Iqbal Z. Khan

The Utility of Neutrophil-to-Lymphocyte Ratio as a Severity Predictor of Acute Appendicitis, Length of Hospital Stay and Postoperative Complication Rates

Background: Numerous screening tools have been reported to aid in diagnosing appendicitis, but have poor severity prediction and lack accurate estimation of postoperative complications or total length of hospital stay (LOS). Aim: This study aims at evaluating the utility of neutrophil-to-lymphocyte (NLR) ratio in predicting the severity of appendicitis, LOS and 30-day complication rates. Methods: Patients who underwent appendicectomy over a 4-year period were evaluated. Demographics, blood results, severity of appendicitis, LOS and 30-day complications were recorded. Recommended cut-off values of NLR and C-reactive protein (CRP) for severity of appendicitis were determined using receiver operating characteristic analysis. The Mann-Whitney test was performed to assess the correlations between LOS and 30-day complications with NLR. Results: A total of 663 patients were included in the study of which 57.3% (n = 380) were male with mean patient age of 23.6 years, and 461 appendix specimens (69.6%) had simple inflammation on histological evaluation. A NLR of >6.35 or CRP of >55.6 were statistically associated with severe acute appendicitis, with a median of one extra hospital day admission (p < 0.0001). Mean NLR was statistically higher in patients with postoperative co(13.69 for severe vs. 7.29 for simple appendicitis group, p = 0.016). Conclusion: We advocate that NLR is a useful adjunct in predicting severity of appendicitis. It aids in delineating severe inflammation requiring surgery without substantial delay.

Recurrent adult jejuno-jejunal intussusception due to inflammatory fibroid polyp - Vanek's tumour: a case report.

BackgroundAdult intussusception is a rare but challenging condition. Preoperative diagnosis is frequently missed or delayed because of nonspecific or sub-acute symptoms.Case presentationWe present the case of a sixty-two year old gentleman who initially presented with pseudo-obstruction. Computerised tomography displayed a jejuno-jejunal intussusception, which was treated by primary laparoscopic reduction. The patient re-presented with acute small bowel obstruction two weeks later. He underwent a laparotomy showing recurrent intussusception and required a small bowel resection with primary anastomosis. Histological examination of the specimen revealed that the intussusception lead point was due to an inflammatory fibroid polyp (Vanek’s tumour) causing double invagination.ConclusionsAdult intussusception presents with a variety of acute, intermittent, and chronic symptoms, thus making its preoperative diagnosis difficult. Although computed tomography is useful in confirming an anatomical abnormality, final diagnosis requires histopathological analysis. Vanek’s tumours arising within the small bowel rarely present with obstruction or intussusception. The optimal surgical management of adult small bowel intussusception varies between reduction and resection. Reduction can be attempted in small bowel intussusceptions provided that the segment involved is viable and malignancy is not suspected.Virtual SlidesThe virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/7292185123639943

A National Evaluation of the Conservative Management of Uncomplicated Acute Appendicitis: How Common Is This and What Are the Issues.

Introduction: The management approach for acute appendicitis has been challenged in recent years, with numerous randomized controlled trials demonstrating that antibiotics/conservative management is an efficacious treatment, with lower complication rates. Methods: A national survey of all consultant general surgeons evaluating their practices was performed. Reasons for changed practices, choice of antibiotics and follow-up investigations were evaluated. In addition, the role of interval appendicectomy and conservative management in the pediatric population was also assessed. Results: The response rate for this survey was 74.7% (n = 74/99). Over one-fifth (n = 17, 22.9%) routinely treat acute appendicitis conservatively, while another 14.8% (n = 11) consider this approach in selected cases. Main reasons for modified practices included the presence of inflammatory phlegmon (75%), delayed presentation (64%), and recent evidence-based medicine developments (46%). Co-amoxiclav/clavulanic acid was the most popular antibiotic for conservative management (53%). Alternatively, combinations of antibiotics were also utilized. One-third felt interval appendicectomy was warranted, while one-fifth supported conservative management in the paediatric setting. The overwhelming majority (>95%) advocate follow-up colonoscopy ± computed tomography in any patient aged >40 years managed conservatively. Conclusion: Considerable variation in management of uncomplicated appendicitis remains in Ireland despite growing evidence suggesting that the non-operative approach is safe. Reasons for adopting a conservative management practice have been identified and reflect the expanding literature on this subject.

