Author Archives: John

Tranexamic Acid Use in Breast Surgery

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“Tranexamic acid (TXA) is an antifibrinolytic agent that competitively inhibits the conversion
of plasminogen to plasmin. TXA is also believed to have an anti-inflammatory effect and may improve platelet function under certain circumstances. TXA has increasingly gained recognition in perioperative use to mitigate the risk of postoperative bleeding. Originating in the field of anesthesiology, TXA is used to control surgical, traumatic, and postpartum hemorrhage. Meanwhile, perioperative TXA administration has been established in orthopedic and cardiothoracic surgery. It is also becoming popular in plastic surgery, especially regarding craniomaxillofacial procedures. Although the evidence on
the use of TXA in breast surgery is improving, its value still needs further investigation.”

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Aspiration versus peritoneal lavage in appendicitis

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“The management of IAA remains controversial with different strategies suggested to decrease its incidence: antibiotic prophylaxis, post-operative antibiotic therapy, peritoneal irrigation with saline solution or suction only of the abscess/purulent liquid without irrigation of the cavity during appendectomy. In the literature, many studies address this topic; however, currently there is no evidence to clearly demonstrate the effectiveness of peritoneal irrigation over suction only. Italian guidelines recommend thorough peritoneal lavage (6–8 L of warm saline) and aspiration to minimize the IAA rate in complicated appendicitis. The recent WSES (World Society of Emergency Surgery) guidelines report that “Peritoneal irrigation does not have any advantage over suction alone in complicated appendicitis in both adults and children. The performance of irrigation during laparoscopic appendectomy does not seem to prevent the development of IAA and wound infections
in neither adults nor paediatric patients”. WSES recommendation is “to perform suction only in complicated appendicitis patients with intra-abdominal collections undergoing laparoscopic appendectomy” [QoE: Moderate; Strength of recommendation: Strong; 1B]). The concern regarding irrigation and lavage is that these procedures might help spread the infectious material.”

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Pembrolizumab for EarlyTriple-Negative Breast Cancer

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“High-risk early triple-negative breast cancer is frequently associated with early recurrence and high mortality. Neo-adjuvant chemotherapy is the preferred treatment approach. In addition to potentially increasing the likelihood of tumor resectability and breast conservation, patients who have a pathological complete response after neoadjuvant therapy have longer event-free survival (defined as the time from randomization to the date of disease progression that precluded definitive surgery, the date of local or distant recurrence or the occurrence of a second primary tumor, or the date of death from any
cause) and overall survival. Accordingly, regulatory guidance supports the use of the pathological complete response as an end point for clinical testing of neoadjuvant treatment in patients with early triple-negative breast cancer.”

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Evaluation of Drain Insertion After Appendicectomy for Complicated Appendicitis

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“This meta-analysis aims to evaluate the comparative outcomes of drain insertion versus no drain after appendicectomy for complicated appendicitis. Abdominal collection, surgical site infection (SSI), bowel obstruction, faecal fistula, paralytic ileus, length of hospital stay (LOS) and mortality were the evaluated outcome parameters for the meta-analysis. Seventeen studies reporting a total number of 4,255 patients who underwent appendicectomy for complicated appendicitis with (n=1,580) or without (n=2,657) drain were included.
There was no significant difference between the two groups regarding abdominal collection (odds ratio (OR)=1.41, P=0.13). No-drain group was superior to the drain group regarding SSI (OR=1.93, P=0.0001), faecal fistula (OR=4.76, P=0.03), intestinal obstruction (OR=2.40, P=0.04) and paralytic ileus (OR=2.07, P=0.01). There was a difference regarding mortality rate between the two groups (3.4% in the drain group vs 0.5% in the no-drain group, risk difference (RD)=0.01, 95% CI (-0.01, 0.04), P=0.36).”

Table 2. Characteristics of included studies.

DG: drain group, NDG: no-drain group, RCT: randomized controlled trial, NA: not available.

