Vaccination Status is Not Associated With Adverse Postoperative Outcomes Following Total Joint Arthroplasty in Patients With a Preoperative COVID-19 Diagnosis

Background

Previous studies have shown that COVID-19 diagnosis increases rates of perioperative infection, readmission, and other complications following surgery. However, the effect of the COVID vaccine in such patients is unknown. We hypothesized that of the patients with COVID diagnosis, vaccinated patients with COVID-19 diagnosis would have lower rates of adverse complications compared to unvaccinated patients undergoing total joint arthroplasty (TJA).

Methods

Using a national database registry, patients aged less than 85 years undergoing elective primary total knee or total hip arthroplasty with at least 90 days of follow-up were included during the first year of COVID-19 pandemic from April 2020-April 2021. Patients were included in the COVID-19 cohort if they had a diagnosis on the day of surgery or within 30 days prior to surgery. Patients with a history of malignancy, joint injection, femoral neck fractures, tibial fractures, and those undergoing revision arthroplasty were excluded from the study. All comparisons were performed using multivariate logistic regression with significance set at P < .05. Odds ratio and 95% confidence interval were reported for all comparisons.

Results

There were a total of 1280 patients with COVID-19 diagnosis matched with 3831 patients without COVID-19 diagnosis. Patients with a COVID-19 diagnosis were at an increased risk of pneumonia, acute kidney injury, urinary tract infection, and readmission following TJA compared to patients without COVID-19 diagnosis. However, there were no differences in any complications assessed between vaccinated patients and unvaccinated patients with COVID-19 diagnosis following TJA.

Conclusions

This study confirms that patients with a COVID-19 diagnosis in the 30 days prior to TJA, whether vaccinated or not, have increased risks of medical complications and hospital utilization. However, this study demonstrates that vaccination status does not appear to be associated with the incidence of adverse postoperative events in patients with a COVID-19 diagnosis prior to TJA.

PErioperative respiratory care aNd outcomes for patients underGoing hIgh risk abdomiNal surgery (PENGUIN): a randomised international internal pilot trial

Background

Infections are a common complication of abdominal surgery in low- and middle-income countries (LMICs). The role of a high fraction of inspired oxygen (FiO2) and chlorhexidine mouthwash in preventing post-operative infections is unconfirmed.

Methods

Internal pilot phase of an international outcome assessor-blinded, 2x2 factorial randomised trial of patients aged ≥10-years undergoing midline laparotomy in LMIC hospitals. The main trial objectives are to compare the clinical effectiveness of preoperative 0.2% chlorhexidine mouthwash in preventing pneumonia versus no mouthwash, and 80-100% perioperative FiO2 to prevent surgical site infection (SSI) versus 21-35% FiO2. This 12-month internal pilot assessed feasibility of hospital site opening, patient recruitment, intervention adherence, patient follow-up and safety. Patients were randomised in a 1:1:1:1 ratio to the four intervention group combinations and followed up for 30 days.

Results

We recruited 927 patients from seven hospitals in India and South Africa over 12 months from November 2020. There were 907 adults (97.8%) and 20 children aged ten or over (2.2%): 89/927 (9.6%) patients died. Site opening reached 70% of our target (7/10) hospitals, and patient recruitment 107% (927/870). 917/927 (99%) patients in the mouthwash arm, and 840/927 (91%) patients in the oxygen arm received the allocated intervention. Lower adherence to the oxygen intervention related mainly to clinically necessary FiO2 increases in the 21-35% FiO2 arm. 30-day follow-up was completed appropriately for 924/927 (99%) patients. and was performed by a masked assessor for all patients. There were no reported safety events.

Conclusion

This pilot showed the feasibility and safety of a major phase III trial in post-operative infection prevention in LMICs.

Trial registration

ClinicalTrials.gov NCT04256798.

Hepatic Portal Venous Perfusion Imaging Using Vessel-Labeling Super-Resolution Ultrasound

OBJECTIVE

Blood flow imaging and perfusion assessment of the hepatic portal vein are critical for the diagnosis of several liver diseases, including cirrhosis, primary and metastatic liver tumors. However, perfusion imaging of the portal vein is challenging due to the unique dual blood supply system of the liver.

METHODS

We developed a novel method for specific perfusion imaging of the portal vein and downstream vessels, which was validated on healthy mice (n = 4). The right lobe of the liver in healthy mice was sequentially imaged using ultrafast plane-wave Doppler imaging and vascular labeling. In each experiment, mice were first injected with phase-change nanodroplets (PCNDs), followed immediately by ultrafast Doppler imaging to determine the imaging section and locate portal vein branches. Through an interactive process, portal vein branches were selected by mouse click for data acquisition of vessel-labeling ultrasound (VLUS) based on PCNDs. Subsequent arrival time calculations and super-resolution ultrasound (SRUS) imaging were performed offline. To demonstrate the specificity of the proposed method for vascular imaging, one mouse was injected with Sonovue microbubbles for plane-wave ultrasound data acquisition and microbubble-based VLUS data acquisition. All imaging experiments were conducted on the Verasonics (Kirkland, WA, USA) Vantage 256 ultrasound system using an L22-8v linear array transducer with a center frequency of 15.625 MHz. The multi-angle coherent compounding plane-wave acquisition frame rate was 500 Hz.

RESULTS

Imaging results from healthy mice (n = 4) demonstrated that VLUS was able to label different branches of the hepatic portal vein and specifically image downstream vessels. Analysis of the in vivo results at different spatial scales showed that the brightness of the downstream perfusion area was significantly enhanced after labeling started, while there was no significant difference in image brightness before the labeling started and after it ended. By analyzing the acoustic field distribution at the focal point, the full width at half maximum in the x1 and z1 directions were 98.56 μm and 526.68 μm, respectively. Along the propagation path of the focused beam (outside the labeling area), no significant activation of the PCNDs was observed (p < 0.0001). Combined with SRUS technology, the resolution of the VLUS portal vein imaging results was further enhanced. The time-intensity curves of the downstream regions of interest indicated that VLUS provided a step input signal to the downstream vessels. Based on the arrival time of the step point in the time-intensity curves, the arrival time distribution map of the downstream vessels relative to the labeling point could be calculated.

CONCLUSION

We propose a novel method for hepatic portal vein perfusion imaging based on VLUS. In vivo experiments, simulation results and statistical analysis demonstrate that this method is able to accurately label portal vein vessels with millimeter-level precision, enabling specific high-resolution imaging and precise, non-invasive measurement of the downstream perfusion area. By combining VLUS with SRUS technology, the resolution of the portal vein imaging results can be further enhanced.

An Australian regional hospital's oesophagectomy experience: A 10-year case series from Tasmania

Introduction

Oesophagectomy is recommended as part of curative treatment for oesophageal cancer but is associated with substantial morbidity. Centralization has been recommended to improve outcomes, but this has not been widely applied in Australia. This study aimed to audit a regional hospital's experience over ten years and compare it to outcomes from national and international centres to support the view that oesophagectomy can be performed safely in select regional centres in Australia.

Methods

Patients undergoing oesophagectomy at a single regional hospital in North-East Tasmania, Australia between January 2014 and December 2023 were retrospectively identified. Preoperative patient and tumour characteristics, and outcomes (mortality, anastomotic leak, length of stay, respiratory complications, long-term complications and survival) were compared to other centres.

Results

65 patients were identified. 53 % were male, mean age was 65.2 years, 29.2 % had respiratory disease and 18.5 % were current smokers. The anastomotic leak rate was 7.7 %. 25 % developed pneumonia postoperatively. Average ICU length of stay was 4.6 days, median acute inpatient length of stay was 15 days. There was one in-hospital mortality and one 30-day mortality. 2 patients (3 %) required diaphragmatic hernia repair; 12 patients (18.5 %) required endoscopic dilatation of anastomotic strictures. The 5-year survival rate was 66 %. Our results compare favourably to published rates of anastomotic leak (10-15 %), inpatient stay (15 days), pneumonia (20-30 %), 30-day mortality (1-4 %) and anastomotic stricture (20 %).

Conclusions

Oesophagectomies can be safely performed in regional centres in Australia that routinely undertake a higher volume of cases per year, provided services required to manage complications are readily available.

Comparison of Sugammadex Versus Neostigmine for Postoperative Outcomes in Coronavirus Disease 2019 Patients Undergoing Thoracic Surgery: A Cohort Study

OBJECTIVE

This study was designed to evaluate whether the use of sugammadex was associated with a lower incidence of pulmonary complications than neostigmine in patients with coronavirus disease 2019 (COVID-19) undergoing thoracic surgery.

DESIGN

This was a matched cohort study using data from the TriNetX database.

SETTING

Operating room.

PARTICIPANTS

Adult patients with COVID-19 within 6 weeks before thoracic surgery.

INTERVENTION

The use of sugammadex or neostigmine to reverse muscular blockade.

MEASUREMENTS AND MAIN RESULTS

Outcomes included the incidence of composite pulmonary complications (CPCs) (primary outcome), pneumonia, respiratory failure, need for intensive care, mortality, sepsis, and acute kidney injury at 30-day follow-up. The potential benefits of sugammadex were also assessed at 90-day follow-up. Predictors of pulmonary complications were identified in those receiving sugammadex. After matching, 985 patients were included in each group. At 30 days, the incidence of CPCs (5.69% v 9.75%; odds ratio [OR]: 0.56, p = 0.0009), pneumonia (1.83% v 4.37%; OR: 0.41, p = 0.0016), and respiratory failure (1.42% v 3.25%; OR: 0.43, p = 0.0087) were significantly lower with sugammadex than neostigmine. No differences were found in other 30-day outcomes. Diabetes and chronic obstructive pulmonary disease were identified as risk factors for pneumonia and respiratory failure. At 90 days, no significant differences were observed, although mortality tended to be lower with sugammadex.

