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The difference in outcome between right (RCD) and left colonic diverticulitis (LCD) is not well established. The aim of this study was to analyse the presentation and surgical outcome of RCD versus left-sided disease following emergency surgery.We conducted a retrospective review of patients presenting with acute diverticulitis over a 10-year period from 2004 to 2014 to a tertiary unit. Patient demographics, Hinchey classification, need for emergency surgery, perioperative outcome and recurrence were evaluated.In total 360 patients presented with acute diverticulitis, 218 (61%) were right-sided and 142 (39%) were left-sided. The mean age (57 yrs vs 68 yrs) and median length of stay (4 days vs 5 days) were significantly less in RCD (p 0.001). The need for emergency surgery was similar between RCD and LCD (30.7% vs 23.2%, p = 0.12). Sixty-seven (31%) patients with RCD required emergency surgery, 42 (62.7%) of these were based on a presumptive diagnosis of appendicitis and underwent laparoscopic appendicectomy only. Operative morbidity (10.4% vs 51.5%, p 0.001) and mortality were significantly higher in LCD (1.5% v 15.2%, p = 0.007). Subgroup analysis of non-appendicectomy, RCD patients, showed LCD were more likely to require surgery (11.5% vs 23.2%, p = 0.003). There was no difference in recurrence (p = 0.6).Right colonic diverticulitis patients are younger and disease course is more benign compared to LCD. Presentation can be confused with appendicitis without proper imaging. In the rare cases where emergency surgery is required, RCD is associated with a lower operative morbidity and mortality compared to left-sided disease.

Background Advances in sphincter-saving procedures improved the quality of life of patients with rectal cancer. However, many of them experienced functional disturbances after surgery, including low anterior resection syndrome. Objective The aim of this study was to evaluate the severity of low anterior resection syndrome after transanal total mesorectal excision and compare it with the conventional transabdominal, top-to-bottom, total mesorectal excision. Design This was a single-center, retrospective analysis. Settings The study was conducted at a tertiary academic institution. Patients This study analyzed patients who underwent total mesorectal excision for mid to low rectal cancer from January 2016 to April 2018. Cases were matched one-to-one according to the tumor height and history of pelvic irradiation using the propensity score. Main outcome measures The primary outcome measured was the severity of low anterior resection syndrome and fecal incontinence at 3, 6, and 12 months after surgery or stoma reversal, whichever was later. Results There were 35 patients in each group after matching; 67.1% were male, and 41.4% had neoadjuvant radiotherapy. At 3 months, the median low anterior resection syndrome score was 37 after transanal total mesorectal excision, which was significantly higher than the conventional approach, 32 (p = 0.045). Apart from this, the low anterior resection syndrome score, severity grading, and the Wexner score were comparable at 6 and 12 months. Limitations A difference between the 2 groups might not be detected because of the study's small sample size and because of its retrospective nature. Conclusions A higher low anterior resection syndrome score was observed after transanal total mesorectal excision at the initial 3-month period, but such a difference was not observed thereafter. This study showed that both surgical techniques had similar anal and bowel functional outcomes in the long run. However, because of the limited case number and study design, further study is needed to prove this. See Video Abstract at http://links.lww.com/DCR/B146. SINDROME DE RESECCION ANTERIOR BAJA DESPUES DE LA ESCISION MESORRECTAL TOTAL TRANSANAL: UNA COMPARACION CON EL ABORDAJE CONVENCIONAL DE SUPERIOR A INFERIOR: Los avances en los procedimientos para salvar esfinteres mejoraron la calidad de vida de los pacientes con cancer rectal. Sin embargo, muchos de ellos sufrieron trastornos funcionales despues de la cirugia, incluyendo el sindrome de reseccion anterior baja.El objetivo de este estudio fue evaluar la gravedad del sindrome de reseccion anterior baja despues de la escision mesorrectal total transanal y comparar con la escision mesorrectal total convencional transabdominal, de arriba a abajo.El estudio se realizo en una institucion academica terciaria.Este fue un analisis retrospectivo de un solo centro de pacientes que se sometieron a una escision mesorrectal total por cancer rectal medio a bajo desde enero de 2016 hasta abril de 2018. Los casos fueron emparejados uno a uno de acuerdo con la altura del tumor y los antecedentes de irradiacion pelvica con puntaje de propension.La gravedad del sindrome de reseccion anterior baja y la incontinencia fecal a los 3, 6 y 12 meses despues de la cirugia o la reversion del estoma, lo que ocurriera mas tarde.Hubo 35 pacientes en cada grupo despues del emparejamiento. El 67.1% eran hombres. El 41,4% tenia radioterapia neoadyuvante. A los tres meses, la puntuacion media del sindrome de reseccion anterior baja fue de 37 despues de la escision mesorrectal transanal total, que fue significativamente mayor que el enfoque convencional, 32 (p = 0.045). Aparte de esto, la puntuacion baja del sindrome de reseccion anterior, la clasificacion de gravedad y la puntuacion de Wexner fueron comparables a los 6 y 12 meses.Es posible que no se detecte una diferencia entre los dos grupos debido al pequeno tamano de la muestra del estudio. La naturaleza retrospectiva del estudio.Se observo una puntuacion mas alta en el sindrome de reseccion anterior baja despues de la escision mesorrectal total transanal en el periodo inicial de tres meses, pero dicha diferencia no se observo posteriormente. Este estudio mostro que ambas tecnicas quirurgicas tuvieron resultados similares de funcionamiento anal e intestinal a largo plazo. Sin embargo, debido al numero limitado de casos y al diseno del estudio, es necesario realizar mas estudios para demostrarlo. Consulte Video Resumen en http://links.lww.com/DCR/B146.

