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Background: Colorectal cancer is the third most common cancer worldwide. Micropapillary carcinoma (MPC) is increasingly identified as a poor prognostic marker in various cancers, including breast, bladder and lung. It remains an under recognized subtype in colorectal cancer. The aim of this study is to evaluate the prevalence, implications and impact on survival of MPC in colorectal cancer in an Australian cohort., Methods: A retrospective review of all colorectal cancer resections in two tertiary centres in Sydney Australia was performed, between 2019 and 2024. MPC was identified on histolopathology as per standard guidelines of the resected specimens. Variables collected included age, sex, TNM, site, lymphovascular invasion (LVI), and lymph node involvement., Results: Of 597 colorectal cancer resections during the study period, 21 cases of MPC were identified (3.5%). Mean age was 60 years (SD 15 years). Twenty patients (95%) had T3-T4 tumours, 19 (90%) had positive lymph node involvement, 18 (86%) had confirmed or suspected LVI, and 4 (19%) had distant metastatic disease. Overall 1-year survival was 90% and 3-year survival was 76%., Conclusion: MPC is associated with high risk features in colorectal adenocarcinoma. Accurate histopathological diagnosis of these more aggressive cancers should guide prognostication, individualized adjuvant treatment and close surveillance., (© 2024 Royal Australasian College of Surgeons.)

Background: Textbook outcome (TO) is a composite measure used in surgery to evaluate post operative outcomes. No review has synthesised the evidence in relation to TO regarding the elements surgeons are utilising to inform their TO composite measure and the rates of TO achieved., Methods: Our systematic review and meta analysis was conducted in line with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) recommendations. PubMed, EMBASE, and Cochrane central registry of controlled trials were searched up to 8th November 2023. Pooled proportions of TO, clinical factors considered and risk factors in relation to TO are reported., Results: Fifteen studies with 301,502 patients were included in our systematic review while fourteen studies comprising of 247,843 patients were included in our meta-analysis. Pooled rates of TO achieved were 55% with a 95% confidence interval (95% CI) of 54-55%. When stratified by elective versus mixed case load, rates were 56% (95% CI 49-62) and 54% (95% CI 50-58), respectively. Studies reported differing definitions of TO. Reported predictors of achieving TO include age, left sided surgery and elective nature., Conclusions: TO is achieved, on average in 55% of reported cases and it may predict short and long term post operative patient outcomes. This study did not detect a difference in rates between elective versus mixed case load TO proportions. There is no standardised definition in use of TO. Standardisation of the composite is likely required to enable meaning comparison using TO in the future and a Delphi consensus is warranted., (© 2024. The Author(s).)

Geriatric patients have difficulty to comply to their medication regimen due to complicated medication administration schedule, dysphagia, reduced ability to swallow tablets and dementia. This is particularly more challenging among the Alzheimer Disease's patients. Therefore, a model drug, memantine hydrochloride has been formulated into an orally disintegrating film (ODF) for easier consumption. However, bitter taste of memantine hydrochloride needs to be solved first if the drug is formulated into an ODF. The objective of this study is to taste mask memantine hydrochloride ODF and conduct a palatability study to evaluate the palatability of the dosage form. Memantine hydrochloride ODF was prepared using solvent casting method followed by freeze drying. The polymeric base consisted of Guar gum, PEG 400 and wheat starch in solvent water, with varying amounts of Aspartame or Acesulfame K for taste masking. The freeze-dried memantine hydrochloride ODFs were evaluated for tensile strength, in-vitro disintegration time, average thickness, dissolution, memantine hydrochloride content, and palatability. Formulation M7 was selected as the best taste masked formulation. Aspartame 30 mg is sufficient to cover the bitter taste of memantine hydrochloride in ODF form. A taste masked memantine hydrochloride ODF of dimensions 20 x 20 mm containing 30mg of aspartame was successfully developed. This formulation has average values for tensile strength 0.03 (0.01) kPa, folding endurance 351.92 (4.82) flips, thickness 0.94 (0.02) mm, and disintegration time 34.15 (2.16) seconds., (Copyright© by International Journal of Pharmaceutical Compounding, Inc.)

Background: Quetiapine fumarate (QTP) is commonly prescribed for schizophrenic patient, typically available in tablet or oral suspension form, presenting challenges such as administration difficulties, fear of choking and distaste for its bitter taste. Fast melt films (FMF) offer an alternative dosage form with a simple development process, ease of administration and rapid drug absorption and action onset., Objective: This study aims to prepare FMF with different formulations using solvent casting methods and to compare the effects of different drying methods, including oven drying and freeze drying, on the properties of the films., Methods: Various formulations were created by manipulating polymer types (starch, hydroxypropyl methylcellulose (HPMC) and guar gum) at different concentrations, along with fixed concentrations of QTP and other excipients. Characterization tests including surface morphology, weight, thickness, pH, tensile strength, elongation length, Young's modulus, folding endurance and disintegration time were conducted. The optimal FMF formulation was identified and further evaluated for moisture and drug content, dissolution behavior, accelerated stability, X-ray diffraction (XRD), and palatability., Results: FMF containing 10 mg guar gum/film developed using oven drying emerged as the optimum choice, exhibiting desirable film appearance, ultra-thin thickness (0.453 ± 0.002 mm), appropriate pH for oral intake (pH 5.0), optimal moisture content of 11.810%, rapid disintegration (52.67 ± 1.53 s), high flexibility (folding endurance > 300 times) and lower Young's modulus (1.308 ± 0.214)., Conclusion: Oven drying method has been proven to be favorable for developing FMF containing QTP, meeting all testing criteria and providing an alternative option for QTP prescription.

The key steps of performing a laparoscopic right hemicolectomy with transvaginal natural orifice specimen extraction surgery., (© 2024 Royal Australasian College of Surgeons.)

