Post-operative Complications of Complicated Paediatric Appendicitis in a Tertiary Teaching Hospital

Background: Acute appendicitis is a common surgical problem, with complicated appendicitis having significant post operative complications, which contribute significantly to cost of medical care. Methodology: A hospital based retrospective study was conducted in department of paediatric surgery, Thiruvananthapuram. Study population consisted of children treated with complicated appendicitis from January 2016 to June 2021. Results: The study had 30.4% surgical site soft tissue infection (SSI). There was 13.48% incidence of major complication, with laparoscopic and open appendicectomies having similar incidence even though not statistically significant. SSI was more common with appendicular abscess and post ileal appendix. Post operative intra-abdominal abscess is more common with open appendicectomy, generalised peritonitis, post ileal appendix and base/proximal perforation of appendix. Post operative adhesive intestinal obstruction was more common with laparoscopic appendicectomy, appendicular abscess and base/proximal perforation of appendix. Total hospital stay correlates significantly with duration of symptoms on presentation with mean hospital stay of 7.72 days. Conclusion: Complicated appendicitis have high incidence of post operative complications, 30.4% SSI and 13.48% serious complications like intra-abdominal collection and adhesive intestinal obstruction. Keywords: Appendicitis, Complication, Surgical site infection, Children.

RESULTS OF SURGICAL TREATMENT OF FIRE WOUNDS OF COLON

The aim of the study. Evaluate the results of surgical treatment of wounded with gunshot wounds of the colon. Materials and methods of research. A retrospective analysis of the results of surgical treatment of 32 wounded with gunshot wounds of the colon, who were treated in the Central Medical Center and area of responsibility (II–IV level of medical care) from 2014 to 2017. Damage to the right half of the colon was observed in 12 wounded (37.4 %), the left half — in 17 (53.2 %), the rectum — in 3 (9.4 %). A differentiated approach to surgical treatment of colon injuries of different localization is applied. Results and discussion. The method of multi-stage surgical treatment “Damage Control Surgery” was used in 12.5 % of patients. The most common complications of the injury were adhesive intestinal obstruction in 6.3 % of cases, the formation of intestinal abscesses — in 6.3 %, the development of post-traumatic pneumonia in 25 % of patients. Conclusions. If the tactics of “Damage Control Surgery” are followed, it is possible to improve the results of surgical treatment of colon injuries in severe and extremely severe patients.

Clinical cases of late adhesive intestinal obstruction after liver and kidney transplantation in children and surgical methods of their treatment

Abdominal adhesions are one of the most common complications in abdominal surgery. In 56-70 % it is the cause of small bowel obstruction, which often requires repeated surgery. To date, a few cases of late adhesive intestinal obstruction (LAIO) as a complication of organ transplantation in children have been described. The purpose of the study was to investigate clinical cases of LAIO in a 9-year-old child after liver transplantation, and in an 8-year-old child after kidney transplantation. Materials and methods. Clinical case I. A 62-day-old girl was treated with Kasai procedure before a liver transplantation, according to type III atresia of the biliary tract. Orthotopic liver transplantation of the left-lateral section from living related donor was performed at the age of 9 months. The surgeries were accompanied by damage to the mesothelium and trauma of the serous membrane, which led to the formation of intraabdominal adhesions. With the growth of the child there was a growth of abdominal organs and adhesions stretching. LAIO was diagnosed 8 years after first surgery. Clinical case II. The boy was diagnosed with hypoplastic dysplasia of the right kidney, left-side ureterohydronephrosis, resulting in chronic end-stage renal disease. Peritoneal dialysis was performed at the age of 6 years. The effect of dialysate on the mesothelium led to the formation of small intestine pseudo-diverticula. At the age of 7 years a bilateral nephrectomy and kidney transplantation from a deceased donor were performed. At the age of 8 LAIO was diagnosed. In both cases, children underwent adhesiolysis. The peritoneum was sutured from the lower and upper edges of the wound to the middle, so that a hole remained in the middle of the wound. A Nelaton catheter was inserted through the hole and 250 ml of sodium hyaluronate solution "Defensal" was injected into the left-lateral part, small pelvis and right lateral abdominal cavity. Then anterior abdominal wall was sutured. Results. The successful surgical treatment of LAIO in children using local adhesiolysis in combination with sodium hyaluronate was performed. The careful handling of vascular anastomoses and changes in organ topography were required during surgery. The purpose of the surgery on LAIO was not only to restore the chyme transport in the gastrointestinal tract, but also to release the small intestine from the adhesions with the normal anatomy and function preservation. The observation of children for 5 years indicate the effectiveness of intraabdominal application of sodium hyaluronate solution.

