Background: In armed conflicts, infected wounds constitute a large portion of the surgical workload. Treatment consists of debridements, change of dressings, and antibiotics. Many surgeons advocate for the use of honey as an adjunct with the rationale that honey has bactericidal and hyperosmotic properties. However, according to a Cochrane review from 2015 there is insufficient data to draw any conclusions regarding the efficacy of honey in treatment of wounds. We, therefore, decided to evaluate if honey is non-inferior to gentamicin in the treatment of infected wounds in a highly translatable porcine wound model. Material and methods: 50 standardized wounds on two pigs were infected with S. aureus and separately treated with either topically applied Manuka honey or intramuscular gentamicin for eight days. Treatment efficacy was evaluated with quantitative cultures, wound area measurements, histological, immunohistochemical assays, and inflammatory response. Results: Topically applied Manuka honey did not reduce bacterial count or wound area for the duration of treatment. Intramuscular gentamicin initially reduced bacterial count (geometric mean 5.59*,0.37 - 4.27 *,0.80 log10 (GSD) CFU/g), but this was not sustained for the duration of the treatment. However, wound area was significantly reduced with intramuscular gentamicin at the end of treatment (mean 112.8 +/- 30.0-67.7 +/- 13.2 (SD) mm(2)). ANOVA-analysis demonstrated no variation in bacterial count for the two treatments but significant variation in wound area (p = 0.0001). The inflammatory response was more persistent in the pig with wounds treated with topically applied Manuka honey than in the pig treated with intramuscular gentamicin. Conclusion: At the end of treatment S. aureus count was the same with topically applied Manuka honey and intramuscular gentamicin. The wound area was unchanged with topically applied Manuka honey and decreased with intramuscular gentamicin. Topically applied Manuka honey could consequently be non inferior to intramuscular gentamicin in reducing S. aureus colonization on the wound's surface, but not in reducing wound size. The use of Manuka honey dressings to prevent further progression of a wound infection may therefore be of value in armed conflicts, where definite care is not immediately available. (C) 2021 The Author(s). Published by Elsevier Ltd.

