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To evaluate comparative outcomes of straight (end-to-end) anastomosis versus colonic J-pouch anastomosis following anterior resection.A systematic search of multiple electronic data sources was conducted, and all studies comparing straight (end-to-end) anastomosis versus J-pouch anastomosis were included. Anastomotic complications, post-operative complications, re-operation, mortality, and functional outcomes were the evaluated outcome parameters. Revman 5.3 was used for data analysis.Twenty-seven studies reporting a total number of 3293 patients who underwent straight anastomosis (n = 1581) or J-pouch (n = 1712) were included. Anastomotic leak and re-operation rates were significantly higher in the straight group compared to the J-pouch group [RD 0.03, P = 0.03] and [OR 1.87, P = 0.003], respectively. Stool frequency per 24 h at 6 months and 12 months was lower in the J-pouch group than the straight group [MD 2.13, P = 0.003] and [MD 1.44, P = 0.00001], respectively. In addition, the use of anti-diarrheal medication is lower at 12 months in the J-pouch group [MD 3.85, P = 0.03]. Moreover, the two groups showed comparable results regarding SSI, sepsis, paralytic ileus, anastomotic stricture formation, anastomotic bleeding, and mortality.J-pouch anastomosis showed lower risk for anastomotic leak and re-operation. Furthermore, better functional outcomes such as stool frequency were achieved using the colonic J-pouch reconstruction over the conventional straight end-to-end anastomosis.

Introduction The ability to predict risk of perforation in acute appendicitis (AA) could direct timely management and reduce morbidity. Platelet-to-lymphocyte ratio (PLR) and neutrophil-to-lymphocyte ratio (NLR) are surrogate severity markers in infections. This study investigates the use of PLR and NLR as a marker for distinguishing uncomplicated (UA) and complicated appendicitis (CA) in children. Materials and methods This retrospective single-center study collected data between January 1, 2014, and December 31, 2020. Children between five and 17 years of age with histologically confirmed appendicitis were included. Cut-off values for NLR and PLR were determined by employing the receiver operating characteristic (ROC) curve with sensitivity and specificity in addition to regression analysis. Results A total of 701 patients were included with a median age of 13 years. Out of which 52% of the cohort was female. The difference between the NLR and PLR ratios between UA and CA was significant (p=0.05, Kruskal-Wallis). For UA, the area under the ROC curve (AUC) and cut-off for NLR and PLR were 0.741, 3.80 with 95% CI of 0.701-0.781 and 0.660, 149.25 with 95% CI of 0.618-0.703, respectively. In CA, using NLR and PLR, AUC and cut-off were 0.776, 8.86 with 95%CI of 0.730-0.822 and 0.694, 193.67 with 95%CI of 0.634-0.755, respectively. All were significant with p0.001. Conclusions NLR and PLR are reliable, synergistic markers predicting complicated appendicitis which can guide non-operative management in children.

Introduction Acute appendicitis (AA) is one of the most common acute general surgical presentations affecting 7% of the population at some point in their lifetime. The ability to assess the risk of complicated appendicitis (CA) from uncomplicated appendicitis (UA) in acute appendicitis (AA) could reduce the associated morbidity and mortality. The value of platelet lymphocyte ratio (PLR) as an inflammatory marker increases when its fluctuations are interpreted along with other complementary hematologic indices, such as neutrophil-to-lymphocyte ratio (NLR), which provides additional information about the disease activity. Hence, we postulated that NLR and/or PLR could serve as a potential surrogate marker in assessing the severity of AA. Aim This study aims to investigate the use of PLR and/or NLR as a surrogate biomarker in differentiating uncomplicated from complicated appendicitis. Material and methods This retrospective study was conducted at Russells Hall Hospital from January 1, 2017, to December 31, 2020. Data of all patients over age 16 years that had histologically confirmed appendicitis were retrieved. NLR and PLR were calculated from the admission hemogram, and the ratios were compared between uncomplicated (UA) or complicated appendicitis (CA). Cut-off values were calculated using the summarized ROC curve; in addition, the sensitivity and specificity with 95% confidence intervals were determined using SPSS 25.0 (IBM Corp., Armonk, NY). Results A total of 799 patients were analyzed, of which 469 (58.7%) were female. The median age was 31.2 years. The difference between NLR and PLR within the two appendicitis groups was significant (P=0.05; Kruskal-Wallis). Cohen's kappa (degree of inter-rater agreement) between NLR and PLR showed a moderate agreement of 0.589 (P0.001). We equally demonstrated an exponential relationship between PLR and NLR (R