Modern methods for adhesive bowel obstruction diagnosis

Topicality. Adhesive intestinal obstruction is a common disease in abdominal surgery with a significant increase from year to year. During the last 20 years, the frequency of cases of adhesive intestinal obstruction (SCN) has increased by 2 times and has no tendency to decrease. In the UK, small bowel obstruction was an indication for 51% of all emergency laparotomies. Scott et al. reported seven emergency surgeries, accounting for 80% of all hospital admissions, morbidity, mortality, and health care costs in relation to general surgery in the United States. These seven operations included partial colectomy, small bowel resection, cholecystectomy, peptic ulcer surgery, adgeolysis, appendectomy, and laparotomy. Adhesive intestinal obstruction of the small intestine was the most frequent diagnosis in the behavior of four out of seven surgical interventions (partial colectomy, resection of the small intestine, adgeolysis and laparotomy). Postoperative adhesive processes are the main cause of small intestine obstruction, accounting for 60% of cases. Among all cases of intestinal obstruction, acute small intestine is 64.3–80%, while having a severe course and a worse prognosis. This causes a high mortality rate in this pathology. It ranges from 5.1% to 8.4%, occupying a leading place among all urgent diseases.The purpose of the study was to evaluate various modern methods of diagnosing adhesive intestinal obstruction.Material and methods. In this study, the method of classical analysis of domestic and foreign literature was applied, based on current data on the diagnosis of adhesive intestinal obstruction.Results. Historically, there has been a certain algorithm for examining patients arriving with suspected adhesive intestinal obstruction, which includes: complaints, anamnesis of the disease and life, objective status, as well as additional diagnostic methods. Patients with OCD usually present a wide range of complaints, such as nausea, vomiting and periodic abdominal pain. Nausea and vomiting follow the appearance of pain and are an early sign of proximal adhesive OCN. However, clinical symptoms are only partially able to diagnose adhesive intestinal obstruction. Laboratory data are of little significance in the diagnosis of intestinal obstruction, but they help to determine the presence and severity of metabolic disorders, homeostasis disorders, as well as to indicate possible starngulation. For the diagnosis of OCN, OBP survey radiography is routinely used. Computed tomography (CT) has a higher sensitivity and specificity compared to abdominal X-ray examination and is recommended by the Bologna Guidelines. Ultrasound examination (ultrasound) is increasingly used in the diagnosis of OCD. Ultrasound is a relatively simple inexpensive non-invasive imaging method that is devoid of radiation exposure, but depends on the operator's experience. To minimize the effects of ionizing radiation in children and pregnant women, magnetic resonance imaging is an effective alternative to computed tomography for intestinal obstruction.Conclusion. The problem of adhesive intestinal obstruction remains highly relevant, given the prevalence of the disease and high mortality rates. Currently, new promising methods for diagnosing this disease, including biomarkers and high-tech methods for visualizing the pathological process, such as computed tomography and magnetic resonance imaging, are acquiring high importance. At the same time, one should not forget about the routine research methods – X-ray of the abdominal cavity and classical methods of examining the patient – collecting complaints, anamnesis and determining the objective status.

