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ᅟ Obstruction and perforation due to colorectal cancer represent challenging matters in terms of diagnosis, life-saving strategies, obstruction resolution and oncologic challenge. The aims of the current paper are to update the previous WSES guidelines for the management of large bowel perforation and obstructive left colon carcinoma (OLCC) and to develop new guidelines on obstructive right colon carcinoma (ORCC). Methods The literature was extensively queried for focused publication until December 2017. Precise analysis and grading of the literature has been performed by a working group formed by a pool of experts: the statements and literature review were presented, discussed and voted at the Consensus Conference of the 4th Congress of the World Society of Emergency Surgery (WSES) held in Campinas in May 2017. Results CT scan is the best imaging technique to evaluate large bowel obstruction and perforation. For OLCC, self-expandable metallic stent (SEMS), when available, offers interesting advantages as compared to emergency surgery; however, the positioning of SEMS for surgically treatable causes carries some long-term oncologic disadvantages, which are still under analysis. In the context of emergency surgery, resection and primary anastomosis (RPA) is preferable to Hartmann’s procedure, whenever the characteristics of the patient and the surgeon are permissive. Right-sided loop colostomy is preferable in rectal cancer, when preoperative therapies are predicted. With regards to the treatment of ORCC, right colectomy represents the procedure of choice; alternatives, such as internal bypass and loop ileostomy, are of limited value. Clinical scenarios in the case of perforation might be dramatic, especially in case of free faecal peritonitis. The importance of an appropriate balance between life-saving surgical procedures and respect of oncologic caveats must be stressed. In selected cases, a damage control approach may be required. Medical treatments including appropriate fluid resuscitation, early antibiotic treatment and management of co-existing medical conditions according to international guidelines must be delivered to all patients at presentation. Conclusions The current guidelines offer an extensive overview of available evidence and a qualitative consensus regarding management of large bowel obstruction and perforation due to colorectal cancer.

In this multicenter, randomized trial comparing primary peritoneal drainage with laparotomy for the management of perforated necrotizing enterocolitis in preterm infants with birth weights less than 1500 g, there were no significant differences between groups in mortality at 90 days, dependence on total parenteral nutrition at 90 days, or length of the hospital stay in surviving infants. These data do not support an advantage of either primary peritoneal drainage or laparotomy over the alternative approach among preterm infants with perforated necrotizing enterocolitis. This trial compared primary peritoneal drainage with laparotomy for the management of perforated necrotizing enterocolitis in preterm infants. There were no significant differences between groups in mortality at 90 days, dependence on total parenteral nutrition at 90 days, or length of the hospital stay in surviving infants. Necrotizing enterocolitis is a severe inflammatory disorder of the intestine occurring in premature infants. It is a major cause of death and morbidity in neonates. 1 In contrast to the improvements during the past 30 years in the outcomes of many conditions affecting premature infants, the mortality rate of 30 to 50 percent for babies with intestinal perforation due to necrotizing enterocolitis remains essentially unchanged. 2 The standard approach to patients with perforated intestine, necrotic intestine, or both is surgical resection of the involved bowel with the creation of intestinal stomas. In a critically ill premature infant, this entails substantial risks. Primary . . .