BACKGROUND: Continent ileostomy is a solution for patients after proctocolectomy. OBJECTIVE: The aim of this study was to assess the long-term complications and failure rate alongside patient satisfaction, function, and quality of life for patients with a continent ileostomy. DESIGN: This was a retrospective, descriptive cross-sectional study. SETTINGS: All patients were operated in 1 center between 1980 and 2016. PATIENTS: A total of 85 patients received a de novo continent ileostomy in our institution. Sixty-nine patients (80%) had ulcerative colitis, 12 (14%) had Crohn’s disease, 2 had indeterminate colitis, and 1 each had familial adenomatous polyposis and anal atresia. MAIN OUTCOME MEASURES: Medical charts were reviewed for reoperations and pouchitis. The 36-Item Short Form, Short Health Scale, and a local continent ileostomy questionnaire were used to assess quality of life, function, and satisfaction. RESULTS: After a median follow-up of 24 years, 67 patients (79%) underwent a total of 237 reoperations, of which 15 were conversions to end ileostomies, that is, failures. Fifty patients (59%) underwent repeat laparotomies, excluding loop ileostomy closures. Nipple detachment was the most common cause for repeat laparotomy, and fistulation was the most common cause for pouch removal. IPAA before continent ileostomy was associated with an increased risk for failure. Crohn’s disease was not associated with an increased risk for reoperation or failure. Forty-three patients (84%) reported that they were satisfied. Seventy patients were available for questionnaires, and 50 patients (71%) answered. There was no difference in the 36-Item Short Form between the continent ileostomy population and an age-matched control population. LIMITATIONS: The retrospective, single-center design of the study alongside <100% response rate are to be considered limitations. CONCLUSIONS: Despite large numbers of complications, patients are generally satisfied with their continent ileostomies, and their quality of life is comparable to the general population. See Video Abstract at http://links.lww.com/DCR/B444. SEGUIMIENTO A LARGO PLAZO, SATISFACCIÓN DEL PACIENTE Y CALIDAD DE VIDA PARA PACIENTES CON ILEOSTOMÍA CONTINENTE DE KOCK ANTECEDENTES: La ileostomía continente es una solución para los pacientes después de una proctocolectomía. OBJETIVO: El objetivo de este estudio fue evaluar las complicaciones a largo plazo y la tasa de fracaso junto con la satisfacción del paciente, la función y la calidad de vida de los pacientes con una ileostomía continente. AJUSTES: Todos los pacientes fueron operados en un centro entre 1980 y 2016. DISEÑO: Estudio retrospectivo, descriptivo y transversal. PACIENTES: Un total de 85 pacientes recibieron una ileostomía continente de novo en nuestra institución. Sesenta y nueve (80%) pacientes tenían colitis ulcerosa, doce (14%) enfermedad de Crohn, dos, colitis indeterminada y uno de poliposis adenomatosa familiar y atresia anal respectivamente. PRINCIPALES MEDIDAS DE RESULTADO: Se revisaron los registros médicos en busca de reintervenciones y pouchitis. Se utilizó SF-36, escala de salud corta y un cuestionario de ileostomía continente local para evaluar la calidad de vida, la función y la satisfacción. RESULTADOS: Después de una mediana de seguimiento de 24 años, 67 (79%) pacientes fueron sometidos a un total de 237 reoperaciones, de las cuales 15 fueron conversiones para terminar con ileostomías, es decir, fracasos. 50 (59%) pacientes se sometieron a laparotomías repetidas, excluyendo los cierres de ileostomía en asa. El desprendimiento del pezón fue la causa más común de repetición de laparotomía y la fistulación fue la causa más común de retiro de la bolsa. La anastomosis anal de la bolsa ileal antes de la ileostomía continente se asoció con un mayor riesgo de fracaso. La enfermedad de Crohn no se asoció con un mayor riesgo de reoperación o fracaso. 43 pacientes (84%) informaron que estaban satisfechos. 70 pacientes estuvieron disponibles para cuestionarios y 50 pacientes (71%) respondieron. No hubo diferencia en SF-36 entre la población de ileostomía continente y una población de control de la misma edad. LIMITACIONES: El diseño retrospectivo y unicéntrico del estudio junto con una tasa de respuesta inferior al 100% deben considerarse limitaciones. CONCLUSIÓN: A pesar del gran número de complicaciones, los pacientes generalmente están satisfechos con sus ileostomías continentes y su calidad de vida es comparable a la de la población general. Consulte Video Resumen en http://links.lww.com/DCR/B444.

In the past decades, surgical management of limb injuries in high-resource settings has improved. The possibility of limb salvage has increased. It is not known whether similar changes have transpired in resource-scarce conflict settings. Retrospective cohort study using routinely collected patient data from the International Committee of the Red Cross hospitals in Pakistan was conducted. Consecutive data from 2009 to 2012 (535 patients) and randomly selected data from 1992 to 1995 (463 patients) were used. Only patients with weapon-related limb injuries were included. Differences in surgical procedures were assessed with logistic regression to adjust for confounding factors. Less injuries were related to mines in 2009–2012 than in 1992–1995 (3.7% vs. 20.3%, p < 0.0001), but injuries from bombs, shells and fragments were more frequent (38.5% vs. 19.4%, p  < 0.0001) as were injuries with only a small degree of tissue damage (42.0% vs. 31.1%, p  = 0.0004). In the logistic regression, the time period did not affect the risk of amputation, debridement, length of hospital stay or in-hospital mortality. The use of external fixation (OR 0.56, 95% CI 0.33–0.96, p  = 0.04), split skin grafts (OR 0.31, 95% CI 0.21–0.45, p  < 0.0001) and blood transfusion (OR 0.43, 95% CI 0.28–0.66, p  = 0.0001) was less frequent in 2009–2012. In this resource-scarce conflict setting, the risk of amputation appears unchanged over time, while the use of external fixation and split skin grafts was less common in 2009–2012 than in 1992–1995. These results contrast with the improved limb salvage results seen in high-resource settings. It likely reflects the challenges of providing advanced limb-preserving techniques in a resource-scarce setting.