Background: Crohn's disease patients may require multiple surgeries during their lifetime. Because operative reports are not standardized, information relevant to future management may not be documented. Synoptic reports used in other fields such as histopathology have proven to be effective and allow consistent documentation of results. The aim of this study was to retrospectively review the completeness of the operative reports for ileocolic Crohn's resections (ICR) and to propose a synoptic report., Methods: A draft synoptic operative report for ICR for Crohn's disease was presented in the IBD multidisciplinary meeting and a Delphi process used to gain consensus for inclusion in the synoptic report. Retrospective analysis of consecutive ICR from January 2010 to April 2023 was undertaken to determine the presence of the standardized criteria., Results: A total of 66 ICR were performed in 63 patients during the study period. No operation reports were excluded. The examination of bowel for macroscopic disease was partially documented in 88% cases. The extent of mesenteric resection and any difficulty encountered during dissection were poorly documented. The remaining length of small and large intestines was not documented in most operative reports. The clinical sections that were compulsory entrance in the electronic operative report achieved 100% compliance., Conclusion: This study has demonstrated that key information was often deficient in the operative report. This may have a significant impact on the future management of Crohn's patients and affects the interpretation of research outcomes. A proposed clinical synoptic operative report is easy to use and ensures compliance., (© 2024 The Authors. ANZ Journal of Surgery published by John Wiley & Sons Australia, Ltd on behalf of Royal Australasian College of Surgeons.)

Background: The decision for resection of adrenal metastasis from colorectal cancers remain controversial and there is no proposed standard treatment. The aim of the article is to review the available literature on outcomes and complications rates following adrenalectomy for adrenal metastasis from colorectal cancer., Methods: Relevant papers were identified through electronic databases. Data was extracted independently by two authors on a Microsoft Excel spreadsheet up to June 2023., Results: A total of 55 studies were included in the final analysis (145 cases). A large proportion of patients had an uneventful postoperative recovery following surgical adrenalectomy. The mean length of follow up ranged from 2 months to 9.5 years. A total of 33 (22.8%) patients were alive and well with no evidence of local or systemic recurrence; 2 (1.4%) patients had recurrence in the bed of adrenalectomy; 2 (1.4%) patients were alive with recurrence in the contralateral adrenal gland; 4 (2.8%) patients were alive with extra-adrenal metastasis, and 7 (4.8%) patients were alive and well with no comments regarding local and systemic recurrence. Post-operative mortality following adrenalectomy was uncommon: 1 patient died due to systemic sepsis following anastomotic leak. 17.2% of patients died due to disease progression., Conclusion: If complete resection can be achieved, surgical adrenalectomy in the surgically fit patient should be strongly considered, especially in patients with solitary adrenal metastasis which may translate into survival benefits and potential surgical cure., (© 2024 The Authors. ANZ Journal of Surgery published by John Wiley & Sons Australia, Ltd on behalf of Royal Australasian College of Surgeons.)

Purpose: Incisional hernia (IH) post renal transplant (RT) is relatively uncommon and can be challenging to manage clinically due to the presence of the kidney graft and patient immunosuppression. This systematic review and meta-analysis synthesises the current literature in relation to IH rates, risk factors and outcomes post RT., Methods: PubMed, EMBASE, and Cochrane Central Registry of Controlled Trials (CENTRAL) were searched up to July 2023. The most up to date Preferred Reporting Items for Systematic Reviews and Meta Analyses guidelines were followed. Pertinent clinical information was synthesised. A meta-analysis of the pooled proportions of IH rates, the rates of patients requiring surgical repair and the rates of recurrence post RT are reported., Results: Twenty studies comprising 16,018 patients were included in this analysis. The pooled rate of IH occurrence post RT was 4% (CI 3-5%). The pooled rate of IH repair post RT was 61% (CI 14-100%). The pooled rate of IH recurrence after repair was 16% (CI 9-23%). Risk factors identified for IH development post RT are BMI, immunosuppression, age, smoking, incision type, reoperation, concurrent abdominal wall hernia, lymphocele formation and pulmonary disease., Conclusions: IH post RT is uncommon and the majority of IH post RT are repaired surgically on an elective basis., (© 2023. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Background/aim: This study reviews the literature to examine the proportion of patients requiring surgical management in ischemic colitis (IC) and identify surgical outcomes., Method: A systematic review of PubMed, EMBASE, and Cochrane Central Register of Controlled Trials was conducted in accordance with the latest Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. English language studies and adult patients were included. Studies with fewer than 10 patients, and IC post aortic or cardiac surgery was excluded. We present our systematic review and meta-analysis with pooled proportions of right sided IC distribution and prevalence of surgical treatment., Results: 23 studies with a total of 12,844 patients were included in the systematic review, with 19 studies and 12,420 patients included in the meta-analysis. Four studies were excluded from the meta-analysis due to only including specific cohorts of patients-two with cocaine induced colitis, one with phlebosclerotic colitis, and one with IC associated with acute myocardial infarction. The pooled proportion of right sided IC distribution was 15% (CI 14%-17%, p < 0.001), whilst the pooled proportion of surgical management of IC was 15% (CI 13%-16% p < 0.001)., Conclusion: Prevalence of surgical management of IC is rare. Right sided IC is associated with higher mortality and higher rates of surgical management. Reporting of surgical outcomes is scant., (© 2024 International Society of Surgery/Société Internationale de Chirurgie (ISS/SIC).)

