. One hundred eighty-five (4.3%) patients were managed conservatively. Major complications occurred in 199 patients (4.6%). The overall mortality rate was 0.28%.

CONCLUSIONS

The results of the present study confirm the clinical value of imaging techniques and prognostic scores. Appendectomy remains the most effective treatment of acute appendicitis. Mortality rate is low.

A Global Declaration on Appropriate Use of Antimicrobial Agents across the Surgical Pathway

This declaration, signed by an interdisciplinary task force of 234 experts from 83 different countries with different backgrounds, highlights the threat posed by antimicrobial resistance and the need for appropriate use of antibiotic agents and antifungal agents in hospitals worldwide especially focusing on surgical infections. As such, it is our intent to raise awareness among healthcare workers and improve antimicrobial prescribing. To facilitate its dissemination, the declaration was translated in different languages.

Morphological Changes in Blood Cells After Implantation of Titanium and Plastic Clips in the Neurocranium - Experimental Study on Dogs

Introduction:

Various studies confirm the biocompatibility and efficacy of clips for certain target tissues, but without any comparative analysis of hematological parameters. Therefore, we conducted a study to assess the possible association of the implantation of titanium and plastic clips in the neurocranium with possible morphological changes in the blood cells of experimental animals.

Materials and Methods:

As a control, the peripheral blood smears were taken before surgery from 12 adult dogs that were divided into two experimental groups. After placing titanium and plastic clips in the neurocranium, the peripheral blood of the first group was analyzed on the seventh postoperative day, while the peripheral blood of the second group was analyzed on the sixtieth day. By microscopy of the blood smears, the following parameters were analyzed: the presence of poikilocytosis of the red blood cells, degenerative changes in the leukocytes and leukogram.

Results:

There were no statistically significant differences between the mean values of the groups. Monocytosis was detected (first group 22.83 % and second 16.30 %), as well as neutropenia (46.80 %, in the second group). Degenerative changes to neutrophils and the occurrence of atypical lymphocytes were observed in the second experimental group (60^th postoperative day).

Conclusion:

A mild adverse effect from the biomaterials present in the neurocranium of dogs was detected, affecting the majority of leukocytic cells. A chronic recurrent inflammatory process was caused by the presence of the plastic and titanium clips in the brain tissue. No adverse effect of biomaterials on erythrocytes in the neurocranium was detected in the dogs studied. Further studies are necessary to explain the occurrence of degenerative changes in the neutrophils and lymphocytes.

Erratum to: Antimicrobials: a global alliance for optimizing their rational use in intra-abdominal infections (AGORA)

[This corrects the article DOI: 10.1186/s13017-016-0089-y.].

Biocompatibility of Plastic Clip in Neurocranium - Experimental Study on Dogs

AIM

A potential advantage of the use of the plastic clips in neurosurgery is their property of causing fewer artifacts than titanium clips as assessed by computed tomography and magnetic resonance scans. The biocompatibility of plastic clips was demonstrated in the peritoneal cavity, but their behavior in the neurocranium is not known.

MATERIAL AND METHODS

Twelve aggressive stray dogs designated for euthanasia were taken for this experimental study. The animals were divided into two groups. In all cases, after anesthesia, a craniotomy was performed, and after opening the dura, a proximal part titanium clip was placed on the isolated superficial Sylvian vein (a permanent Yasargil FT 746 T clip at a 90° angle, while a plastic Hem-o-lok clip ML was placed on another part of the vein). The first group of animals was sacrificed on the 7 < sup > th < /sup > postoperative day and the second group on the 60 < sup > th < /sup > postoperative day. Samples of tissue around the clips were taken for a histopathological evaluation.

RESULTS

The plastic clip caused a more intensive tissue reaction than the titanium clip on the 7 < sup > th < /sup > postoperative day, but there was no statistical difference. Even on the 60 < sup > th < /sup > postoperative day there was no significant difference in tissue reaction between the titanium and plastic clips.

CONCLUSION

These preliminary results confirm the possibility for the use of plastic clips in neurosurgery. Before their use in human neurosurgery, further studies are needed to investigate the long-term effects of the presence of plastic clips in the neurocranium, as well as studies of the aneurysmal model.