Purpose The aim of the study was to analyze the surgical needs of patients seeking emergency care at the Mosul General Hospital in the final phase of the battle of Mosul in northern Iraq between an international military coalition and rebel forces. During the conflict, the International Red Committee of the Red Cross (ICRC) supported the hospital with staff and resources. Ceasefire in the conflict was declared at the end of July 2017. Methods Routinely collected hospital data from the ICRC-supported Mosul General Hospital from June 6, 2017, to October 1, 2017 were collected and analyzed retrospectively. All patients with weapon-related injuries as well as all patients with other types of injuries or acute surgical illness were included. Results Some 265 patients were admitted during the study period. Non-weapon-related conditions were more common than weapon-related (55.1%). The most common non-weapon-related condition was appendicitis followed by hernia and soft tissue wounds. Blast/fragment was the most frequent weapon-related injury mechanism followed by gunshot. The most commonly injured body regions were chest and abdomen. Children accounted for 35.3% of all weapon-related injuries. Patients presented at the hospital with weapon-related injuries more than 2 months after the official declaration of ceasefire. A majority of the non-weapon-related, as well as the weapon-related conditions, needed surgery (88.1% and 87.6%, respectively). Few postoperative complications were reported. Conclusions The number of children affected by the fighting seems to be higher in this cohort compared to previous reports. Even several months after the fighting officially ceased, patients with weapon-related injuries were presenting. Everyday illnesses or non-weapon-related injuries dominated. This finding underlines the importance of providing victims of conflicts with surgery for life-threatening conditions, whether weapon related or not.

With a lifelong perspective, 12% of ulcerative colitis patients will need a colectomy. Further reconstruction via ileo-rectal anastomosis or pouch can be affected by patients’ perspective of their quality of life after surgery. To assess the function and quality of life after restorative procedures with either ileo-rectal anastomosis or ileal pouch-anal anastomosis in relation to the inflammatory activity on endoscopy and in biopsies. A total of 143 UC patients operated with subtotal colectomy and ileo-rectal anastomosis or pouches between 1992 and 2006 at Linköping University Hospital were invited to participate. Those who completed the validated questionnaires (Öresland score, SF-36, Short Health Scale) were offered an endoscopic evaluation including multiple biopsies. Associations between anorectal function and quality of life with type of restorative procedure and severity of endoscopic and histopathologic grading of inflammation were evaluated. Some 77 (53.9%) eligible patients completed questionnaires, of these 68 (88.3%) underwent endoscopic evaluation after a median follow-up of 12.5 (range 3.5–19.4) years after restorative procedure. Patients with ileo-rectal anastomosis reported better overall Öresland score: median = 3 (IQR 2–5) for ileo-rectal anastomosis (n = 38) and 10 (IQR 5–15) for pouch patients (n = 39) (p < 0.001). Anorectal function (Öresland score) and endoscopic findings (Baron-Ginsberg score) were positively correlated in pouch patients (tau: 0.28, p = 0.006). Patients operated with ileo-rectal anastomosis reported better continence compared to pouches. Minor differences were noted regarding the quality of life. Ileo-rectal anastomosis is a valid option for properly selected ulcerative colitis patients if strict postoperative endoscopic surveillance is carried out.

Civilians constitute 33–51% of victims in armed conflicts. Several reports on civilian injuries exist, but few have focused on injuries afflicting females. We analyzed routinely collected data on weapon-related injuries from the International Committee of the Red Cross (ICRC) hospital in northwestern Pakistan in order to define injury patterns and types of surgical treatment for females.