Orally disintegrating tablets, which were originally developed in the pharmaceutical field to improve the compliance of patients who had difficulty swallowing tablets, have become a preferable choice in solid dosage forms since it brings advantages to the patients and consumers in the healthcare system. Among the advantages of this novel dosage form are a faster onset of action, improved bioavailability, and the ease of administration as it can be taken without water. However, there are still some limitations of orally disintegrating tablets that need to be overcome, including a lack of mechanical strength, an unpleasant taste of the drug in the mouth, and a stability issue due to its hygroscopicity nature. This objective of this study was to identify the composition of co-processed excipients comprising of mannitol, microcrystalline cellulose, xylitol, and crospovidone or croscarmellose sodium in order to formulate orally disintegrating tablets containing memantine hydrochloride. This study was carried out in two stages. Firstly, orally disintegrating tablets containing memantine hydrochloride with 6 different formulations, which differed in the percentage of crospovidone or croscarmellose sodium, were formulated and manufactured. Secondly, the orally disintegrating tablets obtained were evaluated through pre- and post-compression tests based on the standard for orally disintegrating tablets. Formulation 3, which consisted of 10% xylitol, 10% mannitol, 72% microcrystalline cellulose, and 8% crospovidone, was chosen as the optimum formulation for the co-processed excipient since it was the fastest disintegration process among all the formulations in the study. In addition, Formulation 3 also showed the acceptable and satisfying results in other evaluation tests such as - weight variation test, hardness test, and friability test. The co-processed excipient comprising of 10% xylitol, 10% mannitol, 72% microcrystalline cellulose, and 8% crospovidone, which is characterized by improved functionalities such as a fast disintegration process, plays a crucial role in the application of orally disintegrating tablets., (Copyright© by International Journal of Pharmaceutical Compounding, Inc.)

Whilst obesity and visceral adipose tissue (VAT) have been reported to be associated with an increased risk of severe AP, the established predictive scoring systems have not yet encompassed the impact of obesity or visceral adiposity. In the acute setting, computed tomography (CT) is often performed to assess AP severity and associated complications. With the added benefit of quantifying body fat distribution, it can be opportunistically used to quantify visceral adiposity and assess its relationship with the course of AP. This systematic review identified fifteen studies evaluating the relationship between visceral adiposity measured on CT and the severity of presentations of acute pancreatitis from January 2000 to November 2022. The primary outcome was to assess the relationship between CT quantified VAT and AP severity. The secondary outcomes were to assess the impact of VAT on patients developing local and systemic complications associated with AP. Whilst ten studies showed there was a significant correlation between an increased VAT and AP severity, five studies found otherwise. The majority of current literature demonstrate a positive correlation between increased VAT and AP severity. CT quantification VAT is a promising prognostic indicator with the potential to guide initial management, prompt more aggressive treatment measures or earlier re-evaluation and to aid disease prognostication in patients with acute pancreatitis., (© 2023. The Author(s) under exclusive licence to Japan Radiological Society.)

Purpose: Cytoreductive surgery (CRS) is often combined with hyperthermic intraperitoneal chemotherapy (HIPEC) for the treatment of peritoneal tumour deposits. Considering CRS, the evidence relating the large incisions, local chemotherapy and abdominal wall trauma to incisional hernias (IH) has not been synthesized. This systematic review and meta-analysis was conducted to examine the proportion of IH present in patients post CRS and the effect HIPEC had on these rates., Methods: PubMed, EMBASE, and Cochrane Central Registry of Trials were searched up to June 2023 to examine studies relating IH and CRS plus or minus HIPEC. The most up to date PRISMA guidelines were followed. Pertinent clinical information was synthesized in tabular form. A meta-analysis reporting the pooled proportions of IH post CRS plus or minus HIPEC, the odds of IH in HIPEC versus non-HIPEC CRS and the difference in follow-up time between groups was conducted., Results: Nine studies comprising 1416 patients were included. The pooled proportion of IH post CRS was 12% (95% confidence interval (CI) 8-16%) in HIPEC and 7% (95% CI 4-10%) in non-HIPEC patients and 11% (95% CI 7-14%) overall. Previously reported rates of IH in midline laparotomy range from 10 to 30%. The odds of IH in the HIPEC was 1.9 times higher compared to non-HIPEC cohorts however this was not statistically significant (odds ratio (OR) 1.9, 95% 0.7-5.2; p = 0.21). There was no significant difference in average follow-up times between HIPEC and non-HIPEC cohorts., Conclusions: IH post CRS plus or minus HIPEC were in the expected range for midline laparotomies. IH in patients receiving HIPEC may occur at a greater proportion than in non-HIPEC patients, however, there were too few studies in our meta-analysis to determine this with statistical significance., (© 2023. The Author(s).)

Background: Colorectal surgery in patients with liver cirrhosis poses a significant challenge due to the associated peri-operative morbidity and mortality risks. The aim of this systematic review was to evaluate the outcomes in this cohort of patients following colorectal surgery., Methods: The PubMed, Embase and Cochrane databases and references were searched up to October 2022 using the PRISMA guidelines. The data collated included: patient demographics, pathology or type of colorectal operation performed, severity of liver cirrhosis, post-operative complication rates, mortality rates and prognostic factors. A quality assessment of included studies was performed with the Newcastle-Ottawa scale., Results: Sixteen studies reporting the outcomes of colorectal surgery in patients with liver cirrhosis were identified, including the results of 8646 patients. The indications, pathologies and/or type of operations varied. The overall complication rate ranged from 29 to 75%, minor complication ranged 14.5-37% and major complication ranged 6.7-59.3%. The mortality rates ranged from 0 to 37%., Conclusion: Colorectal surgery in patients with liver cirrhosis still carries considerable morbidity and mortality rates. This group of patients needs to be managed in a multidisciplinary setting to achieve excellent outcomes. Future research should focus on uniform definitions to enable interpretable outcomes., (© 2023. The Author(s) under exclusive licence to Société Internationale de Chirurgie.)