Formation of adhesion after intraperitoneal application of TiMesh: experimental study on a rodent model

BACKGROUND

After laparoscopic repair of an incisive hernia, intraperitoneal prosthetic mesh, as a foreign material, is a strong stimulus for the development of adhesion, which may be the cause of serious complications. This experimental study compared three different meshes and their ability to prevent the formation of adhesion and shrinkage.

METHODS

Ninety rats were divided randomly into three groups: in Group 1 Proceed mesh was implanted, in Group 2 Ultrapro mesh was implanted, and in Group 3 TiMesh was implanted. Mesh samples were fixed as an intraabdominal mesh in the upper part of the abdomen. Ten animals from each group were sacrificed on days 7, 28 and 60 post-surgery. After opening the abdomen, the formation of adhesion was assessed according to the Surgical Membrane Study Group (SMSG) score, the percentage of shrinkage of the mesh was established and inflammatory reaction scored.

RESULTS

The SMSG score for adhesion was statistically significantly higher on all the postoperative days in the Proceed and Ultrapro mesh groups than in the TiMesh group which caused milder inflammatory reaction on 60th day than others meshes. The size of the mesh after 7 days was statistically significantly smaller in the Proceed and Ultrapro groups than in the TiMesh group, but after 60 days it was statistically significantly larger than in the TiMesh group.

CONCLUSION

The least formation of adhesion was noted in the TiMesh group, in which the highest level of shrinkage was noticed after 28 and 60 days. TiMesh has advantages over the other meshes studied, but a larger size mesh may be recommended for intraperitoneal application.

An Aggressive Form of MALT Lymphoma of the Stomach with Pancreas Infiltration

Introduction:

MALT lymphoma accounts for 7-8% of all B-cell lymphomas and at least 50% of primary gastric lymphoma, with the highest incidence at between 50 and 60 years of age. Aggressive forms are rare, as are indications for multi-visceral resection.

Case study:

A patient, 33 years old, was admitted to the tertiary hospital due to a biopsy at a small community hospital confirming adenocarcinoma of the stomach. She was Helicobacter pylori positive. CT showed thickening of the fundus and corpus wall, up to 2.7. cm., with numerous lymph nodes, along the small curvature and in the peripancreatic region, up to 1.5 cm in size. There was close contact between the changed and tumorous posterior wall of the stomach and the anterior surface of the pancreas. Neoplasm of the stomach was found that had infiltrated the body and tail of the pancreas and spleen hilum. Infiltration of the left crura of the diaphragm was also found, ex tempore biopsy showed inflammatory infiltration without elements of neoplasm. Total gastrectomy with omentectomy, and subtotal pancreatectomy and splenectomy were performed. Definitive patho-histological diagnosis confirmed MALT lymphoma of the stomach with pancreas infiltration, but no tumor cells were found on the spleen. Additional staining and immunohistological examination of the specimen from the community hospital showed that this was a misdiagnosis of carcinoma, and the specimen also contained MALT lymphoma.

Discussion:

MALT lymphoma frequently occurs in the stomach. For patients with MALT, systematic staging is indicated. If MALT is considered in the differential diagnosis, multiple random systematic biopsies within the stomach wall are needed to optimize diagnostic accuracy. Samples should be subject to immune phenotype analysis6. The main tumor cells of MALT are: CD 20+, CD 5-, CD 10-, CD 23-, CD 43+-. It is obvious that this kind of analysis cannot be accomplished in a small community hospital in a poor country such as Bosnia and Herzegovina, and suspicion of MALT indicates referral to a tertiary center. Although the long term risk of transformation of MALT lymphoma into the aggressive form is low9, this case of the aggressive form of MALT indicates the importance of systematic staging.