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s of Scientific Papers-WADEM Congress on Disaster and Emergency Medicine 2017 Collaborative Operations Military Surgical Team Care in Civilian Hospitals during Russia’s Hybrid War against Ukraine: Injury Patterns and Care Practices Oleksandr Garashchuk, Oleksandr Galiiev, Roman Berezskii, Roman Pavchak, Viacheslav Zinchenko, Yurii Bohuslavskyi 1. Medical Director, NGO “Patriot Defence”, Kyiv/Ukraine 2. Icu Dept., Kyiv Municipal Hospital #17, Kyiv/Ukraine 3. Polytrauma Dept., Kyiv Municipal Hospital #17, Kyiv/Ukraine 4. Military Medical Clinical Center ofWestern Region, L’viv/Ukraine 5. Severodonets’k Municipal Hospital, Severodonets’k/Ukraine Study/Objective: The armed aggression of Russian proxy forces started in April 2014 and targeted densely-populated areas of Eastern Ukraine. New hybrid warfare demands an effective response, especially in military medical care.We report on the results of a 12-month service of a Military Mobile Surgical Team (MST) in a near-frontline Local Civilian Hospital (LCH). Background: Casualty care was provided in Military Mobile Hospitals (MMHs) deployed in the conflict zone. Intense shelling in the summer 2014, forced theMMHs to be relocated to a safe distance from the frontline, thus increasing evacuation time. Later, MSTs (a sub-divisions of MMH) were stationed in LCHs close to the war theater, cooperating with domestic personnel and utilizing existing facilities and equipment. Methods: We reviewed case reports and outpatient records, performed by specialized MSTs of the 59th MMH and local physicians in Severodonets’k Municipal Hospital, Luhans’k region, from April 1, 2015 to April 20, 2016. MST was staffed with anesthesiologists, neurosurgeons, thoracic and vascular surgeons, and engaged LCH’s general and orthopedic surgeons. Results: In the study period 248 servicemen were presented to the trauma bay. Among them, 76 were injured due to mortar shelling and mine traps, and 7 had gunshot wounds (GSW). In total, 83 casualties required 212 surgical procedures with an average of 2.55 per case. Additionally, 165 patients were admitted with various traumas and had 73 surgeries performed. Availability of a CT-scanner has allowed 27 craniotomies (12 due to penetrating brain injuries, 15 to trauma). There were 17 patients who received transfusions in total; of 18 175 ml of FFP and 17 515 ml of pRBCs. The in-hospital mortality was 2.82%. Ambulatory trauma care was provided to 513 servicemen. Conclusion: Cooperation of MSTs with LCHs in non-occupied Eastern Ukraine is effective for providing specialized medical care to Ukrainian servicemen. Deployment of MSTs in frontline LCHs shortens time for casualties to reach surgical care, thus essentially influencing outcomes. Prehosp Disaster Med 2017;32(Suppl. 1):s11 doi:10.1017/S1049023X17000541 Outcome for Patients with Extremity Wound Infection Following War-Associated Injuries Andreas Älgå, Måns Muhrbeck, Harald Veen, Peter Andersson, Johan Von Schreeb, Jonas Malmstedt 1. Department Of Public Health Sciences, Karolinska Institutet, Solna/Sweden 2. Department Of Surgery, Vrinnevi Hospital, Norrköping/Sweden 3. International Committee of the Red Cross, Geneva/Switzerland 4. Centre for Teaching and Research in Disaster Medicine and Traumatology, Linköping/Sweden 5. Department Of Clinical Science And Education, Södersjukhuset, Karolinska Instiutet, Stockholm/Sweden Study/Objective: To assess whether ‘wound infection’ is an independent risk factor for amputation or death. Background: Data on the epidemiology of wound infection in patients with war-associated injuries is limited and mainly describes military combatants. It is unknown to what extent wound infection itself is a factor contributing to serious complications. This is an analysis of data containing both civilians and combatants of both sexes and all ages, originating from an International Committee of the Red Cross Hospital in Peshawar, Pakistan. Methods: We included consecutive patients treated between September 27, 2010 and May 9, 2012 that presented with extremity injuries within two weeks after injury. Wounds with pus discharge were defined as infected. To adjust for trauma severity Revised Trauma Score (RTSc) was calculated by using systolic blood pressure, respiratory rate and Glasgow coma scale. We used binary logistic regression models to evaluate the independent effect of wound infection on outcome. P-values< 0.05 were considered significant. Results: Wounds were infected in 108/1,033 (10.5%) patients treated during the study period. Of patients with wound infection 15/108 (13.9%) died, compared to 24/925 (2.6%) of patients without infection, crude relative risk (RR) = 5.4; p< 0.001. Amputation frequency was 16/108 (14.8%) in patients with infection, and 79/925 (8.5%) in patients without infection, RR = 1.7; p = 0.037. RTSc was missing for 31 patients. Mean RTSc was similar in patients with (7.74; 95% CI 7.72-7.76), and without infection (7.68; 95%CI 7.58-7.79). Wound infection was associated with death and amputation after adjustment for age, sex and RTSc, odds ratio = 9.23; (95% CI 4.17-20.44), p< 0.001 and 1.90; (95% CI 1.03-3.52), p = 0.040 respectively. Conclusion: Extremity wound infection following warassociated extremity injuries seems to be associated with an increased risk of amputation and death, even after adjusting for sex, age and RTSc. We aim to develop models to CIVIL-MILITARY COLLABORATIVE OPERATIONS April 2017 Prehospital and Disaster Medicine identify vulnerable patient groups and risk factors for wound infection. Prehosp Disaster Med 2017;32(Suppl. 1):s11–s12 doi:10.1017/S1049023X17000553 Military and Civilian Collaboration within Medical First Responders the Israeli Experience Eyal Furman, Gil Moshkowitz 1. Medical Department, Israel Defense Forces Home Front Command, KFAR MONASH/Israel 2. Deputy Director General, Head Of Operations, Magen David Adom (Israeli EMS), TEL AVIV/Israel Study/Objective: The two major medical first responding organizations in Israel are the Medical Corps, Israel Defence Forces (IDF) Home Front Command (HFC), and the National Israeli EMS provider, Magen David Adom (MDA). We will describe some of the main, unique, and specific areas of cooperation between MDA and the IDF. Background: The Magen David Adom (MDA) Law, an Israeli Parliament Law from 1950, defines MDA as an operative assistance organization to the IDF Home Front Command (HFC) in case of emergencies and during war time. Cooperation, by law, in preparedness, training, and emergency cases has led to collaboration in day-to-day activity and routine emergencies. Methods: 1. Human Resources support between IDF and MDAmedical teams in various medical events. IDF funding of MDA volunteer course. MDA operates the National Blood Bank, the IDF as the main blood donor. Military blood services unit to assist MDA. IDF recruits the MDAmedical personnel. IDF supplies medical personnel to MDA ambulances. Cooperation of medical teams in humanitarian missions. 2. Training combined training and exercises between IDF and MDA. Interagency cooperation in training (IDF, MDA, MOH, hospitals), mass toxicological events, CBRN drills. Military paramedic course conducted by MDA experts. MDA management goes through senior IDF courses. 3. Command control and coordination independent organizations are routine, there is information replaced in any event. MDA works under IDF HFC coordination during emergency events. 4. Doctrine and regulation sharing and supervising. 5. Equipment both logistic departments work together. Mutual influence leading to advanced, up-to-date medical equipment. 6. Scene response organizations, medical teams can be activated by both. Coordination between IDF Air Force and MDA and IDF HFC. Results: There is a better medical response for civilian and military personnel with collaboration and creating synergism Conclusion: The major keys for success will be described. Prehosp Disaster Med 2017;32(Suppl. 1):s12 doi:10.1017/S1049023X17000565 Military and Civilian Experience in Providing Medical Care to Pediatric Patients in Disasters and Mass Casualty Incidents What Can We Learn from Each Other? Katarzyna Dlugosz The Department Of Disaster Medicine And Emergency Care, Jagiellonian University Medical College, Kraków/Poland Study/Objective: The main purpose of this work is to find common areas of combat medicine and civilian medical rescue in mass casualty incidents and disasters were children are the victims. The results of this study provide the basis for the creation of common solutions that will improve the chance for survival of children in disasters and mass casualty incidents. Background: Mass casualty incidents and disasters involving children are difficult situations for medical emergency responders. Rescuing of patients and providing medical emergency care in these types of events is similar to combat medicine. Exchange of experiences, dilemmas and issues in military medical services is the way to improve operation during mass casualty incidents and disasters that involve pediatric patients. Methods: In this research we invited Polish soldiers who are paramedics, and when they were on a military mission, they provided emergency medical care to pediatric victims. A second research group are former civilian medical rescuers, who have provided medical care to pediatric patients of disasters or mass events. Participants were asked questions about difficulties, dilemmas, ways of providing medical care for children, evacuation and transport of pediatric patients from the scene to the hospital. Results: Dilemmas and difficulties in providing medical emergency care to pediatric victims in mass casualty incidents and disasters, are similar to those in combat medicine when the military paramedics save children’s lives. The common areas include ethical dilemmas, regarding providing emergency medical care, opportunities and access to resources, rescuers, medical equipment and pediatric pa

