BACKGROUND: Despite the existing evidence, the omission of antibiotics in the management of acute uncomplicated diverticulitis has not gained widespread acceptance. OBJECTIVE: This study aims to incorporate the input of both patients and physicians on the omission of antibiotics in uncomplicated diverticulitis to generate noninferiority margins for 3 outcomes. DESIGN: This was a mixed-methods study, including in-person interviews with patients and a Delphi process with physicians. SETTINGS: North American patients and physicians participated. PATIENTS: Consecutive patients undergoing colonoscopy, 40% of whom had a previous history of diverticulitis, were selected. INTERVENTIONS: Informational video (for patients) and evidence summaries (for physicians) regarding antibiotics in diverticulitis were reviewed. MAIN OUTCOMES MEASURES: Noninferiority margins were generated for time to reach full recovery, persistent diverticulitis, and progression to complicated diverticulitis in the context of a nonantibiotic strategy. Consensus was defined as an interquartile range <2.5. RESULTS: Fifty patients participated in this study. To avoid antibiotics, patients were willing to accept up to 5.0 (3.0–7.0) days longer to reach full recovery, up to an absolute increase of 4.0% (4.0–6.0) in the risk of developing persistent diverticulitis, and up to an absolute increase of 2.0% (0–3.8) in the risk of progressing to complicated diverticulitis. A total of 55 physicians participated in the Delphi (round 1 response rate = 94.8%; round 2 response rate = 100%). Consensus noninferiority margins were generated for persistent diverticulitis (4.0%, 4.0–5.0) and progression to complicated diverticulitis (3.0%, 2.0–3.0), but could not be generated for time to reach full recovery (5.0 days, 3.5–7.0). LIMITATIONS: Patients were recruited from a single institution, and Delphi participants were invited and not randomly selected. CONCLUSION: Noninferiority margins were generated for 3 important outcomes after the treatment of acute uncomplicated diverticulitis in the context of a nonantibiotic strategy.

Introduction The objective of this study was to evaluate the impact of preoperative bowel stimulation on the development of postoperative ileus (POI) after loop ileostomy closure. Methods This was a multicenter, randomized controlled trial (NCT025596350) including adult (≥ 18 years old) patients who underwent elective loop ileostomy closure at 7 participating hospitals. Participants were randomly assigned (1:1) using a centralized computer-generated sequence with block randomization to either preoperative bowel stimulation or no stimulation (control group). Bowel stimulation consisted of 10 outpatient sessions within the 3 weeks prior to ileostomy closure and was performed by trained Enterostomal Therapy nurses. The primary outcome was POI, defined as an intolerance to oral food in the absence of clinical or radiological signs of obstruction, on or after postoperative day 3, that either (a) required nasogastric tube insertion; or (b) was associated with two of the following: nausea/vomiting, abdominal distension, or the absence of flatus. Results Between January 2017 and November 2020, 101 patients were randomized, and 5 patients never underwent ileostomy closure; thus, 96 patients (47 stimulated vs. 49 control) were analyzed according to a modified intention-to-treat protocol. Baseline characteristics were well balanced in both groups. The incidence of POI was lower among patients randomized to stimulation (6.4% vs. 24.5%, p = 0.034; unadjusted RR: 0.26, 95% CI 0.078–0.87). Stimulated patients also had earlier median time to first flatus (2.0 days (1.0–2.0) vs. 2.0 days (2.0–3.0), p = 0.025), were more likely to pass flatus on postoperative day 1 (46.8% vs. 22.4%, p = 0.022), and had a shorter median postoperative hospital stay (3.0 days (2.0–3.5) vs. 4.0 days (2.0–6.0), p = 0.003). Conclusions Preoperative bowel stimulation via the efferent limb of the ileostomy reduced POI after elective loop ileostomy closure.

Operative classification of ventral abdominal hernias: new and practical classification. Yasser Selim. From the Ministry of Health.Background: Ventral hernias of the abdomen are defined as a noninguinal, nonhiatal defect in the fascia of the abdominal wall. Unfortunately, there is not currently a universal classification system for ventral hernias. One of the more accepted classification systems is that of the European Hernia Society (EHS). Its limitation is that it does not include individual patient risk factors and wound classification. The aim of this work was to find out the basic principles of hernia etiology and pathogenesis, clarify the factors that are important in treatment of ventral hernias, and categorize hernia patients according to those factors. Methods: This retrospective study included 238 patients who presented to our surgery department between 2010 and 2020. A full description of ventral hernias was made, including their type according to the EHS. In addition, abdominal wall components were assessed, including strength of rectus muscles, lateral abdominal muscles, and abdominal fascia, namely the linea alba. Patients with spontaneous hernias were grouped according to the size of the defect and the condition of the rectus abdominis muscles, the fascia and other abdominal muscles. Results: Patients were put into 6 clinical categories: type 1A, type 1B, type 2, type 3, type 4, and type 5. The grouping of patients was done according to the factors we believed affect the choice of surgical procedure and the prognosis of repair. Patients with types 1 and 2 have normal abdominal muscles, whereas those with types 3 and 4 have weak muscles and weak stretched fascia (linea alba). Type 5 includes incisional hernias. Conclusion: The primary purpose of any classification should be to improve the possibility of comparing different studies and their results. By describing hernias in a standardized way, different patient populations can be compared. Numerous classifications for groin and ventral hernias have been proposed over the past 5-6 decades. For primary abdominal wall hernias, there was agreement with EHS classification on the use of localization and size as classification variables.

The Immunity-Related GTPase Family M protein (IRGM) is involved in regulating cellular autophagy. Cellular knockdown of IRGM was shown to allow RNA viruses to hijack the autophagic immune response. Additionally, recent genetic studies have shown that underexpression of IRGM is associated with the incidence of Crohn's disease and infection by Mycobacterium tuberculosis. IRGM is an interferon-induced GTPase with an evolutionary conserved P-loop. It is an effector of the interferon-gamma pathway, but, unlike its protein family members, is not directly activated by the pathway. Its mechanism of action has been proposed to occur by translocation of IRGM to the mitochondria through recognition of cardiolipin, and affecting mitochondrial fission to induce autophagy. This potential interaction with cardiolipin might indicate the presence of a unique GTPase recognition and activation fold within IRGM. Our goal is to determine the X-ray crystal structure of IRGM in an effort to understand its molecular role in normal and diseased states. Additionally, we seek to test its interaction with and mechanism of recognition to mitochondrial cardiolipin as well as other autophagy-inducing binding partners. Currently, we have managed to express human IRGM in bacterial cells and have purified it to homogeneity using affinity and size-exclusion chromatography. These findings will serve to elucidate the mechanism of action of IRGM. Crucially, we hope to gain an understanding of its contributing role to Crohn's disease and tuberculosis infection at the molecular level, potentially paving the way to structure-based drug design and therapeutic opportunities.