Anal squamous cell carcinoma (ASCC) has a generally acceptable outlook in terms of survival. 18-fluorodeoxyglucose-positron emission tomography/computer tomography (FDG PET-CT) is not recommended for routine monitoring post-ASCC treatment. We examine herein if FDG PET-CT has a use in the prognostic evaluation of patients with ASCC, what FDG PET-CT metrics are of value and if a pre- or post-chemo/radiotherapy scan is more prognostic of outcomes. PubMed, EMBASE and Cochrane Central Registry of Controlled Trials were comprehensively searched until 3 May, 2023. A modified Newcastle Ottawa scale was used to assess for study bias. We present our systematic review alongside pooled hazard ratios (HR) for maximum standardised uptake values (SUV) as a predictor of overall survival (OS) and progression-free survival (PFS). Seven studies including 523 patients were included in our systematic review. Current evidence suggests that SUV maximum and median, metabolic tumour volume, total lesion glycolysis and complete and partial metabolic response may be prognostic when considering overall or progression-free survival (OS)/(PFS) along with local recurrence (LR). Pooled HR from two included studies indicate SUV max is prognostic of OS, HR 1.179, CI (1.039-1.338), P = 0.011 and PFS 1.176, CI (1.076-1.285), P < 0.01. FDG PET-CT may have a role to play in the prognostic evaluation of ASCC patients. Current evidence suggests post-treatment scanning may hold superior prognostic value at this time., (© 2023 Royal Australian and New Zealand College of Radiologists.)

Background: This systematic review and meta-analysis seeks to assess the modified protocols used and patient outcomes when enhanced recovery after surgery (ERAS) protocols are utilized in an emergency setting., Methods: PubMed, MEDLINE, EMBASE and Cochrane Central Registry of Controlled Trials were comprehensively searched until 13 March 2023. The Cochrane Risk of Bias Assessment Tool was used to assess for bias, along with funnel plot asymmetry. We present log risk ratios for dichotomous variables and raw mean differences for continuous variables., Results: Seven randomized trials were included, comprising 573 patients. Results of the primary outcomes when comparing ERAS to standard care are as follows; withdrawal of nasogastric tube (raw mean difference -1.87 CI: -2.386 to -1.359), time to first liquid diet (raw mean difference -2.56 CI: -3.435 to -1.669), time to first solid diet (raw mean difference -2.35 CI: -2.933 to -1.76), time to first flatus (raw mean difference -2.73 CI: -5.726 to 0.257), time to first stool passed (raw mean difference -1.83 CI: -2.307 to -1.349), time to removal of drains (raw mean difference -3.23 CI: -3.609 to -2.852), time to removal of urinary catheter (raw mean difference -1.57 CI: -3.472 to 0.334), mean pain score (raw mean difference -1.79 CI: -2.222 to -1.351) and length of hospital stay (raw mean difference -3.16 CI: -3.688 to -2.63)., Conclusions: The adoption of ERAS protocols in an emergency surgery setting was observed to enhance patient recovery, while not indicating any statistically significant increase in adverse outcomes., (© 2023 Royal Australasian College of Surgeons.)

Background: Majority of adhesive small bowel obstruction (SBO) cases can be managed non-operatively. However, a proportion of patients failed non-operative management., Aim: To evaluate the predictors of successful non-operative management in adhesive SBO., Methods: A retrospective study was performed for all consecutive cases of adhesive SBO from November 2015 to May 2018. Data collated included basic demographics, clinical presentation, biochemistry and imaging results and management outcomes. The imaging studies were independently analyzed by a radiologist who was blinded to the clinical outcomes. The patients were divided into group A operative (including those that failed initial non-operative management) and group B non-operative for analysis., Results: Of 252 patients were included in the final analysis; group A ( n = 90) (35.7%) and group B ( n = 162) (64.3%). There were no differences in the clinical features between both groups. Laboratory tests of inflammatory markers and lactate levels were similar in both groups. From the imaging findings, the presence of a definitive transition point [odds ratio (OR) = 2.67, 95% confidence interval (CI): 0.98-7.32, P = 0.048], presence of free fluid (OR = 2.11, 95%CI: 1.15-3.89, P = 0.015) and absence of small bowel faecal signs (OR = 1.70, 95%CI: 1.01-2.88, P = 0.047) were predictive of the need of surgical intervention. In patients that received water soluble contrast medium, the evidence of contrast in colon was 3.83 times predictive of successful non-operative management (95%CI: 1.79-8.21, P = 0.001)., Conclusion: The computed tomography findings can assist clinicians in deciding early surgical intervention in adhesive SBO cases that are unlikely to be successful with non-operative management to prevent associated morbidity and mortality., Competing Interests: Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article. Dr Zi Qin Ng received the General Surgeons Australia Junior Doctor Research Grant in 2018 for this study., (©The Author(s) 2023. Published by Baishideng Publishing Group Inc. All rights reserved.)

Purpose: 15-20% of patients present with near obstructing left-sided colorectal cancer. CT colonography (CTC) or PET-CT has been used to detect synchronous lesions, which may alter preoperative planning of colonic resection. We aim to synthesize the usefulness of CT colonography and/or PET-CT in detecting synchronous proximal colon carcinomas in patients who have undergone an incomplete colonoscopy due to a stenosing or obstructing distal colorectal cancer., Methodology: A systematic review was performed by searching the databases up to December 2021. Data collected included demographics of the study population, rate of detection of synchronous carcinomas and impact on management of detection of synchronous carcinomas., Results: A total of 22 studies were included: 17 studies focused on CTC, 3 on PET-CT, and 2 integrated PET-CT with CTC; 2855 patients were included; 53% of patients were male, and 47% were female. All studies reported detection of synchronous proximal colorectal carcinomas using CTC, PET-CT or CTC, and PET-CT combined. CTC detected synchronous carcinomas in 0.2-12.2% of patients. PET-CT was useful in detecting synchronous carcinomas in 4.05-23% of patients. Integrated PET-CT and CTC detected synchronous carcinomas in 2-15% of patients. The surgical plan was changed in 2.4-14.3% of patients after the use of CTC. One PET-CT study reported a change in management in 13.5%. No complication was reported by the use of CTC., Conclusion: CTC is an effective and useful adjunct to colonoscopy in assessing the proximal colon when colonoscopy fails to do so. However, more evidence is needed with the use of PET-CT for this patient population., (© 2023 Royal Australasian College of Surgeons.)