The Utility of Neutrophil to Lymphocyte Ratio as a Predictor of Intervention in Acute Diverticulitis

Background: Neutrophil to lymphocyte ratio (NLR) is a novel biomarker that has been recently studied in diverticulitis. The primary aim of this study was to assess the accuracy of NLR in predicting which patients had complicated diverticulitis and which patients required a radiological or surgical intervention. The accuracy of NLR was compared to C-reactive protein (CRP), white blood cell (WBC) count, neutrophil count and white cell to lymphocyte ratio (WLR). Methods: Details of all patients admitted with acute diverticulitis over an 18-month period were collected prospectively. Median CRP, WBC, neutrophil count, WLR and NLR values at initial presentation were compared using the Mann-Whitney U test. The diagnostic accuracy of each test was assessed using receiver operating characteristic curve analysis. Optimal cut-off points were determined for each biomarker using Youdens Index (J). Results: CRP, WBC, neutrophil count, WLR and NLR had variable accuracy in predicting complicated diverticulitis. NLR had the greatest accuracy of the 5 biomarkers in predicting the need for intervention with an area under the curve of 0.79 (p < 0.0001). The optimal cut-off point for NLR was 5.34 (J = 0.45). Conclusion: NLR was more accurate than CRP, WBC, neutrophil count and WLR in predicting the need for intervention. This cost-neutral, readily available biomarker can easily be calculated from the complete blood count and is a useful adjunct to CT.

Non-operative treatment of appendicitis: public perception and decision-making

BackgroundAppendectomy has for many years been the accepted treatment of appendicitis. In recent years, non-operative management of appendicitis (NOTA) has been reported as an effective treatment option.AimsWe aimed to assess the perspectives of public hospital attendees regarding the diagnosis and treatment options for appendicitis.MethodsWe conducted a cross-sectional survey of outpatients over a 10-week period (December 2016–March 2017). The questionnaire contained an information sheet and consent form and included open, closed and multiple-choice questions.ResultsTwo hundred forty-four participants (159 female, 85 male) were surveyed. A high level of awareness of appendicitis as a surgical emergency existed amongst the participants. The primary reason participants were reluctant to receive non-operative treatment was a fear of their appendix “bursting” if not removed.ConclusionsParticipant knowledge levels were variable with many concerned that non-operated appendicitis would always perforate. Perceptions of treatment were variable with some believing surgery was an absolute requirement and others preferring antibiotics due to the belief that NOTA is complication-free.

Patterns of retroperitoneal trauma following gunshot violence: A case series

Introduction Abdominal trauma is defined as any injury to the abdomen and its containing viscera. Common penetrating injuries including gunshot or stab injuries are increasing worldwide. However, retroperitoneal gunshot injuries have a lower incidence than trans-abdominal trauma and can have substantially different outcomes. Case report We report a series of three family members involved in gunshot violence over an18-month period. Each sustained retroperitoneal gunshot injuries with varying injuries patterns and treatment courses. Interestingly, one patient had a delayed small bowel perforation on day 6 post injury. Discussion Retroperitoneal trauma following gun violence has a lower incidence than trans-abdominal trauma. There is a paucity of literature describing injury patterns following this type of injury and their subsequent management. In the context of penetrating retroperitoneal trauma, the retroperitoneal organs are at risk and therefore serial clinical and/or radiological assessment is necessary. Delayed small bowel injury as a consequence of retroperitoneal gunshot is an unusual finding, with no reports to our knowledge in the literature. Conclusion this case series highlight that penetrating retroperitoneal trauma can produce a variety of injury patterns. Therefore a wide clinical acumen is needed to ensure a successful outcome. The trajectory of the bullet may help ascertain potential injuries, but serial assessment and observation are also important. Ultimately, individual cases must be treated accordingly, based on clinical stability, severity of injury and radiological findings. Despite initial stability, patients should always be observed for delayed complications.