Citations

Abstract Aim Perianal Paget's disease (PAPD) is a rare disorder with a predisposition to anal and colorectal malignancies and an unclear prognosis. Our previous 25‐year series demonstrated a non‐aggressive nature. This study aims to describe our updated institutional experience. Methods This is a retrospective review of all patients diagnosed with primary PAPD from 1991 to 2021. A prospectively maintained institutional database was searched which included demographics, clinical and pathological manifestations, treatment methods, recurrence, oncological outcome and mortality. Results Thirty patients were diagnosed with PAPD. Fifteen were women (50%); the average age at diagnosis was 71 ± 10.7 years, and the average lesion size was 3.7 ± 2.6 cm. At diagnosis, 12 (40%) were harbouring invasive anal adenocarcinoma. Eight (27%) developed adenocarcinomas concurrent with PAPD recurrence at a mean interval of 9 ± 4.4 years (range 1.9–14.8). The Kaplan–Meier curve estimated overall survival of 93%, 86%, 82%, 65% and 56% at 1, 3, 5, 10 and 15 years, respectively. Median survival was 16 years. Six (20%) had disease‐related mortality. Initially, nine (30%) were treated with abdominoperineal resection (APR), 15 (50%) underwent local resection, three (10%) were treated with radiotherapy, two (7%) received only topical therapy and one (3%) chose observation. Fifteen (50%) experienced recurrence of PAPD, two after undergoing APR. Five (17%) had persistent disease until death. Only 10 (33%) did not experience PAPD recurrence, seven of whom underwent APR. The mean follow‐up time was 9.2 ± 6.2 years. Conclusions Perianal Paget's disease is an aggressive entity with high rates of synchronous anal adenocarcinoma at diagnosis and development of metachronous adenocarcinoma later in life.

Background Renal transplant patients presenting with diverticulitis remain a clinical challenge for health care professionals. Secondary to immunosuppression, renal transplant recipients are often considered for early operative intervention due to concerns for an unreliable physical exam and feared morbidity and mortality associated with non-operative management. Methods This study aimed to evaluate trends in management of renal transplant patients with diverticulitis at a quaternary referral center. Results One hundred ninety-one renal transplant patients admitted to the hospital with diverticulitis were identified. Of this cohort, 71 (37%) underwent surgical resection, of which 20 (28%) were performed emergently. The overall 30-day operative mortality was 8% (6/71), of which there was a significant difference between emergent (25%, 5/20) and elective (2%, 1/51) groups ( P = .006). Patients who underwent elective surgery were more likely to receive a minimally invasive approach (51%) and were significantly more likely to undergo stoma reversal ( P = .006). Discussion Our study shows that not all renal transplants with diverticulitis will require operative intervention and many can be safely treated non-operatively. Elective resection and surgical management should be considered on an individual basis. Patients treated with elective resection were more likely to undergo a minimally invasive approach and restoration of intestinal continuity.

Objective: The aim of this work is to formulate recommendations based on global expert consensus to guide the surgical community on the safe resumption of surgical and endoscopic activities. Background: The COVID-19 pandemic has caused marked disruptions in the delivery of surgical care worldwide. A thoughtful, structured approach to resuming surgical services is necessary as the impact of COVID-19 becomes better controlled. The Coronavirus Global Surgical Collaborative sought to formulate, through rigorous scientific methodology, consensus-based recommendations in collaboration with a multidisciplinary group of international experts and policymakers. Methods: Recommendations were developed following a Delphi process. Domain topics were formulated and subsequently subdivided into questions pertinent to different aspects of surgical care in the COVID-19 crisis. Forty-four experts from 15 countries across 4 continents drafted statements based on the specific questions. Anonymous Delphi voting on the statements was performed in 2 rounds, as well as in a telepresence meeting. Results: One hundred statements were formulated across 10 domains. The statements addressed terminology, impact on procedural services, patient/staff safety, managing a backlog of surgeries, methods to restart and sustain surgical services, education, and research. Eighty-three of the statements were approved during the first round of Delphi voting, and 11 during the second round. A final telepresence meeting and discussion yielded acceptance of 5 other statements. Conclusions: The Delphi process resulted in 99 recommendations. These consensus statements provide expert guidance, based on scientific methodology, for the safe resumption of surgical activities during the COVID-19 pandemic.