CONCLUSION

In patients with COVID-19 undergoing thoracic surgery, sugammadex was associated with a reduction in 30-day postoperative pulmonary complications compared with neostigmine. However, this finding requires validation in larger, randomized trials.

Potentially low-value operative care in abdominal trauma: A retrospective National Trauma Data Bank study

BACKGROUND

We currently lack national data on adherence to American College of Surgeons recommendations on nonoperative management for hemodynamically stable adults with solid-organ injuries. We aimed to estimate the incidence and interhospital variation in potentially low-value operative management for adults with blunt solid abdominal organ injuries.

METHODS

We included adults with blunt solid-organ injury eligible for nonoperative management (grades I-IV spleen and liver and grade I-III kidney, hemodynamically stable on arrival, and no blood products used in the emergency department) who were admitted to trauma centers in the United States that submitted data to the National Trauma Data Bank between 2016 and 2019. Low-value operative management was defined as laparotomy within 6 hours of admission. Interhospital variation was measured using risk-adjusted intraclass correlation coefficients (<5% low, 5-20% moderate, and >20% high).

RESULTS

In total, 62,601 adults in 324 American College of Surgeons-verified level I-III trauma centers and 297 state-designated centers were included. Adjusted incidences of potentially low-value operative management were 2.7% overall (6.8%, 2.1%, 0.8%, for spleen, liver, and kidney injuries) and 2.6%, 2.5%, and 3.0% for American College of Surgeons-verified level I, level II, and state-designated centers. Interhospital variation was moderate to high with a global intraclass correlation coefficient of 21% and intraclass correlation coefficients of 18%, 25%, and 21% for American College of Surgeons-verified level I, level II, and state-designated trauma centers, respectively.

CONCLUSION

Results suggest that low-value operative management is uncommon in US trauma centers, but variation between same-level trauma centers is moderate to high. Future research should strive to identify determinants, and assess impact on patient outcomes.

A Clinical Audit of Surgical Site Infection Surveillance in a Maxillo-Facial and Oral Surgery Unit in an Academic Hospital Complex in South Africa

The clinical outcomes and financial impact of surgical site infection within South Africa is not well known due to the lack of an established national surveillance programme. The aim of this project was to undertake a baseline clinical audit of surgical site infection prevention in a Maxillo-facial and Oral Surgery unit using the National Institute for Health and Care Excellence clinical guideline (NG125) as the benchmark standard. The primary objective was to establish a baseline incidence of surgical site infection. This was a prospective and observational clinical audit undertaken at the MFOS unit in a University Hospital in South Africa. Thirty-seven participants who had surgical procedures were recruited and monitored telephonically post-discharge for a period of 30 days. The composite compliance rate to the process indicators was 39.86% (95% Confidence Interval 37.25-42.46). The incidence rate of surgical site infection was 14.81% (n = 8). The resection of head and neck malignancy contributed majority of the SSI cases (50%, n = 4). Five organ/space SSI cases were detected with a mortality rate of 25% (n = 2). The higher surgical site infection rates may be associated with the lapses in the infection control practices. For example, the lack of an aseptic technique lack or structured approach to wound management. The main recommendation was the development of evidence-based surgical site infection preventative strategies that are applicable to the Maxillo-facial and Oral Surgery procedures to reduce surgical site infection.

Multicentre Study of 10,369 Symptomatic Patients Comparing the Diagnostic Accuracy of Colon Capsule Endoscopy, Colonoscopy and CT Colonography

BACKGROUND

During the COVID-19 pandemic, NHS England introduced colon capsule endoscopy (CCE) at scale to support the recovery of endoscopy. Symptomatic patients referred with suspected colorectal cancer (CRC) and a faecal immunochemical test (FIT) ≤ 100 μg Hb/g faeces were offered CCE.

AIMS

To evaluate the safety, diagnostic accuracy and utility of CCE in this setting.

METHODS

Consenting patients, referred on a suspected CRC pathway with FIT ≤ 100 μg Hb/g faeces, were offered CCE, colonoscopy or CT colonography. Each cohort was to be age-, sex-, symptom- and FIT-matched. We performed a paired comparison of findings in those who required colorectal endoscopy after CCE and recorded clinical outcomes.

RESULTS

We recruited 4878 patients for CCE, 5025 for colonoscopy and 466 for CT colonography patients. CCE was safely tolerated by 98.4% of patients. CCE identified a matched mass lesion in all patients with CRC when the examination was complete and adequately prepared. More polyps ≥ 10 mm and 6-9 mm were detected by CCE than by colonoscopy or CT colonography. Per-patient sensitivities for polyps ≥ 10 mm and 6-9 mm were 97% in those with a paired, complete and adequately prepared CCE than colonoscopy. Completion (74%) and bowel preparation adequacy rates (74%) were poorer than those of colonoscopy and CTC (both 88%). However, CCE usefully performed a filter function in 86% of patients.

CONCLUSIONS

CCE is safe and accurate for the diagnosis of colorectal disease. In the suspected CRC pathway, its 'filter function' complements existing colorectal diagnostic services by creating additional capacity.

Incidence of Compartment Syndrome Following Peri-Pandemic Intervention for Non-traumatic Acute Limb Ischemia

ObjectiveDuring the pandemic, our institution anecdotally observed a significant proportion of acute limb ischemia (ALI) patients developing compartment syndrome (CS) following revascularization compared to pre-pandemic rates. To determine whether this perceived increase was occurring globally, we utilized the TriNetX database to evaluate the incidence of CS secondary to ALI intervention in both the pre-pandemic (2017-2019) and pandemic eras (2020-2022).MethodsWe conducted a multicenter query using the TriNetX global research network for ALI patients receiving treatment. Incidence of CS diagnosis within 1 calendar day of ALI intervention was calculated for each era. Demographics and comorbidities were then compared between CS and non-CS patients within each era. Risk of adverse outcomes within 30 days of CS diagnosis was also determined for each era, including mortality, major amputation, and re-intervention.ResultsThe pre-pandemic cohort contained 7736 patients while the pandemic era cohort included 8,306, for 16,042 total patients. A significant increase in CS incidence (risk ratio (RR) = 1.23, P = 0.0026) was demonstrated within the pandemic era. An increased prevalence of comorbidities such as dyslipidemia (pre-pandemic: P = 0.0022; pandemic: P = 0.0026) and peripheral vascular disease (P < 0.0001, both eras) was observed in the non-CS cohort within both eras. 30-day mortality was significantly increased in CS patients (pre-pandemic: RR = 3.057; pandemic: RR = 2.710; P < 0.0001 both eras) compared to non-CS patients. CS patients were more likely to receive major amputation (pre-pandemic: RR = 3.734; pandemic: RR = 2.809; P < 0.0001 both eras) and/or re-intervention within 30 days (pre-pandemic: RR = 1.871, P < 0.0001; pandemic: RR = 1.370, P = 0.0218) over non-CS patients.ConclusionsThe incidence of CS following revascularization for ALI rose worldwide during the pandemic. Patients who developed CS are younger with fewer comorbidities than non-CS patients. Despite a more favorable comorbid profile, CS patients demonstrate significantly higher rates of adverse outcomes. Further investigation is necessary to determine the specific underlying mechanisms driving this increased incidence in CS among ALI patients.

Current usage and diagnostic performance of cross-sectional imaging in patients with suspected acute appendicitis: a national survey in China

PURPOSE

The role of cross-sectional imaging in the management of acute appendicitis (AA) is contentious. This study aimed to investigate the current usage and diagnostic performance of ultrasound (US) and computed tomography (CT).

METHODS

A national survey was conducted by a core group from The National Ultrasound Quality and Control Center of China among radiologists practicing in medical institutions equipped with emergency departments and regularly performing appendectomies. Radiologists participated by completing the survey online from August 2022 to August 2023 after reviewing medical records of at least 40 patients with suspected AA. Sensitivity, specificity, positive predictive value, and negative predictive value and likelihood ratios were calculated for US and CT, respectively. Diagnostic performance of US between hospital subgroups were also compared.

RESULTS

A total of 141 questionnaires were submitted and 118 were eligible, each representing a distinct hospital. A total of 1844 children and 4165 adults were included. There were 76.4% patients underwent US studies, while 23.9% underwent CT studies. Higher percentage of children underwent US studies than adults (82.2% vs. 73.9%, P = 0.000). In children, the sensitivity and specificity of US were 89% and 90%, and of CT were 90% and 48%. In adults, the sensitivity and specificity of US were 92% and 84%, and of CT were 94% and 79%. The Likelihood ratios of US were higher in specialized hospitals (children's or children's and women's hospitals) than general hospitals (34.1 vs. 6.43).

CONCLUSION

US is more commonly used than CT for diagnosing AA in both adults and children. The diagnostic performance of US is comparable to CT. These findings underscore the recognition of US in clinical practice as a low-cost, non-radiative tool.

Is there consensus on diagnostics and treatment in colonic diverticulitis? Results of international survey

BACKGROUND

Clinical guidelines (CGs) developed by expert communities benefit both the patient and the clinician. Meanwhile a considerable proportion of specialists are not familiar with or follow them in their daily practice. Colonic diverticulitis (CD) is the third most common cause of hospitalization among patients with gastrointestinal diseases and common indication for colon resection. Actual tactics for diagnosis and treatment of CD, as well as data on what influences its choice and how the decisions made agree with the existing CGs can be identified by anonymous surveys.

METHODS

An anonymous internet survey of surgeons and coloproctologists was conducted. Groups of questions included demographics of the respondents; self-esteem score; sources of guidance in decision-making; classification systems for CD; preferable diagnostic tests; management of CD; indications for elective surgery; and outcomes of surgical treatment and others (n = 17). The study was conducted in accordance with the CHERRIES criteria. The required minimum sample size was calculated as 377 participants.

