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Competing Interests: All authors have disclosed no conflicts of interest.

Introduction: The objective of this study was to evaluate the impact of operative timing on outcomes of acute appendicitis., Methods: This study examined adult patients who had presented to the hospital with acute appendicitis and had undergone appendectomy from December 2017 to February 2019. Time delay and outcomes of perforated and non-perforated appendicitis were compared. Patients were classified into five groups based on the period from symptom onset to operation: group 1, <24 hours; group 2, ≥24 and <48 hours; group 3, ≥48 and <72 hours; group 4, ≥72 and <96 hours; and group 5, ≥96 hours. The five groups were compared, with risk of perforation assessed in particular., Results: A total of 255 patients were included in the analysis. Symptom duration, operative time, and length of postoperative hospital stay (P < .001) were significantly longer in the perforated group (n = 49) than in the non-perforated group (n = 206). The perforated group also had a higher conversion rate to open procedures (P = .002) and a higher rate of wound infection (P = .034). Group 1 had 53 patients, group 2 had 95 patients, group 3 had 57 patients, group 4 had 32 patients, and group 5 had 18 patients. The incidence of appendiceal perforation and median operative time progressively increased along with symptom duration in the five groups. In multivariate analyses, independent risk factors for appendiceal perforation were male gender (odds ratio = 2.33, 95% confidence interval [CI]: 1.07-5.08) and symptom duration ≥48 hours (relative to ≥24 and <48 hours) (odds ratio = 4.64, 95%CI: 1.76-12.27). Patients with symptom duration ≥72 hours had a significantly longer operative time than those with symptom duration ≥48 and <72 hours (β = 21.38, 95%CI: 5.66-37.11, P = .008)., Conclusion: The risk of perforation increased significantly 48 hours after the onset of appendicitis. Symptoms duration ≥72 hours was associated with a longer operative time., (© 2020 Asia Endosurgery Task Force and Japan Society of Endoscopic Surgery and John Wiley & Sons Australia, Ltd.)

Objective: Visceral fat is thought to play different roles in the carcinogenesis of the colon with peripheral fat. Our aim was to evaluate the association of body fat distribution measured by bioelectrical impedance analysis (BIA) with the incidence of colorectal adenoma (CRA)., Methods: A total of 410 asymptomatic participants who underwent a screening colonoscopy from July 2017 to December 2019 in our center were recruited, including 230 with adenomas and 180 without detected adenomas. The participants' body fat was measured by BIA, including their body fat mass (BFM), body fat percentage (BFP), and waist-to-hip ratio. Parameters of metabolic syndrome (MetS), including waist circumference, blood pressure, fasting blood glucose (FBG), blood level of triglyceride, cholesterol, and high-density lipoprotein were measured as well., Results: According to univariate analysis, age, male sex, body mass index, waist circumference, BFM, waist-to-hip ratio, blood pressure, and FBG were higher in the adenoma group than in the adenoma-free group (P < 0.05). On multivariate logistical analysis (adjusted for age, sex, smoking, drinking, and family history of CRC), a high waist-to-hip ratio was associated with a high incidence of CRA (odds ratio [OR] 1.84, 95% confidence interval [CI] 1.09-3.09, P = 0.02). Only a large waist circumference in components of MetS was independently associated with the incidence of CRA (OR 1.90, 95% CI 1.17-3.08, P = 0.01) in the multivariate analysis., Conclusion: Body fat distribution is associated with CRA, central obesity is a core risk factor for CRA in MetS. Chinese Clinical Trial Registration number: ChiCTR-RRC-17010862., (© 2021 Chinese Medical Association Shanghai Branch, Chinese Society of Gastroenterology, Renji Hospital Affiliated to Shanghai Jiaotong University School of Medicine and John Wiley & Sons Australia, Ltd.)

Introduction: Acute appendicitis is the commonest surgical emergency during pregnancy. The aim of this study is to evaluate the outcomes between antibiotic therapy and appendectomy in the management of uncomplicated appendicitis during gestation., Methods: From January 2015 to April 2019, there were 2174 emergency appendicitis diagnosed in the University of Hong Kong-Shenzhen Hospital. Among them, 54 pregnant women were diagnosed with acute uncomplicated appendicitis and the clinical records were reviewed. Clinical demographics and outcomes including gestational age at delivery, mode of delivery, birth weight, APGAR score at 1 minute, fetal loss and overall length of stay were compared between the operation group and the antibiotic treatment group., Results: The baseline characteristics showed no statistically significant difference between the two groups (P > .05). In the appendectomy group (n = 20), one patient had wound infection while none of the patients in the antibiotic therapy group (n = 34) experienced any complication. In the antibiotic treatment group, appendicitis recurred in one patient during pregnancy and in two patients after deliveries, which were all treated with appendectomy. The mean hospital stay of the antibiotic treatment group was shorter than that of the appendectomy group, but there was no significant difference (4.94 ± 2.6 days vs 6.25 ± 3.5 days, P = .540). There was no difference in gestational age at delivery, mode of delivery, birth weight and APGAR scores between the two groups (P > .05)., Conclusions: For acute uncomplicated appendicitis during pregnancy, antibiotics treatment is a safe and feasible option., (© 2020 Asia Endosurgery Task Force and Japan Society of Endoscopic Surgery and John Wiley & Sons Australia, Ltd.)

