J Sagar

Meckel's diverticulum is the most common congenital malformation of gastrointestinal tract. It can cause complications in the form of ulceration, haemorrhage, intussusception, intestinal obstruction, perforation and, very rarely, vesicodiverticular fistulae and tumours. These complications, especially bleeding, are more common in the paediatric age group than in adults; however it is not uncommon to miss the diagnosis of Meckel's diverticulum in adults. Here, we reviewed the literature regarding the complications of this forgotten clinical entity in adults with potential diagnostic difficulties and management strategies.

BACKGROUND: Low Rectal Anterior Resection (LAR) is challenging when anal canal mucosa and/or internal sphincter are involved by very low tumors. In these cases, Intersphincteric resection (ISR) with the removal of the internal sphincter is designed to increase the distal margin of resection, thus preserving the external sphincter and pubo-rectalis muscle complex. Aim is to compare results after ISR with those of LAR, including subgroup analysis of open, laparoscopic and robotic ISR. METHODS: Studies published from January 1991 to January 2017 describing ISR and comparing results with LAR in adults were included irrespective of the technique. Tumor and surgical characteristics, clinical, functional and oncological results were collected. RESULTS: 25 non-randomized studies were included. Postoperative mortality ranged between 0% and 2.3%. The hospital stay ranged from 5 days to 40 days, lower in robotic ISR group if compared with laparoscopic ISR. Patients avoiding permanent stoma with ISR accept a lower continence level as satisfactory. Furthermore, anorectal function after ISR often tends to improve. ISR and LAR presented not statistically significant differences. Oncological outcomes were not statistically different Morbidity, blood loss and need for blood transfusions were lower in the laparoscopic ISR if compared with open approach. CONCLUSIONS: Morbidity could more frequently affect open ISR if compared with laparoscopic ISR. Functional outcomes were influenced by neoadjuvant CRT, but not by the surgical approach of reconstruction, while were positively influenced by partial ISR with respect to total ISR.

Concerns over unacceptable high mortality in patients with rectal cancer undergoing surgery or systemic therapy who contract COVID-19 have led to widespread adoption of alternative treatment strategies.The ReCaP study aimed to study these variations and associated outcomes.

We describe the findings of symptomatic cholelithiasis in the double gallbladder of a 75-year-old woman, which was successfully removed laparoscopically. This report highlights the importance of this condition and the effectiveness of magnetic resonance cholangiopancreatography in defining abnormal gallbladder anatomy.

BACKGROUND: Complicated intra-abdominal infections (cIAIs) are associated with significant morbidity and mortality. The aim of this study was to describe the clinical characteristics of patients with cIAI in a multicentre study and to develop clinical prediction models (CPMs) to help identify patients at risk of mortality or relapse. METHODS: A multicentre observational study was conducted from August 2016 to February 2017 in the UK. Adult patients diagnosed with cIAI were included. Multivariable logistic regression was performed to develop CPMs for mortality and cIAI relapse. The c-statistic was used to test model discrimination. Model calibration was tested using calibration slopes and calibration in the large (CITL). The CPMs were then presented as point scoring systems and validated further. RESULTS: Overall, 417 patients from 31 surgical centres were included in the analysis. At 90 days after diagnosis, 17.3 per cent had a cIAI relapse and the mortality rate was 11.3 per cent. Predictors in the mortality model were age, cIAI aetiology, presence of a perforated viscus and source control procedure. Predictors of cIAI relapse included the presence of collections, outcome of initial management, and duration of antibiotic treatment. The c-statistic adjusted for model optimism was 0.79 (95 per cent c.i. 0.75 to 0.87) and 0.74 (0.73 to 0.85) for mortality and cIAI relapse CPMs. Adjusted calibration slopes were 0.88 (95 per cent c.i. 0.76 to 0.90) for the mortality model and 0.91 (0.88 to 0.94) for the relapse model; CITL was -0.19 (95 per cent c.i. -0.39 to -0.12) and - 0.01 (- 0.17 to -0.03) respectively. CONCLUSION: Relapse of infection and death after complicated intra-abdominal infections are common. Clinical prediction models were developed to identify patients at increased risk of relapse or death after treatment, these now require external validation.