Objective: Risk factors of mortality in critically ill children with hemophagocytic lymphohistiocytosis (HLH) are not well described. This systematic review aims to determine overall mortality of critically ill children with HLH, and describes etiologies, treatment, and pediatric intensive care unit (PICU) support employed., Data Sources: PubMed, Embase, Web of Science, CINAHL, and Cochrane Library from inception until February 28, 2022., Study Selection: Observational studies and randomized controlled trials reporting children aged 18 years or below, diagnosed with HLH and admitted to the PICU., Data Extraction: Etiologies, treatment modalities, PICU therapies, and mortality outcomes were summarized. Random-effects meta-analysis was performed., Data Synthesis: Total 36 studies (total patients = 493, mean age: 49.5 months [95% confidence interval (CI): 30.9-79.5]) were included. Pooled mortality rate was 32.6% (95% CI: 23.4-42.4). The most frequent etiologies for HLH were infections (53.3%) and primary HLH (12.8%), while the remaining cases were due to other causes of secondary HLH, including autoimmune diseases, malignancy, and drug-induced and idiopathic HLH. Pooled mortality rate was higher in primary than secondary HLH (72.2%, 95% CI: 57.8-84.5 vs. 23.9%, 95% CI: 14.4-35.02; p < .01). Univariate analysis found that treatment with etoposide was associated with higher mortality, while intravenous immunoglobulins (IVIGs) were associated with lower mortality. Conversely, multivariable analysis adjusted for etiology demonstrated no association between etoposide and IVIG use, and mortality. Twenty-one studies (total patients = 278) had detailed information on PICU therapies. Mechanical ventilation (MV), continuous renal replacement therapy, and inotropes were used in 107 (38.5%), 66 (23.7%), and 51 patients (18.3%), respectively. Need for MV was associated with increased risk of mortality (mean difference = 28%, 95% CI: 9-47)., Conclusion: Critically ill children with HLH have high mortality rates and require substantial PICU support. Collaborative work between multiple centers with standardized data collection can potentially provide more robust data., (© 2022 Wiley Periodicals LLC.)

Competing Interests: Competing interests: None declared.

Objective: Prophylactic knee braces (PKBs) are widely used by athletes in pivoting and landing sports and have the potential to influence knee movement and alignment, thus modulating anterior cruciate ligament (ACL) injury risk. This systematic review analyses current evidence on the biomechanical effects that PKBs have in the prevention of ACL injuries., Data Sources: The review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Searches were conducted on PubMed, Web of Science, Scopus, Ovid MEDLINE, EMBASE, Cochrane, and CINAHL for studies published from inception until May 31, 2021. Included studies assessed the effects of PKBs on biomechanical variables associated with ACL injuries in landing or pivoting tasks, comparing between braced and unbraced conditions., Main Results: A total of 234 articles were identified; from which, 14 controlled, laboratory, biomechanical studies were included in this review. The effects of PKBs on knee biomechanics could be divided into kinematic variables in the coronal, sagittal, and transverse planes; and common kinetic variables, such as ground reaction force (GRF) and ACL load/strain. Also, PKBs were found to have protective effects in coronal and transverse plane kinematics, but results in the sagittal plane were inconclusive. Assessing knee kinetics, PKBs were advantageous in decreasing ACL load/strain but had no significant effect on GRF., Conclusions: Prophylactic knee braces may serve to reduce ACL injury risk by modulating knee coronal and transverse plane movements and ACL load/strain during high-risk maneuvres. Precise recommendations are limited by study heterogeneity. More prospective studies are needed to assess ACL injury risk during high-risk sports using specific PKBs., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Despite the negative effect of sarcopenia on postoperative outcomes being well recognized in the elective setting, there remains a paucity of studies describing this phenomenon in the emergency laparotomy (EL) setting. This systematic review and meta-analysis aimed to compare short- and long-term postoperative outcomes following EL in patients with and without sarcopenia., Methods: A systematic review using PRISMA guidelines was used to identify studies comparing perioperative outcomes following EL for patients with and without sarcopenia. A subsequent meta-analysis was conducted. The following data were extracted from the included studies: patient demographics, pathology or type of operation performed for EL, post-operative mortality at inpatient, 30-day, 90-day and 1-year, and functional outcomes. A quality assessment of included studies was undertaken., Results: Twelve studies reporting the outcomes of sarcopenia following EL were identified. Sarcopenia was significantly associated with higher 30-day and 1-year mortality rates following EL (OR 3.50, P < 0.01; OR 3.49, P < 0.01, respectively). Additionally, sarcopenia was significantly associated with unfavourable functional outcomes at discharge following emergency laparotomy (OR 2.44, p < 0.01)., Conclusion: Opportunistically identified on cross-sectional imaging, sarcopenia is a valuable predictor of short- and long-term morbidity and mortality following EL. Further studies are required to identify the most appropriate diagnostic criteria of sarcopenia and better define this physiological phenomenon., (© 2022 Royal Australasian College of Surgeons.)