There is increasing evidence in a range of cancer types that the microbiome plays a direct role in modulating the anti-cancer immune response both at the gut level and systemically. Differences in the gut microbiota have been shown to correlate with differences in immunotherapy responses in a range of non-gastrointestinal tract cancers. DNA mismatch repair-deficient (dMMR) colorectal cancer (CRC) is radically different to DNA mismatch repair-proficient (pMMR) CRC in clinical phenotype and in its very good responses to immunotherapy. While this has usually been thought to be due to the high mutational burden in dMMR CRC, the gut microbiome is radically different in dMMR and pMMR CRC in terms of both composition and diversity. It is probable that differences in the gut microbiota contribute to the varied responses to immunotherapy in dMMR versus pMMR CRC. Targeting the microbiome offers a way to boost the response and increase the selection of patients who might benefit from this therapy. This paper reviews the available literature on the role of the microbiome in the response to immunotherapy in dMMR and pMMR CRC, explores the potential causal relationship and discusses future directions for study in this exciting and rapidly changing field.

Objective Susceptibility of patients with cancer to COVID-19 pneumonitis has been variable. We aim to quantify the risk of hospitalisation in patients with active cancer and use a machine learning algorithm (MLA) and traditional statistics to predict clinical outcomes and mortality. Design Retrospective cohort study. Setting A single UK district general hospital. Participants Data on total hospital admissions between March 2018 and June 2020, all active cancer diagnoses between March 2019 and June 2020 and clinical parameters of COVID-19-positive admissions between March 2020 and June 2020 were collected. 526 COVID-19 admissions without an active cancer diagnosis were compared with 87 COVID-19 admissions with an active cancer diagnosis. Primary and secondary outcome measures 30-day and 90-day post-COVID-19 survival. Results In total, 613 patients were enrolled with male to female ratio of 1:6 and median age of 77 years. The estimated infection rate of COVID-19 was 87 of 22 729 (0.4%) in the patients with cancer and 526 of 404 379 (0.1%) in the population without cancer (OR of being hospitalised with COVID-19 if having cancer is 2.942671 (95% CI: 2.344522 to 3.693425); p Conclusions Active cancer diagnosis has a threefold increase in risk of hospitalisation with COVID-19. Increased age, urea and CRP predict mortality in patients with cancer. MLA complements traditional statistical analysis in identifying prognostic variables for outcomes of COVID-19 infection in patients with cancer. This study provides proof of concept for MLA in risk prediction for COVID-19 in patients with cancer and should inform a redesign of cancer services to ensure safe delivery of cancer care.

Background Incisional hernia (IH) is a common, late complication of open repair of an abdominal aortic aneurysm (AAA), with a variable high incidence. A cohort study was conducted to investigate the role of a lightweight titanized mesh placed in the pre-peritoneal space after AAA repair. The primary endpoint was to determine the incidence of IH at eight weeks and 12 months. Methods Consecutive patients who underwent open repair of AAA with the prophylactic implantation of a mesh after abdominal wall closure were recruited. The development of IH was evaluated using clinical examination, ultrasonography scan (USS), and computed tomography (CT) scan during the follow-up period. Results Thirty-nine of 45 patients (34 male, 5 female, mean age 69.6 +/- 6.5 years) undergoing open repair of AAA over a five-year period via a preferred roof-top incision were analyzed for this study. One additional (2.5%) patient had the mesh explanted following a re-laparotomy for colonic ischemia and later developed an incisional hernia. There was no incidence of wound or mesh infection overall. One radiologically detected early IH closed spontaneously. There were five (12.8%) radiologically detected late cases of midline or paramedian defects beyond the one-year follow-up though this was not clinically significant; compared to this, there was no incidence of lateral defects in the wound (p