BACKGROUND & AIMS: Patients with ulcerative colitis (UC) have an increased risk of rectal cancer, therefore reconstruction with an ileal pouch-anal anastomosis (IPAA) generally is preferred to an ileorectal anastomosis (IRA) after subtotal colectomy. Similarly, completion proctectomy is recommended for patients with ileostomy and a diverted rectum, although this approach has been questioned because anti-inflammatory agents might reduce cancer risk. We performed a national cohort study in Sweden to assess the risk of rectal cancer in patients with UC who have an IRA, IPAA, or diverted rectum after subtotal colectomy.METHODS: We collected data from the Swedish National Patient Register for a cohort of 5886 patients with UC who underwent subtotal colectomy with an IRA, IPAA, or diverted rectum from 1964 through 2010. Patients who developed rectal cancer were identified from the Swedish National Cancer Register. The risk of rectal cancer was compared between this cohort and the general population by standardized incidence ratio analysis.RESULTS: Rectal cancer occurred in 20 of 1112 patients (1.8%) who received IRA, 1 of 1796 patients (0.06%) who received an IPAA, and 25 of 4358 patients (0.6%) with a diverted rectum. Standardized incidence ratios for rectal cancer were 8.7 in patients with an IRA, 0.4 in patients with an IPAA, and 3.8 in patients with a diverted rectum. Risk factors for rectal cancer were primary sclerosing cholangitis in patients with an IRA (hazard ratio, 6.12), and colonic severe dysplasia or cancer before subtotal colectomy in patients with a diverted rectum (hazard ratio, 3.67).CONCLUSIONS: In an analysis of the Swedish National Patient Register, we found that the risk for rectal cancer after colectomy in patients with UC is low, in relative and absolute terms, after reconstruction with an IPAA. An IRA and diverted rectum are associated with an increased risk of rectal cancer, compared with the general population, but the absolute risk is low. Patients and their health care providers should consider these findings in making decisions to leave the rectum intact, perform completion proctectomy, or reconstruct the colon with an IRA or IPAA.