Background/objective: During multiple organ procurement, blood vessels are routinely retrieved and stored in University of Wisconsin solution and then discarded after two weeks, if not used at organ transplantation owing to lack of a method for long-term preservation. Therefore, the aim of this study is to investigate a method for long-term preservation of vascular allografts in ethanol., Methods: Aorta and vena cava allografts were retrieved and stored in 75% ethanol solution for 12 months at 4°C. Four pigs were divided into two groups. A segment of aorta was excised and replaced by insertion of preserved aorta graft (Group A) or vena cava graft (Group V). The pigs were observed for six weeks. A laparotomy was performed and the vascular graft was harvested for histopathology followed by euthanasia at the end of study., Results: Three pigs recovered uneventfully, while one pig died from venous graft rupture in the third week after surgery. There was no aneurysmal formation or thrombosis in the grafts. Some calcification was seen over aorta allograft. On histopathology, the elastic pattern was almost normal, although the endothelial cells degenerated after preservation. After implantation, the formation of the endothelium cell-like layer was seen in both aorta and vena cava allografts., Conclusion: Vascular allografts were functional after preservation for 12 months. The vena cava grafts had much less wall calcification than the aorta grafts. Further studies are necessary to investigate vascular graft remodelling with a longer observation period after implantation.

Background: Emergency laparotomies (EL) are associated with significant morbidity and mortality. To date, 30-day mortality has been predominately reported, and been the focus of various national emergency laparotomy audits. Only a few studies have reported on the long-term mortality associated with EL. The aim of this study was to review the one-year mortality following EL., Method: A systematic review was conducted using PRISMA guidelines to identify studies published in the last 10 years reporting on long-term mortality associated with EL. The data abstracted included: patient demographics, pathology or type of operation performed for EL, post-operative mortality at 7-day, 30-day, 90-day, 1-year, beyond 1-year and inpatient, functional outcomes and risk factors associated with mortality. A quality assessment of included studies was performed., Results: Fifteen studies reporting long-term outcomes associated with EL were identified, including the results of 48,023 patients. The indications and/or pathologies for ELs varied. The 30-day mortality after EL ranged from 5.3% to 21.8%, and the one-year mortality ranged from 15.1 to 47%. The mortality in the six studies focusing on elderly patients ranged from 30 to 47%., Conclusion: The long-term mortality rate associated with EL is substantial. Further study is required to understand the 1-year mortality described in the studies and translate these findings for meaningful application into the clinical care of these patients., (© 2021. The Author(s) under exclusive licence to Société Internationale de Chirurgie.)

A 50-year-old woman was diagnosed with anal squamous cell carcinoma following a colonoscopy performed for positive test from the National Bowel Screening Programme. During the staging imaging, it was discovered to have a liver lesion that was atypical for metastasis. She underwent a segmental liver resection, and histopathology showed the liver lesion as a metastatic squamous cell carcinoma. We aim to discuss the incidence, presentation and management strategies for this rare hepatic metastasis of anal squamous cell carcinoma., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

The aim of this study was to systematically review the feasibility and safety of non-operative management of small bowel obstruction (SBO) in virgin abdomen. A systematic review was performed through December 2019. The primary outcome was the resolution of non-operative management of SBO in virgin abdomen. Secondary outcomes were the etiology of SBO and findings of exploratory laparotomy. Six studies were included in the analysis. Of the 442 patients, 2 with metastatic cancer received palliative care, and the management in 26 was not reported, so these patients were excluded. A total of 414 patients were ultimately analyzed, including 203 patients (49%) who were managed non-operatively and 211 (51%) who underwent surgical management. Of the 203 managed non-operatively, the condition of 194 (96%) was resolved without further intervention. The remaining 9 (5%) patients failed non-operative management and ultimately required surgery. Of the 211 patients who underwent surgical exploration, only 137 had their intraoperative findings reported. Adhesions (n = 67; 49%) were the main cause, followed by malignancy (n = 14; 10%) and others (n = 33; 24%). No cause was found in 23 patients (17%). In highly select cases of SBO with virgin abdomen, non-operative management can be attempted if patients are clinically stable and computed tomography does not demonstrate concerning features or obvious pathology. Further well-designed prospective studies will be required prior to the introduction of this concept in clinical practice, as current evidence remains heterogeneous., (© 2021. Springer Nature Singapore Pte Ltd.)

Competing Interests: Competing interests: None declared.

Competing Interests: Competing interests: None declared.

Background: Chylous ascites is a rare complication in colorectal surgery with limited evidence., Aim: To systematically review all available evidence to describe the incidence, clinical presentation, risk factors and management strategies., Methods: The systematic review was performed through PubMed, MEDLINE, EMBASE and Cochrane and cross-checked up to November 2020. The data collated included: Demographics, indications (benign vs malignant), site of disease, surgical approach, extent of lymphadenectomy, day to and method of diagnosis of chylous ascites and management strategies., Results: A total of 28 studies were included in the final analysis (426 cases). Patient age ranged from 31 to 89 years. All except one case were performed for malignancy. Of the 426 cases, 195 were right-colonic, 121 left-colonic, 103 pelvic surgeries and 7 others. The majority were diagnosed during the same inpatient stay by recognition of typical drain appearance and increased volume. Three cases were diagnosed during outpatient visits with increased abdominal distention and subsequently underwent paracentesis. Most cases were managed successfully non-operatively (fasting with prolonged drainage, total parenteral nutrition, somatostatin analogues or a combination of these). Only three cases required surgical intervention after failing conservative management and subsequently resolved completely. Risk factors identified include: Right-colonic surgery/ tumour location, extent of lymphadenectomy and number of lymph nodes harvested., Conclusion: Chylous ascites after colorectal surgery is a relatively rare complication. Whilst the majority of cases resolved without surgical intervention, preventative measures should be undertaken such as meticulous dissection and clipping of lymphatics during lymphadenectomy to prevent morbidity., Competing Interests: Conflict-of-interest statement: The authors have no conflict of interest or financial ties to disclose., (©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.)