RESULTS

The study involved 401 respondents from 9 countries: 76.1% were general surgeons and 14.5% were colorectal surgeons. Excellent or good knowledge of the problem was claimed by 82.8% of the colorectal vs 66.2% of the general surgeons (p = 0.013). In decision-making respondents were largely guided by their professional experience, methods adopted in their clinic and domestic CGs. General Surgeons more often chose tactics inconsistent with CGs than coloproctologists. The largest differences between subgroups were noted for awareness of the reversal of Hartmann's procedure, most common postoperative complications and indications for elective surgery.

CONCLUSION

Adherence to the existing CGs was poor, which entails significant variation in the approaches practiced by the respondents from different cohorts. There is no consensus on the aspects that are not yet covered in the CGs. Further research is needed to elucidate these gaps and update the guidelines accordingly.

Meta-analysis and systematic review of long-term quality of life and recurrence following elective surgery versus non-operative management for colonic diverticulitis

BACKGROUND

Limited data exist on long-term outcomes of elective surgery versus nonoperative management of complicated diverticulitis. We aimed to assess long-term outcomes of nonoperative management versus elective surgery in patients initially conservatively treated for diverticulitis.

METHODS

Systematic review of PubMed and Scopus for studies comparing elective resection and nonoperative management of acute diverticulitis from inception to December 2023 was conducted. Studies reporting long-term outcomes (≥2 years) were included. Main outcomes were quality of life, disease recurrence, and long-term ostomy.

RESULTS

After screening 1,488 studies, 3 randomized controlled trials and 6 retrospective studies (3,621 patients; 44.4% males; median age: 59 years) were included. Elective colon resection was associated with significantly higher Gastrointestinal Quality of Life Index scores (mean difference 6.06, 95% confidence interval 2.22-9.9, P = .002), and Short Form Health Survey-36 scores for both mental and physical components (mean differences: 3.47 and 3.42, respectively). Gastrointestinal Quality of Life Index score difference was more noted in the randomized controlled trial subgroup analysis (mean difference: 8.68, 95% confidence interval 3.37-14.0, P = .001). These effect sizes were small according to Cohen d (0.34 and 0.31, respectively). Elective resection was associated with significantly less disease recurrence (odds ratio 0.29, 95% confidence interval 0.13-0.64, P = .002) than nonoperative management. No significant difference in long-term stoma was observed (odds ratio 1.52, 95% confidence interval 0.89-2.6, P = .12).

CONCLUSION

Elective resection was associated with significantly improved long-term quality of life and reduced recurrence of acute diverticulitis. However, the clinical significance of the difference in quality of life scores between the treatment approaches remains uncertain because of the small effect size observed. Any quality of life improvements must be balanced against surgical morbidity and mortality.

MORTALITY OF SEPTIC SHOCK SECONDARY TO PEDIATRIC PRIMARY PERITONITIS PREDICTED BY RESPIRATORY QUOTIENT COMBINED WITH LACTATE: A SURVEY FROM TWO CHILDREN'S HOSPITALS IN NORTHWEST CHINA

ABSTRACT

Background: Pediatric sepsis is a life-threatening condition, with extremely high incidence and mortality among critically ill children worldwide. Patients with septic shock are susceptible to intestinal complications due to altered blood flow distribution, and these complications often correlate directly with a poor prognosis. Early detection of low perfusion and appropriate resuscitation are critical components in the management of patients experiencing shock. Nevertheless, significant debate persists regarding the comparative value of various resuscitation targets. While central venous oxygen saturation (ScvO2) monitoring is frequently advocated, it remains a subject of scrutiny. All pathophysiological mechanisms are intricately linked to cellular hypoxia and energy metabolism, which is why metabolic-related biomarkers, particularly lactate and lactate clearance rate, are highly regarded by critical care experts. Nonetheless, limited research has been conducted on the association between markers of circulatory shock and metabolic disorders in critically ill patients particularly in the field of pediatrics. Physiological indicators, particularly those associated with cell energy metabolism, have shown potentials in predicting sepsis and septic shock. Methods: This was a retrospective study. A total of 63 patients, comprising 30 males and 33 females, who developed septic shock secondary to pediatric primary peritonitis, were admitted to the Intensive Care Department of the Children's Hospital Affiliated to Xi'an Jiaotong University and the Pediatric Intensive Care Unit of Gansu Provincial Maternity and Child-Care Hospital between December 2016 and December 2021. Based on the primary outcome of 28-day all-cause mortality, patients were assigned into the survival group and nonsurvival group. Demographic and clinical data were compared. Risk factors for the prognosis of septic shock secondary to pediatric primary peritonitis were identified by logistic regression, and their potentials in predicting the 28-day survival were assessed by the receiver operating characteristic and Kaplan-Meier survival curves. Results: Among the 63 eligible patients with septic shock secondary to pediatric primary peritonitis, 47 survived. In comparison to the survival group, the nonsurvival group showed significantly higher proportions of mechanical ventilation, surgical intervention, and use of vasoactive drugs, procalcitonin, activated partial thromboplastin time, respiratory quotient (RQ), lactate (Lac), the Pediatric Sequential Organ Failure Assessment score, and the Pediatric Risk of Mortality III score, but lower platelet count, fibrinogen, and mean arterial pressure (all P's < 0.05). RQ (odds ratio [OR], 2.37; 95% confidence interval [CI], 1.41, 3.22; P < 0.05) and Lac (OR, 2.01; 95% CI, 1.15, 3.21; P < 0.05) were independent prognostic factors for septic shock secondary to pediatric primary peritonitis. Their combination (RQ < 1.6 + Lac < 4 mmol/L) achieved a better accuracy in predicting the 28-day cumulative survival. Conclusion: RQ combined with Lac offers an excellent performance in predicting mortality of septic shock secondary to pediatric primary peritonitis.

Analysis of the outcomes of postdiverticulitis investigations: a multicentre cohort study including 1,120 patients

INTRODUCTION

The aim of this study was to assess the yield of the endoscopic investigations performed following the resolution of acute diverticulitis.

METHODS

A retrospective multicentre study included patients with multislice computed tomography (MSCT)-proven diverticulitis, in four NHS hospitals, between January 2016 and April 2023. The primary outcome was the rate of colonic cancer in the diseased segment. Secondary outcomes included the rate of malignancy in the nondiseased colonic segments, the benign colonic polyp detection rate, the rate of malignancy in the resected surgical specimens in patients who underwent an emergency surgery on the index admission and the rate of complications in the investigated group.

RESULTS

A total of 1,120 patients were included in the study, out of which 604 were females, with a median age of 61 years; 731 patients (65%) had uncomplicated diverticulitis (Hinchey 1A) while 389 (35%) had complicated diverticulitis (Hinchey 1B-4). Following the acute episode, 757 (74%) patients had subsequent endoscopic evaluation. The incidence of colorectal cancer (CRC) or advanced adenomas (AA) in patients with uncomplicated diverticulitis was 0.14%. In the complicated diverticulitis group, the incidence of CRC/AA in patients with Hinchey 1b and Hinchey 2 was 1.4% and 5.4%, respectively. Out of the 107 patients who underwent emergency colonic resection for suspected perforated diverticulitis, 18 (16.8%) had histological evidence of colonic malignancy.

CONCLUSIONS

Endoscopic investigations following uncomplicated diverticulitis have a low yield for sinister colonic pathology. Colonoscopy should be planned following complicated diverticulitis and in patients with uncomplicated diverticulitis with suspicious radiological finding on index imaging or in patients with ongoing clinical manifestations. In patients who undergo emergency surgery, oncological principles should be applied whenever possible.

Burden of colorectal cancer attributable to high body-mass index in 204 countries and territories, 1990-2021: Results from the Global Burden of Disease Study 2021

OBJECTIVES

A strong association between high Body Mass Index (BMI) and Colorectal Cancer (CRC) has been well established. However, the global burden of CRC attributable to high BMI remains underexplored. This study aims to examine and analyze the burden of CRC linked to high BMI at global, regional, and national levels from 1990 to 2021.

STUDY DESIGN

A descriptive analysis of the Global Burden of Disease (GBD) Study 2021.

METHODS

Data on the number of deaths and disability-adjusted life years (DALYs), as well as age-standardized mortality rate (ASMR) and age-standardized DALYs rate (ASDR), were extracted from the GBD 2021. Average annual percentage change (AAPC) was calculated to evaluate the temporal change in ASDR and ASMR using Joinpoint regression analysis. The Population Attributable Fractions (PAF) were used to analyze the CRC burden attributed to risk factors.

RESULTS

In 2021, the global deaths and DALYs of CRC attributed to high BMI were 99,270 deaths and 2,364,660 years respectively, more than double the figures from 1990. High SDI regions bore the greatest burden while low-middle and middle SDI regions experienced a faster rise, with individuals over 60 and males being the most affected. East Asia, particularly China, had the heaviest burden globally. ASMR and ASDR were correlated with SDI. The top five risk factors for CRC burden were a diet low in whole grains (17.72 %), a diet low in milk (15.10 %), a diet high in red meat (14.55 %), high BMI (9.69 %) and a diet low in calcium (8.20 %) in 2021.

CONCLUSION

High BMI is a significant risk factor for CRC, with aging, population growth, gender, and SDI contributing to geographic and temporal variations in the burden. These findings highlight the urgent need for targeted prevention strategies, especially in high-risk populations, and emphasize the role of obesity prevention, early screening, lifestyle and dietary modifications, and interventions such as AI-driven technologies to reduce the CRC burden.

Low sarcopenia index predicts intra-abdominal infection in patients with abdominal trauma

OBJECTIVES

Prediction of intra-abdominal infection (IAI) in patients with abdominal trauma is crucial, yet reliable predictive indicators are currently lacking. The sarcopenia index (SI) is a readily available indicator of clinical outcomes in several diseases that holds diagnostic and prognostic value. The aim of this study is to assess the predictive value of SI for IAI in patients with abdominal trauma.