Background. The aim of this study was to examine the effect of colitis and anti-inflammatory therapies on the healing of colonic anastomoses in mice. Methods. Female C57BL/6 mice were randomized into eight groups; four groups receiving plain tap-water and four groups receiving dextran sulfate sodium. Intra-peritoneal treatment was given therapeutically for 14 days with placebo, prednisolone, azathioprine, or infliximab (IFX). Colonic anastomoses were performed and bursting pressure (BP) measurements were recorded and the inflammation evaluated with histology and zymography. Results. The mice with colitis had a more active inflammation based on histology and bowel weight compared with the tap water group, 8.3 (7.6-9.5) mg/mm and 5.5 (4.8-6.2) mg/mm respectively (p < 0.0001). Similarly mice with colitis receiving placebo had a more active inflammation, 12.8 (10.6-15.0) mg/mm, which differed significantly from all the other therapy arms among the colitic mice; prednisolone 8.1 (7.5-9.1) mg/mm (p = 0.014), azathioprine 8.2 (7.0-8.5) mg/mm (p = 0.0046), IFX 6.7 (6.4-7.9) mg/mm (p = 0.0055). BP for the placebo group was 90.0 (71.5-102.8) mmHg and did not differ from azathioprine or IFX groups, 84.4 (70.5-112.5) and 92.3 (75.8-122.3) mmHg respectively. In contrast BP for the prednisolone group was significantly decreased compared to placebo, 55.5 (42.8-73.0) mmHg (p = 0.0004). Conclusions. All therapies had a beneficial effect on the colitis. An impaired BP of colonic anastomoses was noted after preoperative steroids but not after azathioprine or IFX in this model.

Introduction. Restorative surgery for ulcerative colitis with ileal pouch anal anastomosis (IPAA) is frequently accompanied by complications. Volvulus of the ileal pouch is one of the most rarely reported late complications and to our knowledge no report exists on reoperative surgery for this condition. Case Report. A 58-year-old woman who previously had undergone restorative proctocolectomy due to ulcerative colitis with an IPAA presented with volvulus of the pouch. She was operated with a single row pouchopexy to the presacral fascia. Two months later she returned with a recurrent volvulus. At reoperation, the pouch was found to have become completely detached from the fascia. A new pexy was made by firmly anchoring the pouch with two rows of sutures to the presacral fascia as well as with sutures to the lateral pelvic walls. At follow-up after five months she was free of symptoms. Conclusion. This first report ever on reoperative surgery for volvulus of a pelvic pouch indicates that a single row pouchopexy might be insufficient for preventing retwisting. Several rows seem to be needed.