A COMPARATIVE STUDY BETWEEN EARLY EXPLORATIONS VERSUS CONSERVATIVE MANAGEMENT IN MANAGEMENT OF APPENDICULAR LUMP

Background: Acute Appendicitis is one of the most common acute surgical conditions of the abdomen and appendicular lump is formed if treatment is delayed. Appendicular mass is one of its early complications developing in 2-6% cases within48 hours of attack. The traditional treatment of appendicular lump is conservative followed by delayed appendectomy. During conservative treatment 10-20% is not resolved and leads to gangrene or perforation followed by localized abscess or generalized peritonitis requiring early surgical intervention. Aim and Objective: To evaluate the outcome of early surgical exploration and its complications in respect to conservative management of appendicular lump. Material and Methods: Total of 48 patients admitted with diagnosis of appendicular lump were included in our study. This prospective study was conducted in Department of General Surgery of Index Medical College, Hospital and Research Centre, Indore, M.P over period of 2 years [August 2019 to July 2021] in all age group and both sexes. All cases were divided randomly into two groups. Group I, early surgical exploration and Group II, conservative approach with OCHSNER SHERREN REGIME followed by interval appendectomy after 6 weeks. Results: Total 471 patients admitted to hospital with diagnosis of acute appendicitis, out of which total 48 patients were having Appendicular lump suggestive of incidence of 9.81%. Maximum patients were found in age group 21-30 years. Average duration of symptoms was 2 days. Two methods were adopted for the management of appendicular lump. The first group included 24 patients who were operated immediately after investigations and second group of 24 patients were managed conservatively followed by delayed appendectomy. In the first group mean hospitalization time was 4 days. Residual abscess, adhesive intestinal obstruction, failure of treatment and readmission were not found. In the group II, mean hospitalization time 10 days, more chances of residual abscess, adhesive intestinal obstruction, failure of treatment and readmissions were noted. Conclusion: In our study, it can be concluded that early surgical exploration confirms diagnosis and cures the problem, reduce the cost of management, shortens the convalescence and hospital stay with reasonably satisfactory outcome. Key-Words: Appendicular Lump, Ochsner-Sherren Regime Appendectomy.

PREDICTING THE RISK OF DEVELOPING ABDOMINAL ADHESIONS IN CHILDREN DEPENDING ON ACETYLATION GENOTYPE

Objective. To determine the predictive value of the genetic polymorphism of the N-arylacetyltransferase-2 (NAT-2) gene for assessing the risk of postoperative adhesive intestinal obstruction in children. Methods. In all children (36 children with adhesive intestinal obstruction (main group) and 35 planned patients (comparative group)) the acetylation genotype was studied by detecting point mutations of the NAT-2 gene using allele-specific amplification method with analysis of apolymerase chain reaction-restrictionfragmentlengthpolymorphism. Results. The study of the frequency of mutations at position 481 revealed the greatest diversity of the studied variants of genotypes: 33.3% of the children of the main group were homozygous for the wild-type gene, 44.4% were heterozygotes, 22.2% of patients had a homozygous mutant gene. According to the NAT-2 * 6A genotype (G 590 - A), the majority of patients (55.6%) were heterozygotes, 44.4% were homozygotes with the wild-type of the gene. Not a single case of mutation at position 857 has been identified. Among the children of the main group, the share of «fast» acetylators was 69.4%, in the comparison group - 40.0% (χ²=6.215; p=0.013). The development of postoperative adhesive intestinal obstruction in children with the “fast” acetylation genotype occurred in the absence of clinical and anamnestic risk factors and was characterized by a greater severity and prevalence of intra-abdominal adhesive process (PAI was (14.8±1.8) and (8.1±2.4 ), respectively). Conclusion. The risk of developing postoperative adhesive complications in children can be done preventively by determining the genetic polymorphism of the N-acetyltransferase-2 gene. The risk group for developing adhesive intestinal obstruction is made up of children who are the carriers of NAT-2 alleles and correspond to the genotype of «fast» and «moderate» acetylation. Children who are «fast» acetylators have a more pronounced intra-abdominal adhesion process and a higher risk of complications associated with excessive adhesion even in the absence of other risk factors. What this paper adds N-acetyltransferase 2 (NAT2) gene polymorphism as a prognostic risk factor for the development of adhesive intestinal obstruction in children has been studied. Children as the carriers of the «fast» acetylator genotype have a higher risk of developing intra-abdominal adhesions and therefore require more comprehensive preventive measures at all stages of possible influence.