METHODS

This retrospective cohort study enrolled patients with abdominal trauma. Multivariable logistic analyses were used to identify independent factors of IAI. We divided patients into 2 groups based on sex. The receiver operating characteristic (ROC) curve was used to evaluate the performance of SI in predicting IAI. Then, based on the cut-off values of the SI established for males and females, we stratified patients into high and low-IAI risk groups to compare clinical outcomes. Spearman correlation analysis was used for correlation analysis.

RESULTS

A total of 378 participants with abdominal trauma were included. Multivariable logistic analyses identified SI as an independent risk factor for IAI in both males [odds ratio (OR): 0.82, 95% confidence interval (CI): 0.74-0.90, P < 0.001] and females (OR: 0.68, 95% CI: 0.51-0.91, P = 0.009). The area under the ROC curve for SI in predicting IAI was 0.712 for males and 0.733 for females, with optimal cut-off values of 81.430 for males and 57.907 for females. Furthermore, SI showed significant correlations with the length of hospital stay (P = 0.003) and hospital costs (P = 0.042).

CONCLUSIONS

SI was identified as an independent risk factor for IAI in patients with abdominal trauma, offering predictive value for both genders. SI correlates with poor clinical outcomes. This might provide new ideas and theoretical guidance for diagnosing and treating IAI.

Enhanced Recovery Independently Lowers Failure to Rescue After Colorectal Surgery

BACKGROUND

High adherence to the enhanced recovery after surgery pathway reduces morbidity and mortality rates after elective colorectal surgery.

OBJECTIVE

To evaluate the effect of adherence to the enhanced recovery after surgery pathway on the failure to rescue rates after elective colorectal surgery.

DESIGN

Retrospective analysis of a prospective database.

PATIENTS

Adults (18 years or older) who underwent elective colorectal resection with anastomosis for benign and malignant disease.

SETTINGS

Prospective enrollment in 78 centers in Italy from 2019 to 2021.

INTERVENTIONS

All outcomes were measured 60 days after surgery. Several patient-, disease-, treatment-, hospital-, and complication-related variables were analyzed. After univariate analyses, independent predictors of the end points were identified through logistic regression analyses, presenting ORs and 95% CIs.

MAIN OUTCOME MEASURES

Failure to rescue after any adverse event, defined as the ratio between the number of deaths and the number of patients showing any adverse event; failure to rescue after any major adverse event, with the denominator represented by the number of patients showing any major adverse event.

RESULTS

An adverse event was recorded in 2321 of 8359 patients (27.8%), a major adverse event in 523 patients (6.3%), and death in 88 patients (1.0%). The failure to rescue rates were 3.8% after any adverse event and 16.8% after any major adverse event. Independent predictors of primary end points were identified among patient- (age, ASA class, and nutritional status), treatment- (type of resection), and complication-related (anastomotic leakage and reoperation) variables. Enhanced recovery pathway adherence of more than 70% independently reduced failure to rescue rates.

LIMITATIONS

Clustering from multicenter data and unmeasured confounding from observational data.

CONCLUSIONS

After elective colorectal resection, adherence of more than 70% to the enhanced recovery pathway independently decreased failure to rescue rates, along with other patient- or treatment-related factors. See Video Abstract .

LA RECUPERACIN MEJORADA REDUCE DE FORMA INDEPENDIENTE LA POSIBILIDAD DE FRACASO EN EL RESCATE DESPUS DE UNA CIRUGA COLORRECTAL

ANTECEDENTES:La alta adherencia a la vía de recuperación mejorada después de la cirugía reduce las tasas de morbilidad y mortalidad después de la cirugía colorrectal electiva.OBJETIVO:Evaluar el efecto de la adherencia a la vía ERAS en las tasas de fracaso en el rescate después de la cirugía colorrectal electiva.DISEÑO:Análisis retrospectivo de una base de datos prospectiva.PACIENTES:Adultos (≥ 18 años) que se sometieron a una resección colorrectal electiva con anastomosis por enfermedad benigna y maligna.ESCENARIO:Inscripción prospectiva en 78 centros en Italia de 2019 a 2021.INTERVENCIONES:Todos los resultados se midieron a los 60 días después de la cirugía. Se analizaron varias variables relacionadas con el paciente, la enfermedad, el tratamiento, el hospital y las complicaciones para los resultados. Después de los análisis univariados, se identificaron los predictores independientes de los puntos finales a través de análisis de regresión logística, presentando razones de probabilidades e intervalos de confianza del 95%.PRINCIPALES MEDIDAS DE RESULTADOS:Fallo en el rescate después de cualquier evento adverso, definido como la relación entre el número de muertes y el número de pacientes que presentaron cualquier evento adverso; fallo en el rescate después de cualquier evento adverso mayor, con el denominador representado por el número de pacientes que presentaron cualquier evento adverso mayor.RESULTADOS:Se registró un evento adverso en 2321 de 8359 pacientes (27,8%), un evento adverso mayor en 523 pacientes (6,3%) y muerte en 88 pacientes (1,0%). Las tasas de fallo en el rescate fueron del 3,8% después de cualquier evento adverso y del 16,8% después de cualquier evento adverso mayor. Se identificaron predictores independientes de los criterios de valoración primarios entre las variables relacionadas con el paciente (edad, clase de la Sociedad Americana de Anestesiólogos, estado nutricional), el tratamiento (tipo de resección) y las complicaciones (fuga anastomótica, reoperación). La adherencia a la vía de recuperación mejorada > 70% redujo de forma independiente las tasas de fallo en el rescate.LIMITACIONES:Agrupamiento de datos multicéntricos y factores de confusión no medidos a partir de datos observacionales.CONCLUSIONES:Después de una resección colorrectal electiva, la adherencia > 70 % a la vía de recuperación mejorada disminuyó de manera independiente las tasas de fracaso en el rescate, junto con otros factores relacionados con el paciente o el tratamiento. (Traducción-Dr Osvaldo Gauto).

Blood transfusion in older surgical patients: the only option or is there a better approach?

Anemia is a common clinical condition that can significantly affect patient outcomes, particularly in those undergoing surgery. In older adults, the presence of anemia combined with cardiovascular disease can increase surgical morbidity and mortality, influencing surgical decisions and creating a cascade of complications that may negatively impact recovery. Blood transfusion remains the primary response to anemia in the perioperative setting, despite evidence suggesting potential adverse effects on survival and recovery. However, older adults present unique challenges due to age-related physiological changes anda reduced tolerance to anemia and blood loss. The debate between restrictive and liberal blood transfusion strategies in this population remains unresolved. Patient Blood Management (PBM) protocols have been developed to systematically address perioperative anemia. This review emphasizes the need for a nuanced approach to transfusion in older adults, suggesting that while a restrictive strategy may not be universally applicable, decisions should be guided by thorough clinical evaluations. These assessments should prioritize not only hemoglobin levels but also patient-specific factors, including life expectancy, comorbidities, and patient preferences, with the involvement of a multidisciplinary team to tailor the best approach for everyone.

Modified Smead-Jones suture for closure of emergency midline laparotomy incision: systematic review and meta-analysis

Midline laparotomy incision is mostly used in emergent surgery, especially in hemodynamic instability patients. We aim to compare the Modified Smead-Jones (MSJ) and Smead-Jones (SJ) sutures against conventional continuous suture in midline laparotomy closure. PubMed, Scopus, Web of Science, and Ovoid were searched. We utilized Revman 5.4.1 for statistical analysis. Five studies involving 403 patients were included. Compared to continuous sutures, MSJ showed a significant reduction in wound dehiscence, wound infection, and hospital stay (RR = 0.29, 95% CI [0.14-0.59], p = 0.0006), (RR = 0.41, 95% CI [0.26-0.65], p = 0.0002), and (MD = - 4.50, 95% CI [- 5.43 to - 3.57], p = 0.00001). Conversely, the SJ subgroup showed no statistically significant difference in wound dehiscence, wound infection, and hospital stay. Also, both techniques, MSJ and SJ, showed no significant difference in incisional hernia risk (RR = 0.17, 95% CI [0.02-1.33], p = 0.09) and (RR = 5.16, 95% CI [0. 26-103.27], p = 0.28), respectively. MSJ follows the same far-near-near-far pattern as SJ but is applied continuously rather than interrupted. The MSJ suture technique might be promising in reducing wound dehiscence, infection, and hospital stay compared to conventional continuous closure. However, future large-scale RCTs with standardized methodologies and extended follow-up are essential to determine whether MSJ should be established as the preferred technique for midline laparotomy closure.

Quality improvement program for the severely injured

Over recent decades, advancements in trauma care have significantly reduced mortality rates among severely injured patients. These improvements are largely attributable to the establishment of trauma care systems, including prehospital management protocols and the creation of trauma centres with immediate surgical team availability. However, patient outcomes continue to vary, reflecting differences in the quality of trauma care influenced by organisational models and local practices. To address this, governments and scientific organisations have underscored the importance of evaluating care quality at local, national, and international levels. This chapter explores strategies for assessing quality of trauma care, establishing reliable quality indicators (QIs), and standardising auditing processes to guide improvements in patient outcomes and system performance.