Proteins have gained increasing success as therapeutic agents; however, challenges exist in effective and efficient delivery. In this work, we present a simple and versatile method for encapsulating proteins via complex coacervation with oppositely charged polypeptides, poly(l-lysine) (PLys) and poly(d/l-glutamic acid) (PGlu). A model protein system, bovine serum albumin (BSA), was incorporated efficiently into coacervate droplets via electrostatic interaction up to a maximum loading of one BSA per PLys/PGlu pair and could be released under conditions of decreasing pH. Additionally, encapsulation within complex coacervates did not alter the secondary structure of the protein. Lastly the complex coacervate system was shown to be biocompatible and interact well with cells in vitro. A simple, modular system for encapsulation such as the one presented here may be useful in a range of drug delivery applications.

Background There are no data comparing the use of self-gripping mesh with standard mesh in total extraperitoneal repair (TEP). In this prospective study we aim to study the incidence of chronic pain between Progrip (PG) and standard mesh fixed by fibrin sealant (FS). Materials and methods Under Institutional Review Board approval, from April 2016 to May 2017, patients with primary unilateral or bilateral inguinal hernia eligible for TEP were recruited. Before mesh insertion they were randomized into PG or FS (Tisseel). Demographics, intraoperative, and postoperative data were recorded. Patients were followed up for at least 1 year. Visual Analog Scale was used to record pain scores. Primary outcome was the incidence of chronic pain at 3 months after surgery. Results One hundred fifty patients were randomized. Of the 150 patients (193 hernias), 76 were randomized to PG and 74 randomized to FS. Demographic data such as age, presence of comorbidities, smoking history, mean body mass index was comparable in both groups. Bilateral hernias occurred in 25 (32.9%) and 18 (24.3%) patients in PG and FS group, respectively. Mean mesh deployment time was 283.7 seconds (range, 140 to 720 s) in PG group and 301.9 seconds (range, 67 to 1006 s) in FS group (P=0.30). A total of 5 patients were lost at follow-up and they were excluded from subsequent data analysis. Seroma occurred in 15 (20.3%) and 16 (22.5%) patients in PG and FS group, respectively (P=0.45). Mean Visual Analog Scale at 2 weeks (cough) was highest at 1.05 and 1.02 in PG and FS group, respectively (P=0.62). Eight (12.3%) and 15 (23.4%) patients in PG and FG group, respectively, reported pain at 3-month follow-up (P=0.1). Of those who experienced pain, majority was mild pain which did not affect activities of daily living. At a mean follow-up of 13.1±5.4 months, no recurrence was detected. Conclusions There was no significant difference in terms of chronic pain between PG and FS group. The use of PG is effective in TEP.

Background According to the American Joint Committee on Cancer staging for cancer of the colon, a minimum of 12 lymph nodes (LN) has to be sampled for accurate staging. This has bearing on the long-term prognosis and the need for adjuvant chemotherapy. The aim of this study was to revisit the association of lymph node yield and the long-term survival in patients with stages I and II, i.e. node-negative, colon cancer. Method Consecutive patients who underwent elective or emergency curative resections for cancer of colon between the years 2003 and 2012 were retrospectively reviewed. Only patients with stage I or II diseases (AJCC 8th edition) were included. They were analysed in three groups, LN Results There was a total of 659 patients included in the analysis. Twelve or more LN were found in 65.6% of the specimens. The mean follow-up was 83.9 months. LN≥20 had significantly better DFS (p = 0.015) and OS (p = 0.036), whereas LNp = 0.007. Conclusion The lymph node yield had a significant association with survival outcomes. A lymph node yield of 20 or more was associated with better survival outcomes. On the other hand, lymph node yield less than 12 was not shown to have inferior survival outcomes when compared to those between 12 and 19.