The Point-Rating Scale for Determining Treatment Tactics in Patients With Adhesive Small Bowel Obstruction

Relevance. The most practiced method of treating patients with acute intestinal obstruction - urgent surgical intervention - does not guarantee remission, contributing to the progression of morphological changes in the abdominal cavity. From this perspective, a shift in emphasis towards the planned surgical treatment of patients with adhesive disease with the use of the existing anti-adhesive methods after conservative resolution of the intestinal passage disorders looks like a promising direction.Aim of the study. Improving the results of patients with acute adhesive intestinal obstruction treatment by developing a point-rating scale that allows to highlight groups of patients who are prone to conservative resolution of intestinal passage disorders episode, and, thereby, reduces the proportion of urgent interventions.Material and methods. The analysis of the 125 patients treatment results (retrospective group) admitted with symptoms of acute adhesive intestinal obstruction was carried out. On this basis, the point-rating scale was developed including a number of factors that have certain value in terms of predicting the probability of conservative therapy success. Subsequently the developed scale was applied in 170 patients (prospective group) as part of treatment tactics implementation aimed at maximally conservative resolution of adhesive intestinal obstruction without negative effect on the immediate results of patients operated in later periods.Results. The developed point-rating scale made it possible to reduce the frequency of urgent interventions among patients with signs of acute adhesive intestinal obstruction (from 79.2% to 57.6%) due to longer conservative measures — 18.1±17.2 and 11,2±8.7 hours in prospective and retrospective groups, respectively). There was no negative impact on the frequency of resection interventions (12.2 and 16.1% in the prospective and retrospective groups) as well as postoperative complications and overall mortality.Conclusions. The developed point-assessment scale made it possible to stratify patients in accordance with the probability of conservative therapy success and to justify its continuation for more than 12 hours in low-risk patients. The obtained results allow us to recommend the proposed scale for use in clinical practice.

Non-operative Management of Adhesive Intestinal Obstruction in Children over a 12 year period at Waikato Hospital

Title: Non-Operative Management of Adhesive Intestinal Bowel Obstruction in Children over a 12year Period at Waikato HospitalIntroduction: Post-operative small bowel adhesions causing bowel obstruction is common in adults but is uncommon in the paediatric age group. The incidence of adhesive intestinal obstruction (AIO) requiring surgical intervention ranges between 2-8% in paediatric patients and majority would occur within the first 2 years after surgery. Aim: To review our experience at a tertiary centre in children under 15years who were admitted with adhesive intestinal obstruction over a 12 year time period and to compare this with other international reports Methodology: This retrospective case series study of all paediatric surgical patients (aged between 1-15 years) admitted with adhesive intestinal obstruction to Waikato Hospital over a 12 year time period were identified by ICD-10-AM codes. Their demographic variables, information of previous surgery and the admissions details including particulars of management were tabulated. Results: Out of 66 admissions, 10 were excluded and 56 admissions were analysed. 35 patients were successfully managed non-operatively and 21 patients proceeded for operative management (7 early and 14 late). Of the operative group, 3 underwent bowel resections (2 early and 1 late). There was no statistically significant difference between length of stay (LOS) among patients with non-operative and operative management. There was also no statistically significant difference between LOS among patients with early (≤24 hours) operative management and late (>24 hours) operative management. In assessing secondary aims, statistically significant differences in the time of presentation from initial surgery was noted for patients who underwent appendectomy who trended towards earlier presentation compared to other laparotomies. Conclusion: This study demonstrated that there could still be a role of non-operative management of children with adhesive bowel obstruction but decision on further management should be clearly defined within 24hours to prevent development of complications.