Case series suggest that laparoscopic peritoneal lavage might be a promising alternative to sigmoidectomy in patients with perforated diverticulitis. We aimed to assess the superiority of laparoscopic lavage compared with sigmoidectomy in patients with purulent perforated diverticulitis, with respect to overall long-term morbidity and mortality. We did a multicentre, parallel-group, randomised, open-label trial in 34 teaching hospitals and eight academic hospitals in Belgium, Italy, and the Netherlands (the Ladies trial). The Ladies trial is split into two groups: the LOLA group comparing laparoscopic lavage with sigmoidectomy and the DIVA group comparing Hartmann's procedure with sigmoidectomy plus primary anastomosis. The DIVA section of this trial is still underway but here we report the results of the LOLA section. Patients with purulent perforated diverticulitis were enrolled for LOLA, excluding patients with faecal peritonitis, aged older than 85 years, with high-dose steroid use (≥20 mg daily), and haemodynamic instability. Patients were randomly assigned (2:1:1; stratified by age [<60 years vs ≥60 years]) using secure online computer randomisation to laparoscopic lavage, Hartmann's procedure, or primary anastomosis in a parallel design after diagnostic laparoscopy. Patients were analysed according to a modified intention-to-treat principle and were followed up after the index operation at least once in the outpatient setting and after sigmoidoscopy and stoma reversal, according to local protocols. The primary endpoint was a composite endpoint of major morbidity and mortality within 12 months. This trial is registered with ClinicalTrials.gov, number NCT01317485. Between July 1, 2010, and Feb 22, 2013, 90 patients were randomly assigned in the LOLA section of the Ladies trial when the study was terminated by the data and safety monitoring board because of an increased event rate in the lavage group. Two patients were excluded for protocol violations. The primary endpoint occurred in 30 (67%) of 45 patients in the lavage group and 25 (60%) of 42 patients in the sigmoidectomy group (odds ratio 1·28, 95% CI 0·54–3·03, p=0·58). By 12 months, four patients had died after lavage and six patients had died after sigmoidectomy (p=0·43). Laparoscopic lavage is not superior to sigmoidectomy for the treatment of purulent perforated diverticulitis. Netherlands Organisation for Health Research and Development.

Objective The objective of this study was to compare graft outcome, operation time and surgical complications of the double and single perichondrium–cartilage underlay techniques for repairing subtotal tympanic membrane (TM) perforations. Materials and methods Patients with unilateral subtotal perforations undergoing myringoplasty were prospectively randomized to undergo DPCN or SPCN. The operation time, graft success rate, audiometric outcomes, and complications were compared between these groups. Results In total, 53 patients with unilateral subtotal perforations were included (DPCN group, 27; SPCN group, 26).All patients completed 6 months of follow-up. The mean operation time was 41.2 ± 1.8 min in the DPCN group and 37.2 ± 5.4 min in the SPCN group, the difference was not significant ( p =  0.613).The graft success rates were 96.3% (26/27) in the DPCN group and 73.1% (19/26) in the SPCN group, the difference was significant ( p =  0.048). During the period of follow-up, residual perforation was found at postoperative in one (3.7%) in the DPCN group, while cartilage graft slipped (graft lateralization) in 2 (7.7%) and residual perforation in 5 (19.2%) were found in the SPCN group, the difference of residual perforation was not significant among two group ( p =  0.177).In addition, no significant between-group differences were observed pre- ( p =  0.741) or post- ( p =  0.687) operative ABG values or mean ABG gain ( p =  0.659) (Table 2 ).The functional success rates (postoperative ABG ≤ 20 dB) were 85.2% (23/27) in the DPCN group and 73.1% (19/26) in the SPCN group ( p =  0.454). Conclusion Although similar functional result and operation time can be obtained with double perichondrium–cartilage underlay technique compared to the single perichondrium–cartilage underlay technique for endoscopic closure of subtotal perforations, double unerlay technique offers better anatomical result with minimum complications.

Perforated peptic ulcer is a common emergency condition worldwide, with associated mortality rates of up to 30%. A scarcity of high-quality studies about the condition limits the knowledge base for clinical decision making, but a few published randomised trials are available. Although Helicobacter pylori and use of non-steroidal anti-inflammatory drugs are common causes, demographic differences in age, sex, perforation location, and underlying causes exist between countries, and mortality rates also vary. Clinical prediction rules are used, but accuracy varies with study population. Early surgery, either by laparoscopic or open repair, and proper sepsis management are essential for good outcome. Selected patients can be managed non-operatively or with novel endoscopic approaches, but validation of such methods in trials is needed. Quality of care, sepsis care bundles, and postoperative monitoring need further assessment. Adequate trials with low risk of bias are urgently needed to provide better evidence. We summarise the evidence for perforated peptic ulcer management and identify directions for future clinical research.