Background: Post-colonoscopy diverticulitis is increasingly recognized as a potential complication. However, the evidence is sparse in the literature., Aim: To systematically review all available evidence to describe the incidence, clinical course with management and propose a definition., Methods: The databases PubMed, EMBASE and Cochrane databases were searched using with the keywords up to June 2020. Additional manual search was performed and cross-checked for additional references. Data collected included demographics, reason for colonoscopy, time to diagnosis, method of diagnosis (clinical vs imaging) and management outcomes., Results: A total of nine studies were included in the final systematic review with a total of 339 cases. The time to diagnosis post-colonoscopy ranged from 2 h to 30 d. Clinical presentation for these patients were non-specific including abdominal pain, nausea/vomiting, per rectal bleeding and chills/fever. Majority of the cases were diagnosed based on computed tomography scan. The management for these patients were similar to the usual patients presenting with diverticulitis where most resolve with non-operative intervention ( i.e. , antibiotics and bowel rest)., Conclusion: The entity of post-colonoscopy diverticulitis remains contentious where there is a wide duration post-procedure included. Regardless of whether this is a true complication post-colonoscopy or a de novo event, early diagnosis is vital to guide appropriate treatment. Further prospective studies especially registries should include this as a complication to try to capture the true incidence., Competing Interests: Conflict-of-interest statement: The authors declare no conflict of interest., (©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.)

Introduction The Flixene™ vascular graft (Maquet-Atrium Medical, Hudson, NH) has emerged as a new generation synthetic graft, which allows for early needling for haemodialysis. Most studies have shown satisfactory early results. The aim of this study is to report on long-term outcomes of the Flixene graft over eight years in a cohort of patients. Methods From February 2011 to September 2019, 61 patients had 64 arteriovenous graft fistulas (AVGs) by using the Flixene grafts. The median patient age was 67 years; the male to female ratio was 30:31. Diabetes was the reason for the majority of kidney failures (57%). The configuration of the grafts used was mostly upper arm straight AVG. The primary patency rate, secondary patency rate, and surgical complications were assessed. Results In a median follow-up of three years (interquartile range (IQR): 2 - 6), 36 of the AVGs required a fistulogram. Venous side stenosis was the most common cause of high venous pressure or AVG occlusion in 97%. The one-year primary patency rate was 30%. The secondary patency rate was 94.8%, 83.7%, and 77.7% at one, three, and five years, respectively. The longest functional AVG was observed for up to seven years. Conclusions This study has shown satisfactory long-term results of the Flixene graft used for hemodialysis. The Flixene graft could be needled within 72 hours without increased complications, which allows the creation of an AVG under an emergency setting to avoid the placement of a central venous catheter (CVC). This strategy should be advocated in future clinical practice., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2021, He et al.)

Background: Diverticular disease has been linked to obesity. Recent studies have assessed the role of visceral adiposity with diverticulitis and its complications. The aim of this study was to evaluate the association of quantitative radiological measures of visceral adiposity in patients with diverticulitis with vital signs, biochemistry results, uncomplicated versus complicated diverticulitis and its interventions., Methods: A retrospective analysis of all patients with diverticulitis admitted from November 2015 to April 2018 at a single institution was performed. Data collected included demographics, vital signs, biochemistry results, CT scan findings and management outcomes. The patients were divided into uncomplicated (U) and complicated diverticulitis (C) groups. Visceral fat area (VFA), subcutaneous fat area (SFA) and VFA/SFA ratio (V/S) were measured at L4/L5 level by the radiologist. Statistical analysis was performed to evaluate the association of VFA, SFA, V/S with the parameters in both U and C groups., Results: 352 patients were included in this study (U:C = 265:87). There was no significant difference in vital signs and biochemistry results in both groups. There was no significant difference in VFA, SFA, V/S ratios in both groups. In patients with V/S ratio > 0.4, they were 5.06 times more likely to undergo emergency intervention (95% CI 1.10-23.45) (p = 0.03). On multivariate analysis, a heart rate > 100 (OR 2.9, 95% CI 1.2-6.7), CRP > 50 (OR 3.4, 95% CI 1.9-6.0), WCC < 4 or > 12 (OR 2.1, 95% CI 1.2-3.6) and V/S ratio > 0.4 (OR 2.8, 95% CI 1.5-5.4) were predictive of complicated diverticulitis., Conclusion: The quantitative radiological measurement of visceral adiposity is useful in prognostication in patients presenting with diverticulitis.

Objectives: A ureteric stent is routinely placed to minimize urological complications during kidney transplant. However, some complications may occur in association with the ureteric stent, such as urinary tract infections, and the optimal duration for stent placement is unclear. We reviewed the outcomes following early simultaneous removal of the ureteric stent with the urethral catheter in pediatric kidney transplant recipients., Materials and Methods: We reviewed all kidney transplants from January 2009 to January 2019. The data we collated included demographics, donor and recipient characteristics, and perioperative details, including urological complications, stent-related complications, and kidney graft function. The financial cost of late stent removal was calculated. The early stent removal group was defined as 5 days, and the late removal group was about 4 to 6 weeks. The median follow-up time was 60 months (interquartile range, 31.5-91 months)., Results: There were 32 transplants in 31 patients during the study period (early vs late group = 23:9). No urine leak occurred in either group. One patient in the early group developed distal ureteric stenosis, and this condition was managed with interventional balloon dilatation. The median time for stent removal was 6 days in the early group and 39 days in the late group. There were 5 episodes of symptomatic urinary tract infections in 3 patients in the early group and 10 episodes of symptomatic urinary tract infections in 3 patients in the late group. The mean estimated glomerular filtration rate at 12 months was comparable between the 2 groups (84 ± 54 vs 64 ± 21 L/min/1.73 m²; P = .3). The average cost for each early removal was A$772.65 compared with the late group., Conclusions: Early simultaneous removal of the ureteric stent with the urethral catheter in pediatric kidney transplant recipients is feasible, safe, and cost-effective.