Introduction: Real pouch anal anastomosis (IPAA ) is the standard procedure for reconstruction after colectomy for ulcerative colitis (UC). However, ileorectal anastomosis (IRA) as an alternative has, recently experienced a revival. This study from a single center compares the clinical outcomes of these procedures.Methods: From 1992 to 2006, 253 patients consecutively underwent either IRA (n=105) or IPAA (n=148). Selection to either procedure was determined on the basis of rectal inflammation, presence of dysplasia/cancer or patient preferences. Patient-records were retrospectively evaluated. Mean follow-up time was 5.4 and 6.3 years respectively.Results: Major postoperative complications occurred in 12.4% of patients after IRA and in 12.8% after IPAA (ns). Complications of any kind after IRA or IPAA, even including subsequent stoma-closure, occurred in 23.8% and 39.9% respectively (p<0.01). Estimated cumulative failure rates after 5 and 10 years were 10.1% and 24.1% for IRA and 6.1% and 18.6% for IPAA respectively (ns). The most common cause for failure was intractable proctitis (4.8%) and unspecified dysfunction (4.8%) respectively. At follow-up 76.9% of patients with IRA had proctitis and 34.1% with IPAA had pouchitis. Estimated cumulative cancer-risk after 10, 20 and 25 year duration of disease was 0.0%, 2.1% and 8.7% for IRA. Figures for IPAA were 0.7%, 1.8% and 1.8% (ns).Conclusion: Failure-rates did not significantly differ between patients operated with IRA or IPAA. Patients operated with IPAA had a higher cumulative number of postoperative complications. The high long-term cancer-risk after IRA indicates that this procedure should be an interim solution in younger patients. (C) 2013 European Crohn's and Colitis Organisation. Published by Elsevier B.V. All rights reserved.

Adjusted hazard rate (95% confidence interval)

Abstract Background Subspecialisation within general surgery has today reached further than ever. However, on-call time, an unchanged need for broad surgical skills are required to meet the demands of acute surgical disease and trauma. The introduction of a new subspecialty in North America that deals solely with acute care surgery and trauma is an attempt to offer properly trained surgeons also during on-call time. To find out whether such a subspecialty could be helpful in Sweden we analyzed our workload for emergency surgery and trauma. Methods Linköping University Hospital serves a population of 257 000. Data from 2010 for all patients, diagnoses, times and types of operations, surgeons involved, duration of stay, types of injury and deaths regarding emergency procedures were extracted from a prospectively-collected database and analyzed. Results There were 2362 admissions, 1559 emergency interventions; 835 were mainly abdominal operations, and 724 diagnostic or therapeutic endoscopies. Of the 1559 emergency interventions, 641 (41.1%) were made outside office hours, and of 453 minor or intermediate procedures (including appendicectomy, cholecystectomy, or proctological procedures) 276 (60.9%) were done during the evenings or at night. Two hundred and fifty-four patients were admitted with trauma and 29 (11.4%) required operation, of whom general surgeons operated on eight (3.1%). Thirteen consultants and 11 senior registrars were involved in 138 bowel resections and 164 cholecystectomies chosen as index operations for standard emergency surgery. The median (range) number of such operations done by each consultant was 6 (3–17) and 6 (1–22). Corresponding figures for senior registrars were 7 (0–11) and 8 (1–39). Conclusion There was an uneven distribution of exposure to acute surgical problems and trauma among general surgeons. Some were exposed to only a few standard emergency interventions and most surgeons did not operate on a single patient with trauma. Further centralization of trauma care, long-term positions at units for emergency surgery and trauma, and subspecialisation in the fields of emergency surgery and trauma, might be options to solve problems of low volumes.

Background: Objectively assessed physical performance is a strong predictor for morbidity and premature death and there is an increasing interest in the role of sarcopenia in many chronic diseases. There is a need for robust and valid functional tests in clinical practice. Therefore, the repeatability and validity of a newly developed maximal step up test (MST) was assessed.Methods: The MST, assessing maximal step-up height (MSH) in 3-cm increments, was evaluated in 60 healthy middle-aged subjects, 30 women and 30 men. The repeatability of MSH and the correlation between MSH and isokinetic knee extension peak torque (IKEPT), self-reported physical function (SF-36, PF), patient demographics and self-reported physical activity were investigated.Results: The repeatability between occasions and between testers was 6 cm. MSH (range 12-45 cm) was significantly correlated to IKEPT, (r = 0.68, P < 0.001), SF-36 PF score, (r = 0.29, P = 0.03), sex, age, weight and BMI. The results also show that MSH above 32 cm discriminates subjects in our study with no limitation in self-reported physical function.Conclusions: The standardised MST is considered a reliable leg function test for clinical practice. The MSH was related to knee extension strength and self-reported physical function. The precision of the MST for identification of limitations in physical function needs further investigation.