Introduction: Seroma is a commonly encountered sequela after hernia repair. Tremendous effort has been spent to investigate the effective way to prevent this "complication" including the modification of surgical technique, use of per-peritoneal drainage, etc. There were debates about the use of monopolar diathermy versus blunt dissection in laparoscopic TEP in the prevention of seroma formation. This randomized study aims to compare the effects of using 2 techniques in laparoscopic TEP on pre-peritoneal drain output and seroma formation., Method: From 1.9.2018 to 30.9.2019, all male and female patients presented with the first occurrence, unilateral inguinal hernia anticipated for laparoscopic TEP were enrolled into the study after informed consent. Patients were randomized into "monopolar dissection preferred" (MDP) group and "blunt dissection-preferred" (BDP) group just before commencing of operation after general anesthesia. Surgeons were instructed to use monopolar energy as main dissection method for the whole operation if possible (MDP), whereas blunt dissection is the preferred choice in BDP group, but the use of monopolar energy was allowed if needed. Total energy time was measured by a specially designed homemade device attaching to the monopolar pedals as accurate as to millisecond (ms). Pre-peritoneal drains were inserted for drainage and removed 23 h after operation. Drainage output, total operating time, energy time, clinical and ultrasonic seroma sizes at day 1, day 6, 1-month post operations, recurrence are compared between 2 groups., Results: A total of 103 patients where included. There was no significant difference in age, gender, co-morbidities, side of hernia, mean defect size, operating time, fixation adjuncts, or postoperative stay. The drain volume in BDP group is 71.13 ± 31.42 mL while it in MDP group is 56.36 ± 21.46 mL. The MDP group had significantly fewer drain output at 23 h post operation (p = 0.007) and lower seroma incidence on days 6 (p = 0.036). Overall incidence of seroma formation was 12% on postoperative day 1, 11% on postoperative day 7. No statistically differences in postoperative pain score or complications were observed at the first week, 1- and 3-months' post operation. There was no correlation with energy time to the drain output. No recurrence was found in subsequent follow-up., Conclusion: Pre-peritoneal drainage is clinically safe in laparoscopic totally extra-peritoneal hernioplasty and can effectively reduce the size and incidence of seroma. The seroma formation can be further reduced by appropriate use of monopolar energy as preferred dissection approach in lap TEP. Due to limitation in measuring the actual energy time, the result should be further validated by randomized multi-centers trial on its potential benefit in hernia repair by a more accurate measuring device on energy used.

Background: Management errors during pre-hospital care, triage process and resuscitation have been widely reported as the major source of preventable and potentially preventable deaths in multiple trauma patients. Common tools for defining whether it is a preventable, potentially preventable or non-preventable death include the Advanced Trauma Life Support (ATLS ® ) clinical guideline, the Injury Severity Score (ISS) and the Trauma and Injury Severity Score (TRISS). Therefore, these surrogated scores were utilized in reviewing the study's trauma services., Methods: Trauma data were prospectively collected and retrospectively reviewed from January 1, 2018, to December 31, 2018. All cases of trauma death were discussed and audited by the Hospital Trauma Committee on a regular basis. Standardized form was used to document the patient's management flow and details in every case during the meeting, and the final verdict (whether death was preventable or not) was agreed and signed by every member of the team. The reasons for the death of the patients were further classified into severe injuries, inappropriate/delayed examination, inappropriate/delayed treatment, wrong decision, insufficient supervision/guidance or lack of appropriate guidance., Results: A total of 1913 trauma patients were admitted during the study period, 82 of whom were identified as major trauma (either ISS > 15 or trauma team was activated). Among the 82 patients with major trauma, eight were trauma-related deaths, one of which was considered a preventable death and the other 7 were considered unpreventable. The decision from the hospital's performance improvement and patient safety program indicates that for every trauma patient, basic life support principles must be followed in the course of primary investigations for bedside trauma series X-ray (chest and pelvis) and FAST scan in the resuscitation room by a person who meets the criteria for trauma team activation recommended by ATLS ® ., Conclusion: Mechanisms to rectify errors in the management of multiple trauma patients are essential for improving the quality of trauma care. Regular auditing in the trauma service is one of the most important parts of performance improvement and patient safety program, and it should be well established by every major trauma center in Mainland China. It can enhance the trauma management processes, decision-making skills and practical skills, thereby continuously improving quality and reducing mortality of this group of patients.