NEW PROSPECTS OF DIAGNOSIS IN EMERGENCY ABDOMINAL SURGERY

Summary. Aim. Search for new methods for diagnosing acute surgical pathology of the abdominal cavity (ASPAC). Materials and methods. 39 patients: liver abscess — 4, acute appendicitis, periapendicular abscess — 3, acute appendicitis, perito-nitis — 5, acute phlegmonous appendicitis — 7, acute phlegmonous cholecystitis — 4, colon perforation, peritonitis — 3 , acute uncomplicated adhesive intestinal obstruction — 4, uncomplicated peptic ulcer — 4. Measured the optical density of venous blood plasma on a spectrophotometer SF-4A. The control was given to 8 patients (adhesive intestinal obstruction, uncomplicated peptic ulcer disease). Results and discussion. A number of maxima of the values of the optical density of the plasma at wavelengths λ = 3.1, 3.5, 4.3, 6.1, 6.7, 9, 17.5 micrometers were revealed. Indicators differed depending on the type of underlying disease and complications. For analysis and comparison, patients were divided into groups: abscesses, peritonitis, destructive pathology without peritonitis (appendicitis, cholecystitis) and control. At wavelengths λ = 3.1, 6.1, 6.7, 9, 17.5 micrometers, the optical density in patients with no destructive pathology is significantly lower than in patients with such pathology. In addition, the indicators differ in the presence of peritonitis, abscesses and uncomplicated destructive pathology. Conclusions. In the presence of acute surgical diseases of the abdominal cavity in patients, the specific maxima of the optical density of venous blood plasma in the infrared region at wavelengths λ = 3.1, 3.5, 4.3, 6.1, 6.7, 9, 17 , 5 micrometers. Changes in the parameters of optical density differ, depending on the characteristics of the underlying disease and complications and have common patterns in the perforation of hollow organs, abscesses, peritonitis, destructive uncomplicated diseases. Determination of optical density is a promising area for improving the diagnosis of ASPAC.

Emergency laparotomy at district hospitals in a developing nation: a review of indications and outcomes of treatment

Objective: Recently, emergency and essential surgical and anesthesia care at district hospitals is increasingly gaining recognition as a critical, though neglected element of health care system in Africa and other developing nations. Emergency laparotomy is a versatile procedure that can cure a great deal of acute abdominal conditions. The aim of this study was to document the indications and outcomes of laparotomy for emergency abdominal surgical conditions in our district hospitals. Methods: This retrospective study was undertaken in district hospitals from January 2009 to December 2018. Associations between different variables were measured and compared using statistical tests of significance. Results: Of the 879 patients evaluated, appendicitis (n=361, 41.1%) was the most frequent indication for emergency laparotomy followed by complicated external hernias (n=120, 13.7%). Other indications were adhesive intestinal obstruction (n=111, 12.6%), typhoid perforation (n=98, 11.1%), perforated peptic ulcer (n=89, 10.1%), trauma (n=58, 6.6%), colorectal cancer (CRC) (n=18, 2.0%) and others (n=24, 2.8%). The vast majority of patients (n=726, 82.6%) were presented after 24 hours of the onset of disease. Approximately, one-third of patients (n=278, 31.6%) had comorbidities, 867 (98.6%) had high ASA scores (III and IV) and 105 (11.9%) received intestinal resection with or without stoma. The main independent predictors of mortality were late presentation (P=0.003), generalized peritonitis (P=0.001), bowel resection (P=0.000) and high ASA (III and IV) scores (P=.000). Overall, the mortality rate was 10.6%. The commonest complication was wound infection (39.7%), followed by intra-abdominal collection (10.0%). Conclusion: The most common indication for emergency laparotomy was appendicitis followed by complicated hernias. The major independent predictors of mortality included bowel resection, high ASA score, late presentation and generalized peritonitis.