Necrotizing soft tissue infections: a surgical narrative review

Necrotizing soft tissue infections represent a spectrum of diseases characterized by extensive necrosis involving the skin, subcutaneous tissues, fascia or muscles. These infections are generally severe and rapidly progressive, often accompanied by sepsis, septic chock, multiple organ failure and, ultimately, death. Several classifications have been developed based on multiple parameters, such as the anatomical location of the disease, the depth of the lesion or the microbiology. Numerous clinical factors predispose individuals to the development of necrotizing soft tissue infections. The clinical presentation is not always characterized by local signs and systemic symptoms of infection, which can lead to delays in both diagnosis ad treatment. Broad-spectrum antibiotic directed at the likely organisms is essential early in the treatment course, but do not substitute surgical management. Antibiotic therapy should be subsequently tailored to the etiologic micro-organism. Rapid recognition and early surgical intervention form the mainstay of management of necrotizing soft tissue infections. Initial surgical debridement should be promptly performed preferably at the presenting hospital, when adequate infrastructure and personnel are available. Transfer to a referral center may be necessary for definitive surgical and complex wound care. Most patients require more than one debridement. A multidisciplinary approach is also essential to improve the results in the treatment of these patients.

Temporal trends in cross-country inequalities of early-onset pancreatic cancer: a comprehensive analysis for the global burden of disease study 2021

By 2040, pancreatic cancer is expected to become the second leading cause of cancer-related deaths in the U.S., with early-onset pancreatic cancer (EOPC) cases rising among adolescents and young adults. This study uses the global burden of disease (GBD) 2021 dataset to examine global, regional, and national EOPC trends and predicts the burden through 2050. The analysis covers EOPC burden from 1990 to 2021, focusing on age-standardized prevalence rate (ASPR), incidence rate (ASIR), mortality rate (ASMR), and disability-adjusted life years rate (ASDR). Annual percentage change (APC) and average annual percentage change (AAPC) were calculated via joinpoint regression. Clustering and frontier analysis based on the sociodemographic index (SDI) assessed the link between development levels and health outcomes. We used WHO-recommended health equity methods to quantify EOPC burden disparities and applied a Bayesian age-period-cohort (BAPC) model to project trends. In 2021, EOPC cases rose to 42,254, a 73% increase from 1990, while deaths reached 26,996, up 57%. Although ASIR, ASMR, and ASDR declined, ASPR rose (EAPC = 0.1). Central and Eastern Europe had the highest EOPC burden, with the fastest growth in Australasia (EAPC = 2.78) and Western Sub-Saharan Africa (EAPC = 2.25). Males had about double the burden of females, though female prevalence increased. The widening gap in health burden between low- and high-SDI regions is especially concerning. While EOPC currently affects high-SDI countries the most, there is a clear trend over time showing a gradual shift of EOPC burden towards low-SDI countries. By 2050, ASIR, ASPR, ASMR, and ASDR are projected to stabilize, with cases increasing until 2036, then decreasing. High-SDI countries bear a disproportionately high EOPC burden, with significant diagnostic and management challenges, particularly in Central and Eastern Europe. Rising global EOPC prevalence highlights the need to identify burden differences and risk factors across countries to develop targeted prevention and control strategies.

Open abdomen versus primary closure in the management of severe abdominal sepsis: What is the right way? Results of the last 5 years of a reference center

PURPOSE

WSES guidelines allow open abdomen (OA) for critically ill patients due to secondary peritonitis in the case of inadequate source control, but this option results quite vague and with a low grade of evidence (Grade 2 C). Moreover, the emerging increasing in literature of complications, makes the use of OA in secondary peritonitis more debated. The aim of our study is to analyze the postoperative outcomes of patients undergoing OA versus primary closure (PC) in secondary peritonitis.

METHODS

We collected data from Tertiary Trauma Center from 2019 to 2024. The study included patients who underwent urgent laparotomy for severe secondary peritonitis, divided into two groups based on the strategy chosen in the index laparotomy: PC or OA. We retrospectively analyzed the data, considering as primary outcome post-operative mortality, while as secondary outcomes short terms complications and LOS.

RESULTS

283 patients fit the research for the diagnosis of peritonitis but only 176 were included as with a WSES-SSS > = 7. 128 patients (72,7%) were in the PC group, while 48 (27,3%) were managed with an OA strategy. There were no statistical differences in terms of mortality (p = 0.371), between the two groups. Complications were higher in the OA group (p = 0.001). From the logistic regression only MPI resulted an independent factor of mortality (p = 0.016; OR 1.080).

CONCLUSION

The study shows that OA in severe secondary peritonitis does not improve mortality and is associated with higher short-term complications and incisional hernias. However, RCT are necessary to better investigate the role of OA in the management of abdominal sepsis.

Incidence and predictors of perioperative mortality in Ethiopia: a systematic review and meta-analysis

INTRODUCTION

The Lancet Commission on Global Surgery highlights perioperative mortality rate (POMR) as a key indicator of a nation's surgical system effectiveness. While POMR is often measured in high-income countries, it is less studied in low- and middle-income countries (LMICs). This study aims to assess the POMR and its predictors in Ethiopia.

METHODS

We conducted a thorough literature search across PubMed/MEDLINE, Embase, Web of Science, Scopus, and Google Scholar for studies from Ethiopia between 2019 and 2023 reporting POMR for various surgical procedures. Data were extracted in duplicate from eligible studies. We used random-effects meta-analysis to pool estimates of POMR and its predictors.

RESULTS

The meta-analysis revealed a POMR of 5.36%. Identified predictors of perioperative mortality in Ethiopia included older age, comorbidities, ICU admission, and an ASA physical status classification of III or higher and emergency surgeries.

CONCLUSION

Ethiopia's perioperative mortality rate is significantly high. Improving surgical care quality and safety, along with expanding access to surgical services, is crucial for bettering surgical outcomes in the country.

Spatiotemporal trends in hernia disease burden and health workforce correlations in aging populations: a global analysis with projections to 2050

BACKGROUND

Inguinal, femoral, and abdominal wall hernias represent significant health and economic burdens globally, particularly among adults aged 45 and older. In 2021, the Global Burden of Disease Study reported 1.72 million new cases, 6.75 million prevalent cases, and over 41,000 deaths in this population. While age-standardized rates have declined with improved healthcare, absolute burden continues to rise due to population growth and aging. Gender disparities remain pronounced, with men experiencing sevenfold higher incidence than women. This study analyzes global hernia trends, determinants, future projections, and the association between health workforce distribution and hernia burden to inform targeted interventions.

METHODS

Using data from the Global Burden of Disease Study 2021, we analyzed incidence, prevalence, mortality, and disability-adjusted life years (DALYs) for inguinal, femoral, and abdominal wall hernias. Long-term trends were assessed using average annual percentage change (EAPC), with decomposition analyses exploring factors influencing disease burden changes. Spatial and temporal patterns were examined using age-period-cohort and frontier analyses. We conducted health inequality analyses and utilized eight time-series machine learning models to project disease burden from 2022 to 2050. Additionally, we analyzed correlations between health workforce distribution and hernia burden across 204 countries and territories for 1990 and 2019.

RESULTS

In 2021, global incidence of hernias was 1,720,177, with 6,748,203 prevalent cases and 41,834 deaths among individuals aged 45 years and older. Although age-standardized incidence rate (ASIR) decreased from 153.98/100,000 in 1990 to 112.29/100,000 in 2021 (EAPC = -0.83%, 95% CI: -0.95% to -0.70%), and age-standardized mortality rate (ASMR) decreased from 3.19/100,000 to 1.86/100,000 (EAPC = -1.77%, 95% CI: -1.94% to -1.59%), absolute burden continued increasing. Socioeconomic differences were significant, with higher ASIR in high SDI areas (141.94/100,000) than low SDI areas (104.60/100,000) in 2021, but much higher ASMR in low SDI areas (4.14/100,000) than high SDI areas (1.23/100,000). Decomposition analysis revealed population growth as the main driver of increased disease burden, contributing 173.80% to incidence increases. Age-period-cohort analysis showed incidence peaked in the 65-69 age group (RR = 1.43, 95% CI: 1.42-1.43). Male ASIR in 2021 (203.41/100,000) was approximately 7.3 times higher than female ASIR (27.94/100,000). Correlation analyses revealed significant negative associations between pharmaceutical personnel density and hernia disease burden, with correlation coefficients strengthening from 1990 (DALYs: r = -0.39, p < 0.001) to 2019 (DALYs: r = -0.57, p < 0.001). Similar trends were observed for dentistry personnel (DALYs: r = -0.26 in 1990 to r = -0.47 in 2019, p < 0.001). Countries with high hernia burden (Guatemala, Paraguay, Indonesia) consistently demonstrated lower health workforce density compared to low-burden countries. ARIMA model projections showed that by 2050, ASIR would increase slightly from 112.32/100,000 in 2022 to 112.64/100,000, with absolute new cases increasing by 19.70%. ASMR is projected to increase from 1.84/100,000 to 2.11/100,000, with deaths increasing by 8.50%.

CONCLUSIONS

Despite declining age-standardized rates for inguinal, femoral, and abdominal wall hernias, absolute disease burden continues increasing due to demographic factors. Socioeconomic development significantly impacts disease patterns, with higher morbidity but lower mortality in high SDI areas. The strong negative correlation between pharmaceutical and dentistry personnel density and hernia burden suggests potential protective effects of healthcare workforce investment, particularly in resource-constrained settings. Future projections indicate growing absolute burden despite relatively stable age-standardized rates, highlighting the urgent need to strengthen preventive measures, improve treatments, and strategically allocate health workforce resources to address this growing public health challenge.

Risk factors for in-hospital mortality in surgical patients with abdominal sepsis in China: a nested case-control study

OBJECTIVES

To delineate the clinical characteristics and investigate the determinants that may affect the prognosis of surgical patients with abdominal sepsis.

DESIGN

A case-control study was nested in a cohort of surgical patients with abdominal sepsis between 2008 and 2022. We extracted patient' medical records to execute descriptive statistical analyses. Multiple logistic regression models and subgroup analysis were employed to elucidate the risk factors of in-hospital mortality.

SETTING

Two tertiary hospitals in China.

PARTICIPANTS

476 surgical patients diagnosed with abdominal sepsis between 2008 and 2022 were analysed.

INTERVENTIONS

None.