Objectives The clinical diagnosis of complicated acute cholecystitis (CAC) remains difficult with several pathological or ultrasonography criteria used to differentiate it from uncomplicated acute cholecystitis (UAC). This study aims to evaluate the use of combined inflammatory markers C-reactive protein (CRP) and neutrophil-to-lymphocyte ratio (NLR) as surrogate markers to differentiate between UAC and CAC. Methods We identified 600 consecutive patients admitted with biliary symptoms during an acute surgical take from our electronic prospectively maintained database over a period of 55 months. Only patients undergoing emergency cholecystectomy performed during the index admission were included. The primary outcome was the finding of CAC versus UAC. Results A total of 176 patients underwent emergency laparoscopic cholecystectomy (ELC) during the index admission, including 118 (67%) females with a median age of 51 years (range: 21-97 years). The proportion of UAC (130 [74%]) and CAC (46 [26%]) was determined along with demographic data. Multivariate regression analysis showed that patient's age (OR=1.047; p=0.003), higher CRP (OR=1.005; p=0.012) and NLR (OR=1.094; p=0.047) were significant independent factors associated with severity of cholecystitis. Receiver operating characteristic (ROC) analysis for CRP showed an AUC (area under the curve) of 0.773 (95% CI: 0.698- 0.849). Using a cut-off value of 55 mg/L for CRP, the sensitivity of CAC was 73.9% and specificity was 73.1% in predicting CAC. The median post-operative length of stay was four days. The conversion rate from laparoscopic cholecystectomy to open surgery was 2% (4/176), and 5% (9/176) patients suffered post-operative complications with no mortality at 30 days. Conclusion CRP, NLR and age were independent factors associated with the severity of acute cholecystitis. NLR and CRP can be used as surrogate markers to predict patients at risk of CAC during emergency admission, which can inform future guidelines. Moreover, ELC for CAC can be safely performed under the supervision of dedicated upper GI surgeons.

Background and objective Laparoscopic cholecystectomy is used for the treatment of symptomatic gallstones. Intraoperative cholangiogram (IOC) is used to diagnose common bile duct (CBD) stones. There is controversy surrounding routine vs selective use of IOC based on clinical, biochemical and ultrasound criteria. The aim of this study was to evaluate the outcomes from routine IOC and its utility in laparoscopic cholecystectomy. Materials and methods This was a UK-based single-centre retrospective study evaluating the outcomes from IOC for all laparoscopic cholecystectomies performed between May 2014 and February 2020. All adult patients undergoing elective, semi-elective or emergency operations were included. Demographics, biochemistry as well as radiological and endoscopic investigations were analysed. IOC was performed using a standardised technique and was interpreted by a single surgeon. Results A total of 744 out of 804 patients underwent IOC. The median age of the cohort was 51 years (SD: ±17.5); there were 468 females (62.9%) and 276 males (37.1%). Filling defects were identified in 43/744 (5.8%) patients, with 23/43 having stone extraction via endoscopic retrograde cholangiopancreatography (ERCP). Logistic regression analysis identified alkaline phosphatase (ALP) as a predictor of filling defects in IOC (OR: 1.003; 95% CI: 1.001-1.005, p=0.015). Conclusion Based on our findings, the routine use of IOC during laparoscopic cholecystectomy is safe and effective. Preoperative clinical, radiological and biochemical parameters apart from ALP have a limited role in predicting the diagnostic yield of IOC.

Laparoscopic colectomy has become the standard practice for colorectal cancer surgery. A variety of techniques are described for anastomosis including extracorporeal and intracorporeal techniques. Intracorporeal anastomosis may be associated with better cosmesis and post-operative recovery. However, the review by Reddavid et al. (J Gastrointest Surg 24:2389-2392, 2020) describing an intracorporeal stapled technique for ileo-colonic anastomosis has several issues. First, the technique for forming intracorporeal anastomoses is not novel and has been previously reported. The conversion rate to open surgery does not relate to anastomosis technique but the difficulty of dissection and tumour stage. Furthermore, performing the technique requires an additional trocar adding to expense. Moreover, utilizing multiple sutures which close the enterostomy prior to stapling does not stand scrutiny when the defect has already been closed. The additional staple firing is a risky strategy particularly if the stapler splits. Thus, it is vital that new techniques promoted to trainees and residents have a sound technical and evidence base, avoid unnecessary expense or risk technical failure.

Acute or chronic blood loss from pseudoaneurysms of the splanchnic artery in chronic pancreatitis poses diagnostic and management challenges. Arteriographic examination offers both diagnostic and therapeutic options, with success rates of 76%-100% for both modalities. In cases of failure of embolization, repeat embolization is also an option. Surgical intervention is advocated for rebleeding and failure of embolization. Evidence-based guidelines regarding the optimal treatment modality for this condition are lacking. There has been a reported case of dislodgement of coil into the stomach through a gastropseudocystic fistula. We report the case of a migrating steel-wire coil through the gastrointestinal tract and splenic artery pseudoaneurysm. We highlight the potential complications of pseudoaneurysm and other available therapeutic management options.