Objectives: Seroma is a virtually unavoidable early sequela after TEP hernioplasty. This randomised controlled trial evaluated the outcomes of preperitoneal closed-system suction drainage in laparoscopic totally extraperitoneal (TEP) hernioplasty for inguinal hernia., Methods: Ninety patients aged 18-80 years who presented to our hospital between May 2016 and February 2017 with primary unilateral inguinal hernia were randomised into the preperitoneal drain and no-drain groups. The primary outcome was seroma size on postoperative day 6. Secondary outcomes included clinical seroma formation and seroma size on day 1, day 6, 1 and 7 months postoperatively, length of postoperative stay, pain score, and recurrence., Results: There was no significant difference in age, sex, co-morbidities, hernia side, mean hernia size, operating time, fixation adjuncts, or postoperative stay. The overall incidence of clinical seroma formation was 25.6% on postoperative day 1, 60.3% on postoperative day 6, 13.2% 1 month and 0% 7 months postoperatively. The mean drain output was 57.9 ml. The drain group had significantly fewer patients with seroma on day 1 (6 vs 14, p = 0.022) and day 6 (17 vs 30, p = 0.000), and a smaller mean seroma size on days 1 and 6 (p = 0.000). Subgroup analysis showed that sac ligation versus reduction, peritoneal perforation, and fixation adjuncts had no significant effects on seroma formation or size. There is a trend of lower early post-operation VAS score and more urinary retention in drain group was observed but not reaching statistical significance. No differences in postoperative pain score or complications were observed at 1 and 7 months' post operation., Conclusions: Preperitoneal drainage for 23 h after laparoscopic TEP hernioplasty for inguinal hernia can effectively decrease seroma formation in the early postoperative period, and potentially improving postoperative pain. The benefit is short-term and no significant difference was demonstrated after 1-month post operations. This tradition technique applied to novel operative repair of inguinal hernia is safe and feasible with no significant morbidity demonstrated. Preperitoneal drainage after TEP can be considered as an option to improve patient satisfactions and recovery in selected patient group for maximal benefit, especially for those with prolonged operation which may associate with higher chance of seroma formation.

Backgrounds and Aims: The association of melanosis coli with the development of colorectal polyps remains uncertain., Methods: From a total of 18263 patients who had received colonoscopy in our hospital, 219 with melanosis coli cases and 438 controls matched by age and sex (at 1:2 ratio) were included in this study. The association of incidence, number, location, and pathology of colorectal neoplasm with grades and distribution of melanosis coli were analyzed., Results: Melanosis coli was associated with significantly more colorectal polyps than control, a higher incidence of numerous colorectal polyps (number ≥ 20) (7.3% vs 0.5%; p < 0.001), and higher number of small colorectal polyps (diameter ≤ 5 mm; p < 0.01). Patients with melanosis coli had higher incidences of low-grade adenomas (31.1% vs 23.3%, p < 0.05) and non-adenoma polyps (20.1% vs 12.8%, p < 0.05) than the controls. On multivariate analysis, melanosis coli was independently associated with increased detecting rates of low grade adenoma (OR = 1.54; 95%: 1.06-2.23; p < .05), non-adenoma polyp (OR = 1.72; 95%: 1.11-2.70; p < .05) and numerous polyps (OR = 16.2, 95%: 3.66-71.6; p < .05). There was no significant difference in the incidence of high-grade adenomas or adenocarcinomas in the two population groups, but the numbers of these lesions were insufficient to permit firm conclusions. No significant differences in incidence, number, and pathology of colorectal polyps between individuals with melanosis coli of three different grades of severity were found. Melanosis located predominantly in the right colon had an interestingly lower incidence of colonic polyps in right colon than did melanosis located predominantly in the left colon or total colon (8.9% vs. 26.3%, 24.0%, p < 0.05). Patients with melanosis coli had significantly more nonspecific distal ileal ulcers than did controls (8.0% vs 0%, p < 0.001)., Conclusion: Melanosis coli is associated with a higher incidence and number of colonic non-adenoma polyps and low-grade adenomas, and higher incidence of distal ileal ulcers. Melanosis coli may not be a harmless pigmentation, but a sign of chronic injury of colonic and intestinal mucosa.