Antimicrobials: a global alliance for optimizing their rational use in intra-abdominal infections (AGORA)

Intra-abdominal infections (IAI) are an important cause of morbidity and are frequently associated with poor prognosis, particularly in high-risk patients. The cornerstones in the management of complicated IAIs are timely effective source control with appropriate antimicrobial therapy. Empiric antimicrobial therapy is important in the management of intra-abdominal infections and must be broad enough to cover all likely organisms because inappropriate initial antimicrobial therapy is associated with poor patient outcomes and the development of bacterial resistance. The overuse of antimicrobials is widely accepted as a major driver of some emerging infections (such as C. difficile), the selection of resistant pathogens in individual patients, and for the continued development of antimicrobial resistance globally. The growing emergence of multi-drug resistant organisms and the limited development of new agents available to counteract them have caused an impending crisis with alarming implications, especially with regards to Gram-negative bacteria. An international task force from 79 different countries has joined this project by sharing a document on the rational use of antimicrobials for patients with IAIs. The project has been termed AGORA (Antimicrobials: A Global Alliance for Optimizing their Rational Use in Intra-Abdominal Infections). The authors hope that AGORA, involving many of the world's leading experts, can actively raise awareness in health workers and can improve prescribing behavior in treating IAIs.

Global validation of the WSES Sepsis Severity Score for patients with complicated intra-abdominal infections: a prospective multicentre study (WISS Study)

BACKGROUND

To validate a new practical Sepsis Severity Score for patients with complicated intra-abdominal infections (cIAIs) including the clinical conditions at the admission (severe sepsis/septic shock), the origin of the cIAIs, the delay in source control, the setting of acquisition and any risk factors such as age and immunosuppression.

METHODS

The WISS study (WSES cIAIs Score Study) is a multicenter observational study underwent in 132 medical institutions worldwide during a four-month study period (October 2014-February 2015). Four thousand five hundred thirty-three patients with a mean age of 51.2 years (range 18-99) were enrolled in the WISS study.

RESULTS

Univariate analysis has shown that all factors that were previously included in the WSES Sepsis Severity Score were highly statistically significant between those who died and those who survived (p < 0.0001). The multivariate logistic regression model was highly significant (p < 0.0001, R2 = 0.54) and showed that all these factors were independent in predicting mortality of sepsis. Receiver Operator Curve has shown that the WSES Severity Sepsis Score had an excellent prediction for mortality. A score above 5.5 was the best predictor of mortality having a sensitivity of 89.2 %, a specificity of 83.5 % and a positive likelihood ratio of 5.4.

CONCLUSIONS

WSES Sepsis Severity Score for patients with complicated Intra-abdominal infections can be used on global level. It has shown high sensitivity, specificity, and likelihood ratio that may help us in making clinical decisions.

Complicated intra-abdominal infections in Europe: a comprehensive review of the CIAO study

The CIAO Study (“Complicated Intra-Abdominal infection Observational” Study) is a multicenter investigation performed in 68 medical institutions throughout Europe over the course of a 6-month observational period (January-June 2012).

Patients with either community-acquired or healthcare-associated complicated intra-abdominal infections (IAIs) were included in the study.

2,152 patients with a mean age of 53.8 years (range: 4–98 years) were enrolled in the study. 46.3% of the patients were women and 53.7% were men. Intraperitoneal specimens were collected from 62.2% of the enrolled patients, and from these samples, a variety of microorganisms were collectively identified.

The overall mortality rate was 7.5% (163/2.152).

According to multivariate analysis of the compiled data, several criteria were found to be independent variables predictive of patient mortality, including patient age, the presence of an intestinal non-appendicular source of infection (colonic non-diverticular perforation, complicated diverticulitis, small bowel perforation), a delayed initial intervention (a delay exceeding 24 hours), sepsis and septic shock in the immediate post-operative period, and ICU admission.

Given the sweeping geographical distribution of the participating medical centers, the CIAO Study gives an accurate description of the epidemiological, clinical, microbiological, and treatment profiles of complicated intra-abdominal infections (IAIs) throughout Europe.

Complicated intra-abdominal infections in Europe: preliminary data from the first three months of the CIAO Study

The CIAO Study is a multicenter observational study currently underway in 66 European medical institutions over the course of a six-month study period (January-June 2012).

This preliminary report overviews the findings of the first half of the study, which includes all data from the first three months of the six-month study period.

Patients with either community-acquired or healthcare-associated complicated intra-abdominal infections (IAIs) were included in the study.

912 patients with a mean age of 54.4 years (range 4–98) were enrolled in the study during the first three-month period. 47.7% of the patients were women and 52.3% were men. Among these patients, 83.3% were affected by community-acquired IAIs while the remaining 16.7% presented with healthcare-associated infections. Intraperitoneal specimens were collected from 64.2% of the enrolled patients, and from these samples, 825 microorganisms were collectively identified.