Purpose To compare the anatomic and functional outcome of two variants of the inverted internal limiting membrane (I-ILM) flap technique for idiopathic macular holes (IMH) larger than 400 µm. Methods Twenty-seven consecutive patients undergoing PPV for IMH were randomly assigned to different variants of I-ILM technique: the Cover group included 14 patients in which the I-ILM was folded upside-down over the MH as a single layer while the Fill group enrolled 13 patients in which the I-ILM was folded within the MH in multiple layers. Results MH closed in 12/14 Cover and in 13/13 Fill eyes (84.6 vs. 100%, p  = 0.14; n.s.). Vision at 1 month was Snellen 0.44 ± 0.17 vs. 0.28 ± 0.21 ( p  = 0.05) and 0.48 ± 0.20 vs. 0.37 ± 0.25 (n.s.) at 3 months. IS/OS line interruption width was 463 ± 385 vs. 602 ± 210 µm, respectively, at 1 month (n.s.) and 602 ± 210 vs. 563 ± 209 µm at 3 months (n.s.). The Cover group showed outer retina cystic changes more often ( p  < 0.01). MH over 700 µm closed in 0/2 and in 2/2 cases, respectively, in the Cover and Fill groups (0.045). Conclusions Cover and Fill I-ILM techniques allowed similar closure rates and post-operative vision at 3 months. The Cover group showed better anatomical restoration and vision at 1 month while the Fill technique might be more efficient in closing larger MHs.

Background Perforated peptic ulcers (PPU) represent a significant complication of peptic ulcers, associated with high mortality. As no systematic review of the literature on PPU in children currently exists, this study aims to summarize findings from studies focusing on its risk factors, etiology, treatment modalities, and outcomes. Methods A systematic review was conducted following the PRISMA guidelines. A literature search was performed on 24 November 2024, using four electronic databases: Web of Science, Scopus, PubMed, and ScienceDirect. The inclusion criteria were studies published in English, focusing on perforated peptic ulcers in paediatric patients. The exclusion criteria were: studies published in languages other than English; publication formats such as conference abstracts, personal communications, and single case reports; studies focusing on non-perforated peptic ulcers; studies involving participants > 18 years; and studies reporting ulcer perforations outside the stomach or duodenum. Results Out of 1963 records identified, 12 studies met the inclusion criteria and were included in the review. A total of 239 children with perforated peptic ulcers were analyzed, with a median age of 11 years (range 3.2–16.5 years). The results indicate that ulcer perforations were more prevalent in males (74.8%). Furthermore, duodenal perforations (73%) were more common than gastric perforations (27%). The most commonly reported symptoms were abdominal pain ( n  = 175, 73.2%), vomiting ( n  = 82, 34.3%), peritoneal signs ( n  = 79, 33%), and fever ( n  = 38, 15.9%). Subdiaphragmatic free air was detected in 141 patients (58.9%). Of the total number of patients, 207 (86.6%) were treated surgically, while 32 (13.4%) received conservative treatment. Regarding the surgical approach, most patients underwent open surgery ( n  = 143, 69%) compared to laparoscopic repair ( n  = 64, 31%). Among the surgical procedures, 114 involved simple sutures, with or without an omental patch. Postoperative complications were reported in 30 children (14.5%). Reoperation was required in 4 patients (1.9%), and mortality was recorded in 9 patients (3.8%). Conclusions PPU was more prevalent in males and predominantly located in the duodenum. Ulcer suturing, with or without an omental patch, was the most commonly utilized treatment modality, demonstrating a relatively low complication rate. Further studies are needed to provide more comprehensive and unbiased evidence on PPU in children.

BackgroundThis study aimed to compare laparoscopic lavage and sigmoidectomy as treatment for perforated diverticulitis with purulent peritonitis during a 36 month follow-up of the LOLA trial.MethodsWithin the LOLA arm of the international, multicentre LADIES trial, patients with perforated diverticulitis with purulent peritonitis were randomised between laparoscopic lavage and sigmoidectomy. Outcomes were collected up to 36 months. The primary outcome of the present study was cumulative morbidity and mortality. Secondary outcomes included reoperations (including stoma reversals), stoma rates, and sigmoidectomy rates in the lavage group.ResultsLong-term follow-up was recorded in 77 of the 88 originally included patients, 39 were randomised to sigmoidectomy (51%) and 38 to laparoscopic lavage (49%). After 36 months, overall cumulative morbidity (sigmoidectomy 28/39 (72%) versus lavage 32/38 (84%), p = 0·272) and mortality (sigmoidectomy 7/39 (18%) versus lavage 6/38 (16%), p = 1·000) did not differ. The number of patients who underwent a reoperation was significantly lower for lavage compared to sigmoidectomy (sigmoidectomy 27/39 (69%) versus lavage 17/38 (45%), p = 0·039). After 36 months, patients alive with stoma in situ was lower in the lavage group (proportion calculated from the Kaplan–Meier life table, sigmoidectomy 17% vs lavage 11%, log-rank p = 0·0268). Eventually, 17 of 38 (45%) patients allocated to lavage underwent sigmoidectomy.ConclusionLong-term outcomes showed that laparoscopic lavage was associated with less patients who underwent reoperations and lower stoma rates in patients alive after 36 months compared to sigmoidectomy. No differences were found in terms of cumulative morbidity or mortality. Patient selection should be improved to reduce risk for short-term complications after which lavage could still be a valuable treatment option.