OUTCOME MEASURES

Descriptive statistics were used to examine pertinent patient information, including demographic details, laboratory findings, surgical interventions and anaesthetic records. Multivariate logistic regression was used to identify independent risk factors for in-hospital mortality. Subgroup analyses were conducted to explore the impact of specific clinical characteristics on outcomes.

RESULTS

476 patients diagnosed with abdominal sepsis were analysed, exhibiting an in-hospital mortality rate of 7.56%. Advanced age (OR 6.77, 95% CI 2.46 to 18.66, p<0.001), the presence of diabetes (OR 2.61, 95% CI 1.04 to 6.56, p=0.041) and higher preoperative Sequential Organ Failure Assessment (SOFA) score (OR 3.48, 95% CI 1.16 to 10.43, p=0.026) were identified as significant predictors of increased in-hospital mortality risk through a multinomial logistic regression model. Conversely, individuals afflicted with biliary diseases (OR 0.15, 95% CI 0.04 to 0.64, p=0.010) demonstrated a reduced risk of in-hospital mortality. Subgroup analysis revealed that low serum albumin levels emerged as a risk factor for in-hospital mortality in the patients with gastrointestinal diseases (OR 20.23, 95% CI 2.21 to 184.84, p=0.008) or advanced age (OR 10.52, 95% CI 2.29 to 48.31, p=0.002) through multinomial logistic regression analysis.

CONCLUSION

In this retrospective analysis, we delineated the clinical characteristics of surgical patients with abdominal sepsis and pinpointed risk factors associated with in-hospital mortality. These findings underscore the necessity for more tailored perioperative management strategies for patients with sepsis characterised by advanced age, diabetes, higher preoperative SOFA score and reduced preoperative albumin levels. Clinicians should prioritise early recognition and aggressive management of these high-risk individuals, including timely surgical intervention, optimisation of nutritional status and vigilant monitoring of organ function. These insights underscore the critical role of individualised care in enhancing the prognosis of surgical patients with abdominal sepsis.

TRIAL REGISTRATION NUMBER

ChiCTR2400081823.

The impact of COVID-19 on inflammatory bowel disease surgery: a systematic review

INTRODUCTION

The COVID-19 pandemic caused a significant disruption to the delivery of surgical services. Guidance prioritising life-saving and cancer surgery was issued. Inflammatory bowel disease (IBD) often requires considered, timely surgery, which may have not been feasible under the conditions imposed by the pandemic. This systematic review aims to quantify the impact of COVID-19 on IBD surgery and assess the safety of performing such surgery.

METHODS

A systematic review of MEDLINE, Embase and Web of Science was performed. Studies that included a prepandemic and a pandemic cohort for comparison and reported on numbers of IBD surgeries or postoperative outcomes following IBD surgery were included. Heterogeneity of included studies precluded any meta-analyses.

FINDINGS

In total, 1,220 titles were screened and 13 were included in the final review. All were cohort studies other than one case-control study. A total of 1,673,282 and 1,445,971 patients were included in the prepandemic and pandemic cohorts, respectively. Rates of elective surgery during the pandemic varied from a 66% reduction to a 9.66% increase and emergency surgery varied from no difference to an 18% reduction. Urgent surgery in IBD inpatients appears to be unaffected. Postoperative outcomes were not shown to be negatively impacted by resource limitations.

CONCLUSIONS

The COVID-19 pandemic affected IBD surgical services considerably; however, those who did undergo surgery during this period do not appear to have been at an increased risk of adverse outcomes. Further work is required to describe the long-term impacts of these cancellations on IBD services and patient morbidity.

The Impact of Climate Change on Cancer Surgery and Healthcare Delivery: A Review of Environmental and Surgical Challenges

PURPOSE

More than 10 million annual global cancer deaths are exacerbated by the impact of climate change and environmental determinants of health. This brief report provides a summary of and mitigating recommendations for the complex intersection between climate change and surgical cancer care.

METHODS

A review of scientific literature from the last 10 years was conducted to assess the current impact of climate change on cancer care with a focus on surgical interventions. Studies with an impact score of 6 or higher and the keywords of climate change, extreme weather, cancer care, and surgery were reviewed. After removing duplicates and excluded studies, 30 studies remained and were reviewed by two reviewers.

RESULTS

Climate-related factors impacting surgical care result in a myriad of healthcare impacts, including disruption of services, impact on patient outcomes and survival, as well as an overburdening of hospital and surgical services.

CONCLUSION

Climate change, including extreme weather events, threatens cancer surgical care and delivery by exacerbating comorbidities, disrupting healthcare systems, and increasing disparities in cancer care. Climate change is a burgeoning threat to global health, cancer care, patients, and communities.

Potency and Safety of KRAS G12C Inhibitors in Solid Tumors: A Systematic Review

Background

The Kirsten rat sarcoma viral oncogene homolog (KRAS) gene, specifically the cysteine residue mutation KRAS (G12C), has garnered significant attention as a therapeutic target for solid cancer patients with KRAS mutations. Despite this interest, the efficacy and safety profiles of KRAS G12C inhibitors remain incompletely understood. In this study, we comprehensively evaluate the effectiveness and toxicity of relevant KRAS G12C inhibitors (Sotorasib, Adagrasib, Garsorasib, and Divarasib) in patients with colorectal cancer (CRC), non-small-cell lung cancer (NSCLC), and pancreatic ductal adenocarcinomas (PDAC).

Methods

Our systematic review is guided by Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We review the available clinical trials data on KRAS G12C inhibitors in KRAS G12C-mutated solid tumors. We searched PubMed, EMBASE, Cochrane Library, and major international conferences for clinical trials from January 2020 until August 2023.

Results

A total of 17 eligible studies were included. KRAS G12C inhibitions with Sotorasib (41.2%) and Adagrasib (41.2%) each of them were reported in 7 studies. Divarasib was reported in 2 studies (11.8%) and Garsorasib was reported in 1 study (6.7%). Sotorasib showed a significant clinical benefit in terms of objective response rate (ORR) (7.1%-47%), progression-free survival (PFS) (4-6.8 months), and overall survival (OS) (4-24 months); it is more efficient in NSCLC patients with an OS of 2 years, PFS of 6.3 months, and an ORR of 41%. Adagrasib also showed significant clinical activity with an ORR (19%-53%), PFS (3.3-11.1 months), and OS (10.5-23.4 months), with more effectiveness in NSCLC patients with an OS of 23.4 months, PFS of 11.1 months, and an ORR of 53.3%. Adagrasib is more efficient with an ORR of 35.1%, PFS of 7.4 months, and an OS of 14 months in patients with PDAC, than Sotorasib which showed an ORR of 21%, PFS of 4 months, and an OS of 6.9 months. However, Adagrasib and Sotorasib are moderately efficient in CRC clinical trials.

Conclusion

This study confirms that patients treated with these KRAS G12C inhibitors, exclusively or combined with conventional therapies, achieve better treatment responses and modulate the progressions of these solid tumors.

SAGES white paper on antibiotic omission in the management of acute uncomplicated diverticulitis: why, when, who, and most importantly, how

BACKGROUND

Historically, the management of acute uncomplicated diverticulitis was centered on antibiotics. However, modern theories regarding the pathogenesis of diverticulitis have challenged the notion that antibiotics are necessary in all cases. Despite major reform in many societal guidelines, the adoption of non-antibiotic therapy for uncomplicated diverticulitis has been limited, especially in North America. The purpose of this SAGES White Paper was to review the available evidence on antibiotic omission in uncomplicated diverticulitis and to explore methods of safe implementation.

METHODS

A task force within the SAGES Colorectal Surgery Committee was formed to work on this White Paper. The committee and its leadership approved an outline that would focus on the following topics: (1) Defining the problem with unnecessary antibiotic exposure; (2) Evaluating the evidence on antibiotic omission in uncomplicated diverticulitis; (3) Identifying the appropriate patient for antibiotic omission; (4) Outlining how to counsel patients who are treated without antibiotics; (5) Reviewing methods to safely implement this practice in both the hospital and community setting. These topics were divided up among members of the task force who performed a structured literature search in preparation for their assignments.

RESULTS

Antibiotics are associated with several patient and societal adverse effects, including the rising problem of antimicrobial resistance. Randomized controlled trials have demonstrated no superiority to the routine administration of antibiotics in acute uncomplicated diverticulitis. Appropriate patients for antibiotic omission include those who are immunocompetent, non-septic, and have mild symptoms/disease severity on imaging. Existing frameworks for the safe implementation of new practices can be referenced to help increase adoption of non-antibiotic therapy.

CONCLUSION

The existing body of evidence supports antibiotic omission in appropriate cases of acute uncomplicated diverticulitis. In order to increase the widespread adoption of this practice, buy-in from key stakeholders (both healthcare professionals and patients) is necessary.

Prevention of infection in aortic or aortoiliac peripheral arterial reconstruction

BACKGROUND

Peripheral arterial disease (PAD) results from the narrowing of arteries. Aortic aneurysms - abnormal dilatations in artery walls - are a related concern. For severe cases, arterial reconstruction surgery is the treatment option. Surgical site infections (SSIs) are a feared and common complication of vascular surgery. These infections have a significant global healthcare impact. Evaluating the effectiveness of preventive measures is essential.

OBJECTIVES

To assess the effects of pharmacological and non-pharmacological interventions, including antimicrobial therapy, antisepsis, and wound management, for the prevention of infection in people undergoing any open or hybrid aortic or aortoiliac peripheral arterial reconstruction.

SEARCH METHODS

The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL databases, and the World Health Organization International Clinical Trials Registry Platform, LILACS, and ClinicalTrials.gov up to 11 November 2024.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) with a parallel (e.g. cluster or individual) or split-body design, and quasi-RCTs, which assessed any intervention to reduce or prevent infection following aortic or aortoiliac procedures for the treatment of aneurysm or PAD. There were no limitations regarding age and sex.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures. Two review authors independently extracted the data and assessed the risk of bias of the trials. A third review author resolved disagreements when necessary. We assessed the evidence certainty for key outcomes using GRADE.