Summary There are few data regarding postoperative hyperglycaemia in non‐diabetic compared with diabetic patients following postoperative nausea and vomiting prophylaxis with dexamethasone. Eighty‐five non‐diabetic patients and patients with type‐2 diabetes were randomly allocated to receive intravenous dexamethasone (8 mg) or ondansetron (4 mg). Blood glucose levels were measured at baseline and then 2, 4 and 24 h following induction of anaesthesia. In non‐diabetic patients, the mean ( SD ) maximum blood glucose was higher in those who received dexamethasone compared with ondansetron (9.1 (2.2) mmol.l −1 vs. 7.8 (1.4) mmol.l −1 , p = 0.04). In diabetic patients, the mean ( SD ) maximum blood glucose was also higher in those who received dexamethasone compared with ondansetron (14.0 (2.5) mmol.l −1 vs. 10.7 (2.4) mmol.l −1 , p < 0.01). Multivariate analysis demonstrated that dexamethasone administration was a significant predictor of maximum postoperative blood glucose increase (p < 0.01) after adjusting for potential confounders. There was no interaction between baseline blood glucose level, or presence or absence of diabetes, and dexamethasone administration. We conclude that dexamethasone increases postoperative blood glucose levels in both non‐diabetics and diabetics.

Background: Antiemetic guidelines recommend a combination of serotonin (5-HT 3 ) with a second agent such as droperidol or dexamethasone. Physicians have been reluctant to employ these guidelines due to concerns over the black-box warning of droperidol and safety concerns with a steroid. Objective: To assess the safety profiles of 5-HT 3 receptor antagonist (5-HT 3 RA) monotherapy and combination therapy with a steroid or droperidol for prophylaxis of postoperative nausea and vomiting (PONV). Methods: A MEDLINE search of English-language reports of randomized controlled trials (RCTs) was conducted (1966–September 2005) using the key terms 5-HT 3 , granisetron, ondansetron, dolasetron, tropisetron, PONV, postoperative, vomiting, emesis, and nausea. RCTs with treatment arms comparing 5-HT 3 RA monotherapy (granisetron, ondansetron, dolasetron, or tropisetron) with dexamethasone or droperidol or 5-HT 3 RA combinations and providing incidence data on adverse events were identified and reviewed. Within-study odds ratios with 95% confidence intervals were calculated to determine the incidence rates of all adverse events in RCTs using 5-HT 3 RA monotherapy and combination therapies. Overall effect sizes for frequently reported adverse events were estimated by pooling ORs using fixed- and random-effect models. Results: Pooled ORs (OR pooled ) for adverse events with 5-HT3RA/dexamethasone versus 5-HT 3 RA for PONV prophylaxis were not significant for any reported adverse events or the overall incidence of adverse events; 5-HT 3 RA/droperidol versus 5-HT 3 RA was significant only for decreased headache incidence (fixed model: OR pooled 0.35; 95% CI 0.18 to 0.69). The OR pooled for 5-HT 3 RA/dexamethasone versus dexamethasone was not significant for any reported adverse events except headaches (fixed model OR pooled 1.75; 95% CI 1.01 to 3.03), none of which was serious. OR pooled for 5-HT 3 RA/droperidol versus droperidol was not significant for any reported adverse events. Avascular necrosis, occult infection, and delayed wound healing were not observed with either combination therapy. Cardiac abnormalities were observed with 5-HT 3 RA/droperidol therapy. Conclusions: This meta-analysis indicates that either therapy has a safety profile similar to that of dexamethasone, droperidol, or 5-HT 3 RA.