The overall mortality rate was 6.4% (58/912). According to univariate statistical analysis of the data, critical clinical condition of the patient upon hospital admission (defined by severe sepsis and septic shock) as well as healthcare-associated infections, non-appendicular origin, generalized peritonitis, and serious comorbidities such as malignancy and severe cardiovascular disease were all significant risk factors for patient mortality.

White Blood Cell counts (WBCs) greater than 12,000 or less than 4,000 and core body temperatures exceeding 38°C or less than 36°C by the third post-operative day were statistically significant indicators of patient mortality.

APACHE II scoring system is superior in the prediction of the outcome in critically ill patients with perforative peritonitis

BACKGROUND

There are several scoring systems used in the prediction of outcome in critically ill patients. This study was undertaken to evaluate APACHE II, SAPS I, Sepsis score, MOF, TISS-28 and MPI scoring systems in prediction of the outcome in patients with perforative peritonitis.

PATIENTS AND METHODS

The prospective study of 145 patients of both sexes with perforative peritonitis was performed. The main outcome of study was peritonitis-related death. Variables necessary for calculation of the scoring systems were recorded at the initial admission to the hospital and the third and seventh day of hospitalization, except Mannheim Peritonitis Index, which was calculated during the first 24 hours after hospitalization. Cut-off points were specified and all values greater than cut-off points were taken to predict death. Sensitivity and specificity are graphically shown for the different values of cut-off points and represented with the receiver-operating characteristic curve. The difference in the area below the curve between scoring systems was statistically compared.

RESULTS

The area under the curve for the first postoperative day was 0.87 for TISS-28 score, 0.86 for APACHE II score, 0.83 for MOF and SAPS I, 0.72 for MPI and 0.70 for Sepsis score. This demonstrated that TISS-28 and APACHE II are significantly better than other systems (p < 0.01). In addition, this discriminatory ability remained on the third and seventh postoperative day as well. The highest rate of correlation between the observed and the expected mortality rate for the first (Kendall's tau correlation 0.964) and the third day (Kendall's ścorrelation 0.810) was in APACHE II system.

CONCLUSION

APACHE II is superior in prediction of the outcome to other tested scoring systems.

Laparoscopic appendectomy is safe procedure in the pregnant patients in second trimester

Optimal approach to appendicitis in pregnancy remains controversial issue. There is also some concern that laparoscopy during pregnancy may cause fetal injury and alter fetal perfusion. Supporters of laparoscopy claim that minimally invasive approach even in pregnant state possesses several advantages, including fewer wound complications and less postoperative pain, producing faster return to normal activities and early hospital discharge, with no increased fetal risk. We present our series of pregnant patients who underwent laparoscopic appendectomy that shows that in the hands of an experienced surgeon, this method is a safe option in pregnant patients in the second trimester.

Succcessful laparoscopic treatment of cholecystoduodenal fistula

BACKGROUND

Cholecystoduodenal fistula (CD) is a rare complication of gallstone disease. Laparoscopic stapling techniques have been reported as feasible methods for treating this fistula, however these procedures are not always performed successfully. We have reported five cases of CD diagnosed intraoperatively, managed successfully by laparoscopic approach.

MATERIALS AND METHODS

During the 3-year period, from 2007 to 2009, 1500 patients underwent LC for gallstone desease, five of them (3.3%), who presented with classic symptoms of symptomatic cholelithiasis, intraoperatively CD were found. Data were collected on patients' age, sex, pre-operative diagnoses, operative methods, morbidity and management. Laparoscopic surgery was performed using the standard three trocars technique.

RESULTS

All patients were females, 67 years old on average. They had gallstones detected by abdominal ultrasound, but CD's were found during operative treatment of gallstones. In three cases CD was completely mobilized with a combination of blunt and sharp dissection and divided using the endoscopic linear stapling device. In the other two cases after division of the cystic duct and artery the gallbladder was dissected from the liver bed, leaving just the fistulous connection to the duodenum. Then division of the fistula was completed using the same stapling device. All five patients had uneventful postoperative course. The hospital stay of five patients ranged from 5 do 10 days (median 6 days).

CONCLUSION

CD does not preclude a laparoscopic approach. With more experience and improved techniques, most of these cases could be performed laparoscopically, with all of the advan-tages of minimally invasive surgery.