StudyCountryType of the studyNumber of patientsType of operationInclusion/exclusion criteria and definition of complicated appendicitis
Stone et al., 1978 [25]GeorgiaRetrospective cohortTotal: 94; DG: 49; NDG: 45OpenInclusion and exclusion criteria: NA. Definition of complicated appendicitis: gangrenous or perforated appendicitis
Greenall et al., 1978 [26]United KingdomRCTTotal: 103; DG: 48; NDG: 55OpenExclusion criteria: appendicular mass/abscess. Definition of complicated appendicitis: gangrenous appendicitis, associated with turbid infected fluid
Dandapat and Panda, 1992 [27]IndiaRCTTotal: 86; DG: 40; NDG: 46NANA
Tander et al., 2003 [28]TurkeyRCTTotal: 140; DG: 70; NDG: 70OpenInclusion criteria: paediatric cases with uncomplicated perforated appendicitis. Exclusion criteria: appendicular mass/abscess. Definition of complicated appendicitis: gross or microscopic evidence of appendicular perforation with no more discolouration of peritoneal fluid after washing out
Narci et al., 2007 [29]TurkeyRetrospective cohortTotal: 226; DG: 109; NDG: 117OpenInclusion criteria: children with macroscopic perforation. Exclusion criteria: appendix could not be visualized and drained without appendectomy. Definition of complicated appendicitis: macroscopic perforation
Allemann et al., 2011 [30]SwitzerlandCase match studyTotal: 260; DG: 130; NDG: 130LaparoscopicExclusion criteria: simple acute appendicitis (i.e., no peritoneal reaction), generalized peritonitis, preoperatively known immunodeficiencies, aged <16 years and incomplete dataset. Definition of complicated appendicitis: localized peritonitis, perforation of the appendix, presence of pus or fibrin membranes around the appendix or frank peri-appendicular abscess
Jani and Nyaga, 2011 [31]KenyaRCTTotal: 90; DG: 45; NDG: 45OpenInclusion criteria: advanced appendicular pathology and aged over 13 years. Exclusion criteria: simple acute appendicitis or laparoscopic appendicectomy. Definition of complicated appendicitis: perforated, mass or phlegmon
Pakula et al., 2014 [32]USARetrospective cohortTotal: 148; DG: 43; NDG: 105LaparoscopicInclusion criteria: patients with the diagnosis of gangrenous or perforated appendicitis based on the review of pathology and operative reports. Exclusion criteria: simple or suppurative appendicitis and those treated with interval appendectomy. Definition of complicated appendicitis: gangrenous and perforated appendicitis
Song and Jung, 2015 [33]KoreaRetrospective cohortTotal: 342; DG: 108; NDG: 234Open: 181; Laparoscopic: 161Inclusion criteria: children under 18 years old who were diagnosed with acute appendicitis. Definition of complicated appendicitis: perforated appendicitis
Schlottmann et al., 2016 [35]ArgentinaRetrospective cohortTotal: 225; DG: 169; NDG: 56LaparoscopicInclusion and exclusion criteria: NA. Definition of complicated appendicitis: intraoperatively as the presence of gangrenous/perforated appendicitis with peritonitis
Abdulhamid and Sarker, 2018 [36]IraqRetrospective cohortTotal: 227; DG: 114; NDG: 113OpenInclusion criteria: open appendectomy for complicated appendicitis irrespective of age. Definition of complicated appendicitis: perforated with localized abscess formation
Aneiros Castro et al., 2018 [37]SpainRetrospective cohortTotal: 192; DG: 79; NDG: 63LaparoscopicInclusion criteria: patients with perforated appendicitis. Exclusion criteria: incidental appendectomy during another laparoscopic surgical procedure and those treated with interval appendectomy. Definition of complicated appendicitis: identifiable macroscopic hole in the appendix during the surgery
Miranda-Rosales et al., 2019 [38]PeruRetrospective cohortTotal: 150; DG: 50; NDG: 100OpenInclusion criteria: aged >18 years with complicated appendicitis. Exclusion criteria: laparoscopic appendicectomy, patients on anticoagulation, immunocompromised and pregnancy. Definition of complicated appendicitis: localized or generalized peritonitis and appendicular abscess
Fujishiro et al., 2021 [39]JapanPropensity-matched studyTotal: 1,762; DG: 485; NDG: 1304Open: 346; Laparoscopic: 958Inclusion criteria: complicated appendicitis in children (aged 15 years and below). Exclusion criteria: interval appendectomies. Definition of complicated appendicitis: perforation, gangrene or intra-abdominal abscess
Nazarian et al., 2021 [40]UKRetrospective cohortTotal: 76; DG: 26; NDG: 50LaparoscopicInclusion criteria: over the age of 16 with complicated appendicitis. Exclusion criteria: caecal/appendicular malignancy. Definition of complicated appendicitis: histologically proven gangrenous or perforated appendicitis
Schmidt et al., 2020 [41]GermanyRetrospective cohortTotal: 65; DG: 32; NDG: 33Open: 11; Laparoscopic: 55Inclusion criteria: age range from two to 17 years who presented with perforated appendicitis. Exclusion criteria: severe neurological dysfunction and inflammatory bowel disease. Definition of complicated appendicitis: perforated appendicitis on histology
Mustafa et al., 2020 [34]PakistanRCTTotal: 68; DG: 34; NDG: 34OpenExclusion criteria: immunocompromised patients and those with generalized peritonitis (perforated appendix with pus in three or more quadrants of the abdominal cavity visible per-operatively). Definition of complicated appendicitis: perforated appendicitis intra-operatively
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Role of right hepatic lobectomy in the treatment of isolated right-sided hepatolithiasis

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“Hepatic resection has been thought to he the most effective treatment modality for selected patients who have left-sided hepatolithiasis and meet the criteria of resection.” Under the same criteria the role of right hepatic resection, especially right hepatic lobectomy, is still ambiguous for patients who have right-sided hepatolithiasis because of the higher operative risk. This report presents the results of right hepatic lobectomy in the treatment of patients with right-sided hepatolithiasis after careful selection. In particular, we focus on the
rationale and indications for this procedure,”

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Safety Zones for Anterior Abdominal Wall Entry During Laparoscopy

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“Trauma to abdominal wall blood vessels occurs in 0.2% to 2% of laparoscopic procedures. Both superficial and deep abdominal wall vessels are at risk. The superficial vessels may be located by transillumination; however, the deep epigastric vessels cannot be effectively located by transillumination and, thus, other techniques should be used to minimize the risk of injury to these vessels.”

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Gastrojejunal anastomotic strictures following laparoscopic Roux-en-Y gastric bypass surgery

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“The development of an anastomotic stricture at the site of the gastrojejunostomy following Roux-en-Y gastric bypass (RYGBP) is associated with substantial morbidity. Various techniques are available for creating the gastrojejunal anastomosis, including hand-sewing and using a circular or linear stapler, to reduce complication rates. The aim of this study was to assess the incidence of gastrojejunal anastomotic strictures in patients who underwent antecolic antegastric Roux-en-Y gastric bypass (AA-RYGBP) with the use of a linear stapler and to evaluate the outcomes of endoscopic pneumatic dilatation as a treatment option for patients with anastomotic stricture.”

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