Background and Aim: Appendicitis after colonoscopy is an exceedingly rare complication. It remains to be explored if this entity is truly a complication of colonoscopy or a coincidental occurrence of appendicitis post-colonoscopy. The aim of this study was to systematically review all the available evidence since it was first described in 1988., Methods: The literature on post-colonoscopy appendicitis was searched using PubMed, EMBASE, and Cochrane databases. Additional manual search was performed and cross-checked for additional references. The search was performed up to November 2019. Data collected included demographics, reason for colonoscopy, time to diagnosis, imaging performed, management, and outcome., Results: Fifty-three cases were found in the systematic review with a median age of 55 years (24-84 years). The time to diagnosis post-colonoscopy was mostly within 24-48 h. Clinical features mimicked those of common acute appendicitis. In the past decade, computed tomography scan has been the imaging choice to investigate abdominal pain after colonoscopy, mainly to rule out perforation. The mainstay of management was appendectomy (open or laparoscopy). Four of the 12 cases (33.3%) were treated successfully with antibiotics alone. There has been a twofold increase in cases reported in the past decade (2009-2019, n = 31 vs 1999-2008, n = 15)., Conclusion: There is a considerable variation in the definition of post-colonoscopy appendicitis in the current literature. Regardless of whether post-colonoscopy appendicitis is a true entity, it should be considered as a differential diagnosis in any patient presenting with acute abdomen following colonoscopy., (© 2020 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Background: Recent evidence suggested that radiological measures of visceral adiposity are a better tool for risk assessment of colorectal adenomas. The aim of this study was to investigate the association of visceral adiposity with the development of colorectal adenomas., Methods: A retrospective review of all cases of computed tomography-confirmed acute diverticulitis from November 2015 to April 2018 was performed. Data collated included basic demographics, computed tomography scan results (uncomplicated versus complicated diverticulitis), treatment modality (conservative versus intervention), outcomes and follow-up colonoscopy results within 12 months of presentation. The patients were divided into no adenoma (A) and adenoma (B) groups. Visceral fat area (VFA), subcutaneous fat area (SFA) and VFA/SFA ratio (V/S) were measured at L4/L5 level. Statistical analysis was performed to evaluation the association of VFA, SFA, V/S and different thresholds with the risk of adenoma formation., Results: A total of 169 patients were included in this study (A:B = 123:46). The mean ± standard deviation for VFA was higher in group B (201 ± 87 cm 2 versus 176 ± 79 cm 2 ) with a trend towards statistical significance (P = 0.08). There was no difference in SFA and V/S in both groups. When the VFA >200 cm 2 was analysed, it was associated with a threefold risk of adenoma formation (odds ratio 2.7, 95% confidence interval 1.35-5.50, P = 0.006). Subgroup analysis of gender with VFA, SFA and V/S found that males have a significantly higher VFA in group B (220.0 ± 95.2 cm 2 versus 187.3 ± 69.2 cm 2 ; P = 0.05)., Conclusions: The radiological measurement of visceral adiposity is a useful tool for opportunistic assessment of risk of colorectal adenoma., (© 2020 Royal Australasian College of Surgeons.)

The aim of this study is to report long-term outcomes of kidney transplantation by using the kidney graft after a small tumour ex vivo excision. A structured programme was established to use the restored kidney graft from urological referral after radical nephrectomy. The criteria were defined as tumour size ≤3 cm, margin clear on frozen section and recipients aged ≥60 years or those on the urgent list for transplantation as a result of imminent lack of dialysis access. The recipients were followed up regularly for surveillance of tumour recurrence. Between February 2007 and February 2018, 28 recipients had kidney transplantation by using the restored kidney grafts. The tumour size was 2.6 ± 0.7 cm. The follow-up was median 7 years without evidence of tumour recurrence. The patient and graft survival was satisfactory. Kidney transplantation by using restored kidneys after a small tumour excision is a novel source for selected recipients. The long-term patient and graft survival is satisfactory. Although there is a risk of tumour recurrence, it is rare event. Together with literature review, we would support use of kidney graft after a small tumour excision for selected recipients., (© 2020 Steunstichting ESOT. Published by John Wiley & Sons Ltd.)

Background: Recent evidence supports the safety of early reversal of a temporary stoma, within 14 days of construction. The aim of this systematic review and meta-analysis was to evaluate the post-operative morbidity and overall feasibility of early stoma reversal., Methods: Medline and Cochrane databases were searched for studies up to June 2019 that investigated the outcomes of early stoma reversal (EC, defined as closure ≤14 days from the index operation) versus late stoma reversal (LC, ≥8 weeks from the index operation). Meta-analysis was performed on the respective rates of post-operative morbidity, anastomotic leak, wound infection, bleeding, sepsis, small bowel obstruction and ileus., Results: Nine studies were included (667 patients analysed). Meta-analysis showed no significant difference in the post-operative morbidity rate, anastomotic leak rate, rates of small bowel obstruction, bleeding and ileus between EC and LC. However, the wound infection rate was significantly higher after EC than LC; relative difference 0.10 (95% confidence interval 0.00-0.19, P = 0.047). The stoma-related complication rate was significantly higher after LC than EC; relative difference -0.28 (95% confidence interval -0.45 to -0.11, P = 0.001)., Conclusion: The concept of early stoma reversal is appealing, and this meta-analysis confirms the safety of early stoma closure with an associated reduction in stoma-related complications despite higher wound infection rates. However, the results need to be interpreted with caution due to the heterogeneity of the studies included, especially in respect of the definition of complications that were used. Further well-designed prospective studies are required prior to confident adoption of early stoma closure into clinical practice., (© 2020 Royal Australasian College of Surgeons.)