Background: Angioleiomyoma is an uncommon benign soft tissue tumor and originates from the vascular smooth muscle. It often causes pain and is rarely found in inguinal region. We present a rare case of inguinal canal angioleiomyoma of a female patient who suffered from right groin pain for 4 years and mimicking inguinal hernia clinically., Presentation of Case: A 53-year-old Chinese female patient presented with 4-year history of right groin pain which was exacerbated by movement. Magnetic resonance imaging was performed in view of atypical presentation and absence of cough impulse. Inguinal canal was subsequently explored by open approach and the mass was found arising from the posterior wall of the inguinal canal and measured 5.2 cm × 3.8 cm. The posterior wall was repaired by Bassini approach after the mass was resected en-bloc. Inguinal pain was resolved and no hernia was found during follow-up. Pathology of the resected specimen confirmed angioleiomyoma with clear resection margins., Conclusion: This is the first report of a case of angioleiomyoma of the inguinal canal, which presents as a painful mass. Magnetic resonance imaging should be considered when presenting history and physical examination does not confirm with the diagnosis of inguinal hernia. After inguinal canal exploration, suture or mesh repair should be performed to prevent weakening of posterior wall leading to inguinal hernia.

Background: The city of Shenzhen, China, is planning to establish a trauma system. At present, there are few data on the geographical distribution of incidents, which is key to deciding on the location of trauma centres. The aim of this study was to perform a geographical analysis in order to inform the development of a trauma system in Shenzhen., Methods: Retrospective analysis of trauma incidents attended by Shenzhen Emergency Medical Services (EMS) in 2014. Data were obtained from Shenzhen EMS. Incident distribution was explored using dot and kernel density estimate maps. Clustering was determined using the nearest neighbour index. The type of healthcare facilities which patients were taken to was compared against patients' needs, as assessed using the Field Triage Decision Scheme., Results: There were 49,082 recorded incidents. A total of 3513 were classed as major trauma. Mapping demonstrates that incidents predominantly occurred in the western part of Shenzhen, with identifiable clusters. Nearest neighbour index was 0.048. Of patients deemed to have suffered major trauma, 8.5% were taken to a teaching hospital, 13.6% to a regional hospital, 42.6% to a community hospital, and 35.3% to a private hospital. The proportions of Step 1 or 2 negative patients were almost identical., Conclusion: The majority of trauma patients, including trauma patients who are at greater likelihood of severe injury, are taken to regional and community hospitals. There are areas with identifiable concentrations of volume, which should be considered for the siting of high-level trauma centres, although further modelling is required to make firm recommendations.

Objectives: The use of absorbable polylactic acid hook self-gripping polypropylene mesh in open inguinal hernia may potentially reduce operative time and enhance patient recovery. The objective of this randomized trial is to compare the outcomes following self-gripping mesh repair to polypropylene mesh secured with sutures in open inguinal hernioplasty., Method: Eligible patients aged 18-80 years old, who had primary unilateral uncomplicated inguinal hernia, were randomized into either Polypropylene (PL) group or PROGRIP (PG) group just before the placement of mesh intra-operatively by computer generated code. The primary outcome was the time from mesh placement to end of operation, whereas secondary outcomes included the total operative time, amount of analgesic used, length of post-operative stay, seroma formation, chronic discomfort, chronic pain score and recurrence. The study has been registered in http://www.clinicaltrial.gov carrying an ID of NCT00960011. Patients were followed-up in outpatient clinic for up to 6 years after operation., Results: From March 2009 to April 2016, 45 patients were included. The mean age of PG group (n = 22) was 62.0 ± 15.7 years old while that of the PL group was 62.6 ± 4.9 years old (n = 23). There was no significant difference regarding the smoking habit, drinking habit, comorbidities, previous hernia operation and Nyhus type of hernia between the two groups. The size of defects, the time of groin dissection and the size of incision were similar. In the PG group, there was significant reduction in the time for mesh placement (11.8 ± 3.1 vs. 21.0 ± 6.2 min, p < 0.001) and total operative time (39.2 ± 9.8 vs. 47.7 ± 8.0 min, p = 0.003). There was one recurrence in PL group and nil in PG group. Although there was a significant difference in paresthesia between 2 groups after operation, the difference disappears with time and comparable from post-operative 1 year onwards. There was no difference in chronic pain, chronic discomfort, affect daily activities, palpable mesh demonstrated throughout the whole study period till 6 years after operation., Conclusions: The use of polylactic acid self-gripping mesh in open inguinal hernia repair effectively reduces the operating time with comparable long-term surgical outcome with traditional polypropylene mesh.