Introduction: Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is increasingly used to treat peritoneal metastases from appendiceal or colorectal origin. We evaluate our institution's experience and survival outcomes with this procedure, and its efficacy in symptom relief. Methods: This is a single-centre retrospective observational study on patients with peritoneal metastases (PM) from appendiceal neoplasm or colorectal cancer who underwent CRS/HIPEC in Queen Mary Hospital. Our primary endpoints were overall survival (OS) and morbidity and mortality of this procedure; secondary endpoints included disease-free survival (DFS) and symptom-free survival. Results: Between 2006 and 2018, thirty CRS/HIPEC procedures were performed for 28 patients – 17 (60.7%) had appendiceal PM while 11 (39.9%) had colorectal PM. The median peritoneal cancer index was 20; complete cytoreduction was achieved in 83.3% patients. High-grade morbidity occurred in 13.3% cases. There was no 30-day mortality. Two-year OS were 71.6% and 50% for low-grade appendiceal PM and colorectal PM patients (p = 0.20). Complete cytoreduction improved OS (2-year OS 75.4% vs 20%, p = 0.04). Median DFS was 11.8 months. Median symptom-free duration was 36.8 months; patients with complete cytoreduction were more likely to remain asymptomatic (82.9% at 1 year, vs 60% in incomplete cytoreduction group, p

Inguinal omental fibromatosis is a rare disease entity that could mimic incarcerated inguinal hernia clinically. In the present study, we review the incidence of inguinal omental fibromatosis at our centre. From 1 January1996 to 30 June 2016, all hernia operations performed in all the affiliated hospitals of the University of Hong Kong were reviewed retrospectively; data were retrieved from patient records. A total of 7039 hernia operations were carried out during the period, in which 564 were incarcerated or strangulated hernia operations, and two were omental fibromatosis, accounting for an incidence of 0.028 per cent of groin explorations. In the present study, we report the second case at our centre. A 26-year-old man was admitted with a history of reducible right groin mass from birth. The mass had become irreducible for 2 months. The patient had no symptoms of bowel obstruction. On palpation, a firm mass was found in the right groin extending to the right scrotum, and could not be reduced completely. Bilateral testes in the scrotum were palpable. Computed tomography scan of pelvic cavity showed that there was a herniated omentum in the right scrotum. The omental mass was completely resected and free-tension repair was performed. The histopathological examination revealed that the tumour consisted of spindle-shaped cells that were consistent with fibromatosis. Inguinal omental fibromatosis is rare and could present as incarcerated hernia clinically. Fibromatosis could be part of a syndromal disease presentation, such as Gardner syndrome. Recurrence is higher than in sporadic cases, despite radical surgery.

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. 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. 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

Background Perfusion plays an important role in anastomotic healing. Indocyanine-green fluorescence angiogram allows objective bowel perfusion assessment. This study aimed to investigate the impact of perfusion assessment on intraoperative decision during left-sided colorectal resections. Method This was a prospective, single-centre, observational study recruiting patients with left-sided colorectal resections. Perfusion of bowel segment was assessed with ICG fluorescence angiogram prior to resection and anastomosis intra-operatively. The planned transection site and the actual transection site after perfusion assessment were compared. The decision for diversion stoma was also evaluated. Results 110 patients with cancer of the sigmoid colon (29.1%) and rectum (70.9%) were recruited. Total mesorectal excision was performed in 51.8% of patients. The transection site was revised in 34.5% of cases: 30.9% more proximally and 3.6% more distally. The median distance between the intended and actual transection sites was 2 cm (range 1–17 cm). A proximal revision in the transection site was more likely seen in rectal cancers (p = 0.036, OR 3.58, 95% CI 1.09–11.78) and relatively under-perfused left colon (p = 0.036, OR 1.01, 95% CI 1.01–1.02). Three (2.7%) patients were spared from a diversion stoma. The overall anastomotic leakage rate was 5.5%. Conclusion ICG fluorescence angiogram altered operative decisions in a significant proportion of cases. The impact on transection site was more pronounced in patients with rectal cancers and those with relatively under-perfused colon.