MAIN RESULTS

We included 21 RCTs with 4952 participants. Fifteen studies were assessed as having a high risk of bias in at least one domain, and 19 studies had an unclear risk of bias in at least one domain. We analysed 10 different comparisons for eight different outcomes. The comparisons were antibiotic versus placebo or no treatment; short-duration antibiotics (≤ 24 hours) versus long-duration antibiotics (> 24 hours); different types of systemic antibiotics (one versus another); antibiotic-bonded implant versus standard implant; Dacron graft versus stretch polytetrafluoroethylene graft; prophylactic closed suction drainage versus undrained wound; individualised goal-directed therapy (IGDT) versus fluid therapy based on losses, standard haemodynamic parameters and arterial blood gas values (standard care); comprehensive geriatric assessment versus standard preoperative care; percutaneous versus open-access technique; and negative pressure wound therapy (NPWT) versus standard dressing. The primary outcomes were graft infection rate and SSI rate. The secondary outcomes included all-cause mortality, arterial reconstruction failure rate, re-intervention rate, amputation rate, pain resulting from the intervention, and adverse events resulting from the interventions to prevent infection. We did not assess all the outcomes across the different comparisons. The main findings are presented below. Antibiotic versus placebo or no treatment (five studies) Very low-certainty evidence from five included studies suggests that antibiotic prophylaxis reduces SSI (risk ratio (RR) 0.33, 95% confidence interval (CI) 0.15 to 0.71; 5 studies, 583 participants; number needed to treat for an additional beneficial outcome (NNT) 9). With very low- to low-certainty evidence, there was little or no difference between the groups in the other assessed outcomes (graft infection rate, all-cause mortality, re-intervention rate, and amputation rate). We did not quantitatively assess other outcomes in this comparison. Short duration antibiotics (≤ 24 hours) versus long duration antibiotics (> 24 hours) (three studies) Very low-certainty evidence from three included studies suggests that there is little or no difference in graft infection rate (RR 2.74, 95% CI 0.11 to 65.59; 1 study, 88 participants) or SSI rate (RR 3.65, 95% CI 0.59 to 7.71; 1 study, 88 participants) between short- and long-duration antibiotic prophylaxis. We did not quantitatively assess other outcomes in this comparison. Different types of systemic antibiotics (one versus another) (seven studies) We grouped seven studies comparing one antibiotic to another into three subgroups that compared different classes of antibiotics amongst themselves. We found little or no difference between the groups analysed. Graft infection rate: beta-lactams versus cephalosporins (RR 0.36, 95% CI 0.02 to 8.71; 1 study, 88 participants; very low-certainty evidence); glycopeptides versus cephalosporins (RR 5.00, 95% CI 0.24 to 103.05; 1 study, 238 participants; low-certainty evidence); one cephalosporin versus another (RR not estimable, CI not estimable; 1 study; 69 participants; very low-certainty evidence); SSI rate: beta-lactams and cephalosporins (RR 0.27, 95% CI 0.03 to 2.53; 2 studies, 229 participants; very low-certainty evidence); glycopeptides versus cephalosporins (RR 2.17, 95% CI 0.65 to 7.23; 2 studies, 312 participants; very low-certainty evidence); and one cephalosporin versus another (RR 1.26, 95% CI 0.21 to 7.45; 3 studies, 625 participants; very low-certainty evidence). We could extract all-cause mortality data for the glycopeptide versus cephalosporin comparison; there was little or no difference between groups (RR 1.33, 95% CI 0.30 to 5.83; 1 study, 238 participants; low-certainty evidence). We did not quantitatively assess other outcomes in this comparison.

AUTHORS' CONCLUSIONS

Very low-certainty evidence suggests that the use of prophylactic antibiotics may prevent SSIs in aortic or aortoiliac peripheral arterial reconstruction. We found no superiority amongst specific antibiotics or differences in extended antibiotic use (over 24 hours) compared with shorter use (up to 24 hours), with low-certainty evidence. For other interventions, very low- to moderate-certainty evidence showed little or no difference across various outcomes. We advise interpreting these conclusions with caution due to the limited number of events in all groups and comparisons.

Miniaturized soft growing robots for minimally invasive surgeries: challenges and opportunities

Advancements in assistive robots have significantly transformed healthcare procedures in recent years. Clinical continuum robots have enhanced minimally invasive surgeries, offering benefits to patients such as reduced blood loss and a short recovery time. However, controlling these devices is difficult due to their limited accuracy in three-dimensional deflections and challenging localization, particularly in confined spaces like human internal organs. Consequently, there has been growing research interest in employing miniaturized soft growing robots, a promising alternative that provides enhanced flexibility and maneuverability. In this work, we extensively investigated issues concerning their designs and interactions with humans in clinical contexts. We took insights from the open challenges of the generic soft growing robots to examine implications for miniaturization, actuation, and biocompatibility. We proposed technological concepts and provided detailed discussions on leveraging existing technologies, such as smart sensors, haptic feedback, and artificial intelligence, to ensure the safe and efficient deployment of the robots. Finally, we offer an array of opinions from a biomedical engineering perspective that contributes to advancing research in this domain for future research to transition from conceptualization to practical clinical application of miniature soft growing robots.

Middle-Lobe Bronchus Transection in Blunt Thoracic Trauma From a High-Speed Motor Vehicle Collision: A Case Report

BACKGROUND Bronchial rupture following blunt thoracic trauma is an uncommon but potentially fatal injury that requires early recognition and appropriate intervention. Timely diagnosis and multidisciplinary trauma care are essential for improving outcomes and preventing complications. CASE REPORT A 52-year-old man with no prior medical history was admitted to the Emergency Department after a high-speed motor vehicle collision. He presented with multiple injuries, dyspnea, and thoracic and pelvic pain. His initial Glasgow Coma Scale (GCS) score was 15/15. Physical examination revealed subcutaneous emphysema in the cervical region, a distended right hemiabdomen, and absent breath sounds in the right lung. Multiple right-sided chest wall lacerations were noted. An extended focused assessment with sonography in trauma (eFAST) was suggestive of intra-abdominal free fluid, prompting further imaging. A chest CT confirmed the right pneumothorax. An exploratory laparotomy revealed 200 cc of hemoperitoneum, grade 1 liver trauma (segments II and IV), and a non-bleeding hepatic hilum hematoma. Additional procedures included cystostomy, left iliac vein clamping, and pelvic bone stabilization with external fixators. Due to worsening respiratory status on postoperative day 2, the patient underwent an emergency thoracotomy, which revealed a 200-mL clot hemothorax in the costodiaphragmatic recess, middle-lobe contusions, ischemia, and a complete transection of the middle-lobe bronchus extending to the intermediate bronchus. Rib fractures (5th and 6th) necessitated a middle lobectomy and rib fixation. CONCLUSIONS This case underscores the importance of a high index of suspicion for tracheobronchial injuries in blunt thoracic trauma. While eFAST aids in initial assessment, definitive diagnosis requires advanced imaging modalities such as CT and bronchoscopy. Timely surgical interventions and a coordinated multidisciplinary approach are essential for optimal patient outcomes. By sharing this case, we aim to contribute to the understanding and management of rare bronchial injuries.

Perioperative Coronavirus Disease 2019 Infection and Its Impact on Postoperative Outcomes: Pulmonary Complications and Mortality Based on Korean National Health Insurance Data

Background/Objectives: The coronavirus disease 2019 (COVID-19) pandemic significantly disrupted global healthcare. This study explores the effects of perioperative COVID-19 infection on postoperative outcomes, aiming to refine risk assessment and enhance personalized perioperative care using a comprehensive dataset from the Korean National Health Insurance Service. This analysis extends previous research by providing a large-scale validation of risk factors associated with COVID-19 in a perioperative setting. Methods: In this retrospective cohort study, we analyzed data from 2,903,858 patients who underwent surgery under general anesthesia between January 2020 and December 2021. Patients were categorized into COVID-19 (+) and COVID-19 (-) groups within 30 d before or after surgery. Logistic regression models were used to identify independent risk factors for mortality and pulmonary complications. Results: After propensity score matching, the final cohort comprised 19,235 patients (COVID-19 (+): 3847; COVID-19 (-): 15,388). The COVID-19 (+) group had significantly higher overall mortality than the COVID-19 (-) group. No significant difference was observed between the groups concerning 30 d mortality. Pulmonary complications, including pneumonia and acute respiratory distress syndrome, were significantly more frequent in the COVID-19 (+) group. The independent predictors of 30 d mortality included advanced age, emergency surgery, and the American Society of Anesthesiologists physical status classification. Conclusions: Our study confirms that perioperative COVID-19 infection significantly elevates overall mortality and pulmonary complications, emphasizing the necessity of tailored perioperative management. Incorporating individual risk factors into care protocols not only reduces risks for surgical patients but also enhances treatment approaches. These findings advocate for the implementation of personalized medicine principles in surgical settings to improve patient outcomes during and after the COVID-19 pandemic. This research uses a comprehensive national medical claims dataset to set new standards for studying pandemic health impacts and improving clinical strategies.

SARS-CoV-2 infection and complicated appendicitis in adults in Lima, Peru: a matched case-control study

BACKGROUND

Acute appendicitis may be uncomplicated or may present with life threatening complications. Since the outbreak of the COVID-19 pandemic, there has been an increase in the number of cases of complicated appendicitis, suggesting a possible association between them. Therefore, we aimed to determine the association between SARS-CoV-2 infection and complicated appendicitis in surgical patients in Lima, Peru, from March 2020 to December 2021.