Treatment of common bile duct stones--is the role of ERCP changed in era of minimally invasive surgery?

In 10-15% of the patients that underwent cholecystectomy, common bile duct stones were found either during the preoperative, intraoperative or postoperative evaluation. Their treatment traditionally was based on open approach and extraction of calculi, with development of endoscopic procedures we have ERCP with endoscopic sphincterotomy, but due to rapid development of laparoscopic procedures now-days we have other therapeutic options such as laparoscopic transcystic extraction and laparoscopic choledohotomy.

METHODS

During the period between 2007-2009 we treated 168 patients with common bile duct stones. Age range was 21-78 years, 105 female and 63 male patients. We have performed 47 open explorations, 9 laparoscopic transcystic exploration, as well as 112 ERCP and ES. We monitored the rate of success (%), intra- and postoperative complications.

RESULTS

The success rate of the cases of open exploration was 95%, in 2 cases postoperative cholangiogram showed concrement residues that were successfully treated later on with ERCP+ES. Out of 9 transcystic LCBDE we have performed, in 4 cases extraction was successful, 3 patients underwent conversion into open exploration, and 2 patients were successfully treated with postoperative ERCP. A total of 69 patients were treated with ERCP and ES with the 82% success rate of stone extraction.

CONCLUSION

Even though laparoscopic and endoscopic procedures have revolutionized treatment of common bile duct stones, the role of ERCP is not changed. Treatment in general hospital settings largely depends on availability of endoscopic and laparoscopic equipment and expertise, and must be individualized according to methods that are available. In our settings we have found that best summary of these demands are achieved by ERCP and laparoscopic approach.

Laparoscopic appendectomy in the treatment of acute appendicitis

BACKGROUND

Laparoscopic appendectomy (LA) has many advantages over the classic appendectomy (CA), but this method has not been accepted yet in Bosnia and Herzegovina. Therefore, we attempted controlled randomized study in order to compare classic appendectomy with laparoscopic appendectomy and confirm eventual advantages of caring base of appendix with hem-o-lok clips regarding ordinary accepted endoloop method during laparoscopic appendectomy.

METHODS

In this prospective study 120 patients were involved which are divided into two groups. In group 1, 60 patients were operated with classic method, and group II was divided into two subgroups; 30 patients were operated with laparoscopic method in which the base of appendix was cared by double endo-loop method and 30 patients were operated by plastic non-resorptive hem-o-lok clip. During this study the time duration of operation was measured, the duration of application of hem-o-lok and endo-loop, postoperative analgesia, the duration of hospitalization, intra-operative complications, anatomic position of appendix, appendicitis, and postoperative complications.

RESULTS

The results of the study showed that laparoscopic appendectomy is shorter in duration if compared to the classical appendectomy with statistical significance p < 0.001 (CA 69,4 min; LAH 36,6 min; LAE 37,1 min), hospitalization is shorter p < 0.0001 (CA 3,6 days; LAH 2,3 days; LAE 2,2 days). Quantity of given analgesics in LA is less than in CA without statistical significance between LAE and CA (p > 0.340) and between LAE and LAH (p > 0.148) while there is positive statistical significance between LAH and CA (p < 0.015). Precise period of cicatrization of wound of patients operated by CA was 43 (71.66%) cases, with infection of wound in 3(5%) cases, phlegm of wound in 2 (3.3%) cases, healing of wound per sekundam in 9 (15%) cases and ileus in one (1.6%) patient. One patient had an infection of umbilical wound in LA and the other had cellulitis of front abdominal wall. Duration of application of hem-o-lok is shorter compared to endo-loop with statistical significance p < 0.013 (LAH 68,2 s; LAE 176,9 s).

CONCLUSION

Time of surgery is shorter and the duration of hospitalization, amount of given analgesic is smaller, less number of postoperative complications, better cosmetic effect and advantages of application of hem-o-lok over endo-loop laparoscopic appendectomy is preferred.