Over the past few decades, studies have focused on the safety of stapled anastomosis, especially when compared to that of the handsewn technique. However, studies on the improvement of stapling technology are limited. This study aimed to investigate whether linear triple-row staples (tri-staples) had any advantage over double-row staples. This is a retrospective review of all cases of functional end-to-end anastomoses with linear staplers performed at two centers between 2005 and 2015. Data were retrieved from a prospectively maintained database. Cases of anastomoses performed with double-row (DS) and triple-row (TS) staples were matched according to propensity scores. The rates of anastomotic leakage, bleeding, reoperation, and 30-day mortality were compared. Functional end-to-end ileocolic anastomoses were performed in 563 consecutive patients during the study period. Double- and triple-row stapling devices were used in 389 and 174 anastomoses, respectively. With propensity score matching, 170 cases were chosen from each group. Both groups showed comparable baseline characteristics. The anastomotic leakage, anastomotic bleeding, and intra-abdominal collection rates were 2.4 and 0% (p = 0.123), 1.2 and 0% (p = 0.499), and 3.5 and 1.2% (p = 0.283) for DS and TS, respectively. The reoperation and 30-day mortality rates were 5.9 and 1.8% (p = 0.048) and 0.6 and 1.2% (p = 1.000) for DS and TS, respectively. The median lengths of stay were 5 and 6 days (p = 0.072) for DS and TS, respectively. Anastomoses with triple-row staples tended to have a lower morbidity rate, but a significant advantage over double-row staples was not demonstrated in this study.

© 2016 by JSLS, Journal of the Society of Laparoendoscopic Surgeons. Background and Objectives: There has been great enthusiasm for the technique of transanal total mesorectal excision. Coupled with this procedure, we performed single-incision laparoscopic surgery for left colon mobilization. This is a description of our initial experience with the combined approach. Methods: Patients with distal or mid rectal cancer were included. The operation was performed by 2 teams: one team performed the single-incision mobilization of the left colon via the right lower quadrant ileostomy site, and the other team performed the total mesorectal excision with a transanal platform. Results: During the study period, 10 patients (5 men) with cancer of the rectum underwent the surgery. The mean age was 62.2 ± 11.1 years, and the mean body mass index was 23.4 ± 3.2 kg/m 2 . The tumorâ s mean distance from the anal verge was 5.1 ± 2.5 cm. The median operating time was 247.5 minutes (range, 188â 462 minutes). The mean estimated blood loss was 124 ± 126 mL (range, 10â 188 mL). Conversion to multiport laparoscopy was needed in one case (10%). Postoperative pain, as reflected by the pain score, was minimal. The mean number of lymph nodes harvested was 15.6 ± 3.8. All specimens had clear distal and circumferential radial margins. The overall complication rate was 10%. Conclusion: Our experience showed transanal total mesorectal excision with single-incision laparoscopy to be a feasible option for rectal cancer. Patients reported minimal postoperative pain. Further studies on the long-term outcome are warranted., Link_to_subscribed_fulltext

Ruptured abdominal aortic aneurysm (AAA) is an important cause of unheralded deaths in people older than 65 years. The survival of these patients depends on prompt diagnosis with immediate resuscitation and emergency surgery. Hypotension, pulsatile abdominal mass, and flank or back pain, constitute the classic triad for ruptured AAA. However, this triad may be incomplete in as many as 50% of patients. A high index of suspicion is required for prompt treatment of this intra-abdominal catastrophe. We report three cases of ruptured AAA who presented atypically to our hospital.

Background Although thyroidectomy for Graves' disease (GD) is well established, surgical indications remain less well defined. This study aimed to evaluate the changes in surgical indication, type of resection, and surgical outcomes at a single institution. Methods A total of 346 patients who underwent thyroidectomy for GD were divided into 2 time periods: period 1 (1995–2001) and period 2 (2002–2008). Their surgical indication, type of resection, and surgical outcomes were compared. Results Patients in the earlier period were significantly younger, suffered more previous relapses, and were on a longer duration of antithyroid drugs before surgery. Graves' ophthalmopathy and refusal for radioactive iodine were the indications that changed significantly between the 2 periods. Total/near-total thyroidectomy was performed more commonly and resulted in a higher temporary hypoparathyroidism rate in the latter period ( P Conclusions Over the study period, significant changes in surgical indication, type of resection, and surgical outcomes were noted. Graves' ophthalmopathy became one of the most common surgical indications. Total thyroidectomy became the preferred surgery but that resulted in a higher temporary hypoparathyroidism rate.

Emotions influence negotiations. While research exploring the link between discrete emotions and negotiated outcomes has been steadily growing, there is still ambiguity about how and why emotions h...

Research has suggested that people often use their momentary emotional states as a source of information when making judgments in intrapersonal and social domains (e.g., Pham, 2004; Schwarz & Clore...