Surgery continues to play an important role in the therapeutic arsenal in ulcerative colitis. In acute colitis, close collaboration between the gastroenterologist and the surgeon is pertinent. Absolute indications for surgery include toxic megacolon, perforation, and severe colorectal bleeding. In addition, surgery should always be considered upon deterioration during medical therapy. The recommended operation in acute colitis is colectomy and ileostomy, with the rectum left in situ; reconstruction is not an option in the acute setting. In chronic continuous colitis, often with long-term steroid therapy, healing conditions are poor. A staged procedure is preferred also in these cases. In cases with dysplasia, surgery should be done after verifying the dysplasia since these patients often have little symptoms from their colitis. The proctocolectomy should in these cases include total mesorectal excision. Ileal pouch-anal anastomosis is the standard bowel reconstruction in ulcerative colitis. The various options should, however, always be thoroughly discussed, considering the pros and cons in each individual patient, before a choice is made. Ileorectal anastomosis is a temporary alternative in select cases (e.g. young women not having had children). Reconstructive surgery is best done approximately 6 months after primary surgery. Surgery for ulcerative colitis should be seen as complementary to medical treatment and may prevent complications, improve the patients’ quality of life and occasionally be life-saving. Correct assessment and optimised medical treatment are prerequisites for surgery on accurate indications and good surgical results. Therefore, close interactions between gastroenterologists and colorectal surgeons are mandatory for optimal patient outcome.

Inflammatory bowel disease (IBD) is a term used to describe ulcerative colitis and Crohn's disease. Both are chronic, lifelong conditions characterised by periods of exacerbation and remission. The management of IBD is complex for the health care team. Following an exploration of the physical, psychological and sociological impact of the condition, the medications used to control the symptoms are described, together with consideration of the surgical options used in the management of IBD. Finally, the role of the nurse in meeting holistically the needs of patients with IBD is highlighted.

A phytobezoar is a rare differential diagnosis in the acute abdomen. An 89-year-old woman presented with lower abdominal pain. A computed tomography scan and ultrasound suggested the presence of a bezoar. A phytobezoar was extracted surgically, and a resection was performed of the perforated small bowel segment. The etiology and management of phytobezoars are discussed.

PURPOSE:Thiopurines are important as maintenance therapy in Crohn's disease, but there have been concerns whether thiopurines increase the risk for anastomotic complications. The present study was performed to assess whether thiopurines alone, or together with other possible risk factors, are associated with postoperative intra-abdominal septic complications after abdominal surgery for Crohn's disease.METHODS:Prospectively registered data regarding perioperative factors were collected at a single tertiary referral center from 1989 to 2002. Data from 343 consecutive abdominal operations on patients with Crohn's disease were entered into a multivariate analysis to evaluate risk factors for intra-abdominal septic complications. All operations involved either anastomoses, strictureplasties, or both; no operations, however, involved proximal diversion.RESULTS:Intra-abdominal septic complications occurred in 26 of 343 operations (8%). Thiopurine therapy was associated with an increased risk of intra-abdominal septic complications (16% with therapy; 6% without therapy; P = 0.044). Together with established risk factors such as preoperative intra-abdominal sepsis (18% with sepsis; 6% without sepsis; P = 0.024) and colo-colonic anastomosis (16% with such anastomosis; 6% with other types of anastomosis; P = 0.031), thiopurine therapy was associated with intra-abdominal septic complications in 24% if any 2 or all 3 risk factors were present compared with 13% if any 1 factor was present, and only 4% in patients if none of these factors were present (P < 0.0001).CONCLUSIONS:Thiopurine therapy is associated with postoperative intra-abdominal septic complications. The risk for intra-abdominal septic complications was related to the number of identified risk factors. This increased risk should be taken into consideration when planning surgery for Crohn's disease.