Laparoscopic repair of traumatic diaphragmatic hernia

Diaphragm injuries are diagnosed in the acute phase of blunt trauma only in 10% of cases--more often they are presented as hernia. Traumatic diaphragmatic hernia presents unique obstacles to a minimal invasive approach. However, with the proper training and equipment, most of these hernias are amenable to laparoscopic approach. These patients can expect the same well-known benefits of laparoscopic approach. We report here the case of a 56-year-old man, admitted to hospital with symptoms of vomiting, abdominal pain and dispnea who sustained blunt abdominal trauma in a high speed motor vehicle accident nine months ago. X-ray and CT scans confirmed suspected strangulated diaphragmatic hernia which contained stomach, colon, majoromentum and spleen in left hemithorax. The urgent laparoscopic procedure was performed--omentum, colon and stomach were taken backthrough diaphragmatic defect but the spleen was tightly fixed in thoracal cavity and splenectomy was performed. The diaphragmatic defect was repaired with interruptured sutures. This case proves that laparoscopic repair of diaphragmatic hernia is effective, but this should be carried out with caution, sometimes it needs additional complex procedure in emergency setting like splenectomy in this case.

Laparoscopic splenectomy in blunt trauma: is the procedure safe in pregnant patient?

There are increasing reports about laparoscopic splenectomy being performed even in blunt trauma patients, especially when conservative treatment has failed, but there are very rare reports involving pregnant patients operated laparoscopically due to a blunt trauma. The fear of possible injury of the fetus and effects on the course of the pregnancy limited the use of laparoscopic surgery in pregnant trauma patients. We report here a case of the laparoscopic splenectomy performed in a pregnant patient who sustained a blunt abdominal trauma, with grade V splenic injury. After diagnostic laparoscopy, which revealed the presence of a large amount of free fluid in the abdomen and a lesion on hilum of the spleen, laparoscopic splenectomy was performed with vascular staple. The patient had an uneventful recovery and was discharged with no discernible effects on the course of the pregnancy. This case shows that laparoscopic splenectomy is feasible and a safe procedure in pregnant patients who sustained a blunt abdominal trauma, but it requires adequate experience in elective laparoscopic surgery of spleen, continuous monitoring of fetal vitality is required.

Possibility of simplification of APACHE II scoring system in the prediction of the outcome in critically ill patients with perforative peritonitis

BACKGROUND

Simplification of APACHE II scoring system in the prediction of the outcome in critically ill patients with perforative peritonitis can be a useful and a cheaper model than the standard APACHE II system. We tested APACHE II and SAPS I scoring systems and variables of arterial pH, pO2, pCO2 and HCO3, cholesterol and albumin in the prediction of the outcome in these patients.

PATIENTS AND METHODS

The prospective study involved 145 patients of both sexes with perforative peritonitis. The main outcome of this study was peritonitis-related death. APACHE II and SAPS I scoring systems were calculated on the admission (during the first 24 hours). Cutoff points were specified and all values greater than the cut-off points were taken to predict death. Sensitivity and specificity are graphically shown for the different values of cut-off points. They are presented with the ROC curve. Variables of arterial pH, pO2, pCO2 and HCO3 were tested with Feed-Forward Artificial Neural Network which had 4 hidden layers with 8 neurons in the layer. We used Levenberg-Marquardt method for training, and 16 variables for the entrance in the network. We tested correlation between cholesterol and albumin levels with the patient outcome.

RESULTS

APACHE II ROC curve demonstrated that its discriminatory ability was better than the SAPS ROC curve. The area under the curve was 0.86 for APACHE II score in comparison to 0.83 for SAPS score. This illustrated that APACHE II is significantly better (P < 0.01) at determining of outcome. Use of FeedForward Artificial Neural Network (ANN) for analysis of variables such as arterial pH, pO2, pCO2 and HCO3, showed that withdrawal of these variables lead to the decreased power of prediction of APACHE II scoring system. Measurement of the correlation between the cholesterol and albumin levels and the patient outcome revealed that there was no significance between these parameters, as the level of correlation for cholesterol and albumin was -, 1, and -, 14, respectively.

CONCLUSION

APACHE II has better prognostic power than SAPS scoring system. Withdrawal of variables such as arterial pH, pO2, pCO2 and HCO3, reduces the prognostic power of APACHE II system.