ObjectivesPerforation is the most serious complication associated with endoscopic mucosal resection (EMR). We propose a new classification for the appearance and integrity of the muscularis propria (MP) after EMR including various extents of deep mural injury (DMI). Risk factors for these injuries were analysed.DesignEndoscopic images and histological specimens of consecutive patients undergoing EMR of colonic laterally spreading lesions ≥20 mm at a large Australian tertiary referral endoscopy unit were retrospectively analysed using our new DMI classification system. DMI was graded according to MP injury (I/II intact MP without/with fibrosis, III target sign, IV/V obvious transmural perforation without/with contamination). Histological specimens were examined for included MP and patient outcomes were recorded. All type III–V DMI signs were clipped if possible, types I and II DMI were clipped at the endoscopists’ discretion.ResultsEMR was performed in 911 lesions (mean size 37 mm) in 802 patients (male sex 51.4%, mean age 67 years). DMI signs were identified in 83 patients (10.3%). Type III–V DMI was identified in 24 patients (3.0%); clipping was successfully performed in all patients. A clinically significant perforation occurred in two patients (0.2%). Only one of the 59 type I/II cases experienced a delayed perforation. 85.5% of patients with DMI were discharged on the same day, all without sequelae. On multivariable analysis, type III–V DMI was associated with transverse colon location (OR 3.55, p=0.028), en bloc resection (OR 3.84, p=0.005) and high-grade dysplasia or submucosal invasive cancer (OR 2.97, p 0.014).ConclusionsIn this retrospective analysis, use of the new classification and management with clips appeared to be a safe approach. Advanced DMI types (III–V) occurred in 3.0% of patients and were associated with identifiable risk factors. Further prospective clinical studies should use this new classification.Trial registration numberNCT01368289; results.

Background Prolonged postoperative ileus is linked to a higher risk of additional complications, longer hospital stays, and higher healthcare expenses. There are few randomized controlled trials on the impact of chewing gum on the duration of ileus in patients undergoing emergency surgery, notably those with peritonitis. Compelling evidence from studies on elective procedures demonstrates that chewing gum can lessen the duration of ileus. This trial aimed to examine the effect of chewing gum on the length of the postoperative ileus which develop after laparotomy for gastroduodenal perforations. Materials and methods Multicentre randomized controlled trial. Fifty-two patients were randomly assigned to two treatment groups. Group A received routine care with chewing gum, while group B only received routine care. The primary outcome was the length of postoperative ileus, while the secondary outcomes were the length of hospital stay, in-hospital morbidity, and mortality. The continuous variables were compared using the nonparametric Wilcoxon Rank sum (Mann-Whitney U) test while the categorical outcomes were compared using the chi-squared test in SPSS version 26. The protocol was retrospectively registered with the WHO Pan African Clinical Trial Registry (Number: PACTR202206468032528 ) on the 1st of June 2022. Results Of the 52 participants included in the analysis, the majority were males (80.8%) with a mean age of 34.23 (SD = 11.52) years. There was no statistically significant difference in the baseline characteristics of the study participants between the two groups ( P  > 0.05 for all). The median duration of postoperative ileus was 21.5 h less in the chewing gum group (28.5 versus 50.0, P  = 0.002), while the length of hospital stay was 2.5 days less in the chewing gum group (5.4 versus 7.9, P  = 0.007). There was no significant difference noted in the occurrence of complications. Conclusion Chewing gum that is readily available and reasonably priced may help shorten the duration of post-operative ileus, which has the extra benefit of enabling early discharge.