Laparoscopic appendectomy in Bosnia and Herzegovina: the state of laparoscopic procedure in the treatment of acute appendicitis

BACKGROUND

Laparoscopic appendectomy (LA) has recently become a standard procedure in the treatment of acute appendicitis, as it has been shown to be advantageous over open appendectomy. Since laparoscopic appendectomy was recently introduced in Bosnia and Herzegovina, we evaluated the practice of this procedure in the treatment of acute appendicitis.

METHODS

An audit was carried out through a written questionnaire sent to 16 different medical hospitals in Bosnia and Herzegovina. The questionnaire examined the use of laparoscopic appendectomy since the period of its introduction to the end of 2007, including operative time, hospital stay, morbidity and mortality rates, conversion rate and the reasons for the conversion and laparoscopic technique.

RESULTS

The response rate from the questionnaire was 37.5%, but only three institutions (18.75%) perform LA. The mean interval from introduction of laparoscopic surgery to inception of LA was 5 years. In period from inception of LA to the end of 2007, 243 appendectomies were done by laparoscopic approach. Correct diagnosis were made in 229/243 cases. Mean hospital stay was 2.2 +/- 0.4 days. Postoperative complications were observed in 13/243 patients. The most frequent complications were intrabdominal abscess (4/13), wound infection (4/13) and intrabdominal bleeding (2/13). Nine conversions from LA into open procedure were done, two due to technical reasons (equipment malfunction), two due to mesoappendix bleeding and five due to periapendicular block or retrocecal position. Conversions and postoperative complications were observed only at the start of the introduction of this procedure.

CONCLUSION

Only three institutions in Bosnia and Herzegovina, with small surgical teams, routinely perform laparoscopic appendectomy. Thus, there is a need for systemic education of surgical teams across the country. Laparoscopic appendectomy could be the first operation in the acquisition of laparoscopic skills.

Laparoscopic treatment of lower abdominal pain related to chronic appendicitis

The appendicitis is one of the most common entities that could be met at surgical department. Chronic pelvic pain of right iliac fossa is common and it causes disability and distress and results in significant costs to health services. Often, investigation by laparoscopy reveals no obvious cause for pain. There are several possible explanations for chronic pelvic pain including undetected irritable bowel syndrome, the vascular hypothesis where pain is thought to arise from dilated pelvic veins in which blood flow is markedly reduced and altered spinal cord and brain processing of stimuli in women with chronic pelvic pain. As the pathophysiology of chronic pelvic pain is not well understood, its treatment is often unsatisfactory and limited to symptom relief. We aimed to identify and review treatments for chronic pelvic pain related to appendicitis. Frequently ultrasound and CT scan cannot confirm the diagnosis of chronic appendicitis due to non significant swelling of vermiform appendix. The study excludes patients with a diagnosis of pelvic congestion syndrome, those with pain known to be caused by gynecological disorders or irritable bowel syndrome. Detailed history, clinical examination, and serological and radiological investigations failed to reveal the cause of the pain in all cases. We presumed that pain is caused by chronic appendicitis with appendicolithiasis and that removal of appendix will result in symptom relief. We performed study with 75 patients treated by laparoscopic appendectomy. Duration of symptoms ranged from 3 to 48 months, with a mean of 13.1 months. All patients included in this study had right iliac fossa pain lasting more than three months. We performed radiological contrast studies to verify appendicolithiasis of irregularity of appendicular wall. Patient with mild symptoms were excluded, only patients that have symptoms that cause disability were operated. We compared pain according to localization, duration and character. We evaluated the pain one month after operation and compared its characteristics with preoperative pain. There is strong evidence that postoperative pain is significantly lower in operated patients and most of them are without any symptoms after operation.

Pathophysiological changes in peritonitis

Peritonitis signifies inflammation of peritoneum, whose cause is not specific. It can be regarded as local equivalent of systemic inflammatory response which is seen after any trigger of inflammation and referred to as "systemic inflammatory response syndrome (SIRS)". Intraabdominal infection is actually peritonitis caused by bacteria (local systemic inflammatory process caused by bacteria and their toxins). It can be regarded as a local equivalent of systemic sepsis. Because most of clinically significant peritonitis are caused by bacteria, both of terms are used simultaneously. Peritonitis takes place together with many, complex pathophysiological changes on systemic and cellular level. Consequences of peritonitis depend on the result of the battle between two main forces: the patient's systemic and peritoneal defense on one side, and the nature and duration of contamination on other side.