METHODS

A matched case-control study was conducted. Clinical records of patients ≥ 18 years old who underwent surgery for appendicitis and had at least one positive SARS-CoV-2 diagnostic test were selected. Patients undergoing surgery for complicated appendicitis were considered cases, and patients undergoing surgery for uncomplicated appendicitis were controls. A 1:1 matching by sex, age, and month of surgery was performed. Conditional logistic regression modeling was performed to calculate crude and adjusted conditional odds ratios (cOR).

RESULTS

The positivity rate for COVID-19 tests was 73.6% for cases and 26.4% for controls. The crude cOR was 4.88 (95% IC 2.89-8.23, p < 0.001), and the adjusted cOR was 3.52 (95%IC 1.82-6.81, p = 0.001), after controlling for onset time of symptoms and awaiting time before surgery.

CONCLUSIONS

Surgery for complicated appendicitis was associated with SARS-CoV-2 infection. Patients with this infection may be at higher risk of complicated appendicitis and thus may need additional clinical monitoring.

A qualitative study on factors influencing health workers' uptake of a pilot surgical antibiotic prophylaxis stewardship programme in selected Georgian hospitals

Antimicrobial misuse in surgical antibiotic prophylaxis (SAP) can include the inappropriate use of broad-spectrum antibiotics or prolonged dosing. In 2021, a pilot antimicrobial stewardship programme (ASP) was launched in Georgia, which involved developing and adapting SAP guidelines, establishing an interprofessional SAP prescribing approach, collecting surgical site infection (SSI) data via routinely collected data and telephonic patient follow-ups, and providing surgical unit staff with prescribing feedback and training on antimicrobial resistance (AMR) and antimicrobial stewardship (AMS). ASP introduction was staggered across ten hospitals over three years. This study explored behavioural determinants of surgical teams' ASP uptake in five hospitals where the ASP was introduced or about to be introduced. Findings primarily concerned epidemiologists' and nurses' ASP-related behaviour. Those at ASP non-introduced hospitals were less involved in the SAP prescribing process, had lower AMR awareness, and lacked professional development opportunities. Those at ASP-introduced hospitals exhibited higher AMR knowledge and felt ASP participation boosted confidence, facilitated work, and furnished key professional development. Results indicate interprofessional collaboration on SAP prescribing supported ASP uptake across teams, and investment in health worker training and administrative encouragement ensured effective ASP participation and implementation. Findings highlight the crucial role of epidemiologists in SAP and illustrate a need for developing Georgian nurses' AMR competencies as a vehicle to address public AMR knowledge gaps. Longer-term ASP uptake will need to consider the regulatory context in which hospitals lack access to national-level SSI data and feedback on SSI reporting but are fined for reporting non-compliance. Despite resource limitations and a small sample size, the study engaged all pilot ASP health workers. Respondents' inexperience of qualitative research participation and ensuant hesitation limited exploration of motivational factors supporting health workers' ASP uptake, which could be explored in further research.

Optimizing timing for elective surgery in cancer patients following COVID-19 infection; a post-pandemic analysis

INTRODUCTION

The COVID-19 pandemic introduced challenges including delaying elective surgery. For cancer patients, reducing delays is preferred to prevent unfavorable outcomes. there is a lack of consensus regarding the optimal timing of elective surgery following a SARS-CoV-2. This study aimed to find the optimal time to elective surgery to minimize 30-day postoperative morbidity and mortality.

METHODS

This is a retrospective chart review of all adult patients who underwent elective surgery with a confirmed preoperative COVID-19 diagnosis between September 2020 and April 2023. Patients' elective surgeries delays were examined to determine the optimal time to surgery in terms of postoperative complications. Analysis was controlled for age, ASA score, comorbidities, and smoking status.

RESULTS

358 records examined, 94.7% had delayed surgery and 5.3% had cancelled surgery. The optimal time to surgery was ≥ 17 days to minimize postoperative pulmonary complications [OR: 0.299, p = 0.048], other postoperative complications [OR: 0.459, p = 0.01], and a decrease in length of hospital stay. In multivariate analysis, the only significant predictors for postoperative complications were time to surgery; surgery ≥ 17 days after diagnosis had better postoperative outcomes [p < 0.001], and COVID-19 symptoms status [p = 0.019].

CONCLUSION

The best time to surgery in this cohort is at least 17 days (or a range of 2-3 weeks) for optimal results. Further research is needed to investigate the effect of such delays on oncological outcomes in this cohort.

Rethinking vasopressor use in the trauma bay: a shifting perspective

The use of vasopressors during the acute resuscitation of severely injured patients with trauma has long been controversial. Building on the concept of permissive hypotension, damage control resuscitation focuses on hemostatic transfusion of blood products to maintain perfusion pressures. However, targeting lower perfusion pressures while awaiting definitive hemorrhage control is contraindicated in some patient subpopulations and may be detrimental. Coupled with the shift towards a circulation-first approach to resuscitation, there is increasing interest in the use of vasopressors in the trauma bay. This narrative review aims to summarize the evidence behind trauma bay vasopressors and identify the potential role of vasoactive medications in the early phases of trauma care.

Epidemiology of Pediatric Transports and First Aid in a German Municipal Emergency Medical Services (EMS) System: A Cohort Study

Background: Pediatric emergencies remain a significant challenge for emergency services. The study aimed to retrospectively analyze invasive measures and medication administered during prehospital care. The analysis focused on invasive procedures (e.g., tracheal intubation and vascular access) performed on pediatric patients (aged 1 month to 12 years) admitted via the Central Emergency Department (ED) or directly to the University Pediatric Intensive Care Unit (PICU) of the University Hospital of Cologne. These findings provide insights into quality assurance and improvement of prehospital care and invasive emergency techniques in pediatrics. Methods: Emergency protocols were evaluated, including parameters such as the Glasgow Coma Scale (GCS) and National Advisory Committee for Aeronautics (NACA) score. Patients were categorized based on diagnosis, medication administration, and invasive emergency techniques. Results: A total of 373 patients were admitted to the ED, and 237 patients were admitted to the PICU between 01/2015 and 05/2020. Sedation was at similar in both groups, while catecholamines were more frequently used in the PICU group. Invasive procedures, such as tracheal intubation, were rare (PICU: 9.5%; ED: 5.8%; p=0.093). Peripheral venous access was performed in 33.7% of PICU cases and 51.2% of ED cases, whereas central venous access was almost never performed. 19 children admitted to the PICU died compared to one in the ED (p < 0.001). Conclusion: Invasive procedures are rarely performed during prehospital care for pediatric patients. Trauma cases predominated in the ED group (99.2%), whereas the PICU group exhibited greater diagnostic variability, including trauma and internal emergencies. This study identified significant gaps in medical documentation. Training for paramedics and emergency health workers should prioritize airway management, including supraglottic airway (SGA) devices, thoracic drainage, and vascular access techniques such as peripheral intravenous (PIV) and intraosseous (IO) access. Additionally, efforts to improve medical documentation should be emphasized to enhance pediatric emergency care.

Case Report: Management of cerebral arterial gas embolism via transfer to an outpatient hyperbaric chamber

Gas embolisms can be caused by iatrogenic interventions, resulting in various manifestations. We present a patient who experienced loss of consciousness and simultaneous paralysis during a percutaneous needle biopsy of the lung. A CT scan of the head revealed a cerebral arterial gas embolism. Because the treating hospital did not have access to hyperbaric oxygen for immediate treatment, the patient was transferred to an outpatient wound care facility. There, the patient initially improved when treated with hyperbaric oxygen therapy but deteriorated with resumption of ambient pressure. Continued treatment occurred at another hospital where the patient's condition normalized. The initial transfer of the patient to another facility was notable because it was a transfer from a rural hospital, a higher-level facility, to an offsite wound care center with a hyperbaric chamber, a lower-level facility that could provide a higher level of care. This case report demonstrates the importance of immediate treatment of iatrogenic gas embolism with hyperbaric oxygen, which often is not available at many hospitals, and highlights the necessity to adapt to the transport of the patient from a higher-level facility to a lower-level facility when such transportation is necessary to provide effective and immediate care. This report is not recommending routinely transferring such patients to a lower level of care facility. However, when deemed clinically necessary and safe by bedside emergency physicians/critical care pulmonary physicians, it is a viable option. Explicit guidelines for transfers to lower-level facilities should be established to avoid delays in these situations.

Incidence and risk factors of postpartum urinary retention following cesarean section: a retrospective nationwide inpatient sample database study

AIM

To investigate the risk factors associated with postpartum urinary retention after cesarean section (CS) and to determine the associated morbidity rate.

METHODS

This study was a population-based retrospective case-control study analyzed using National Inpatient Sample (NIS) data from 2010 to 2019. The study classified women according to whether they developed postpartum urinary retention after delivery. Predictors of postpartum urinary retention occurring after CS were identified by multivariate logistic regression analysis, and the corresponding incidence rates were examined after adjusting for basic maternal demographic and clinical characteristics.

RESULTS

A total of 2,397,168 CSs were extracted from the NIS database. The overall incidence of urinary retention after CS was 0.20%. Patients who experienced urinary retention after CS demonstrated longer length of stay (LOS), higher total costs, and more postoperative complications. The following variables have been identified as potential risk factors for urinary retention: age between 25 and 34 years (OR = 1.27; 95% CI = 1.17-1.38; P < 0.001), 35 years and older (OR = 1.35; 95% CI = 1.22-1.48; P < 0.001), Asian and Pacific Islander (OR = 1.85; 95% CI = 1.68-2.05; P < 0.001), one comorbidity (OR = 1.51; 95% CI = 1.28-1.79; P < 0.001), two comorbidities (OR = 1.51; 95% CI = 1.09-2.08; P = 0.013), three and more comorbidities (OR = 1.79; 95% CI = 1.06-3.04; P = 0.031), large hospitals (OR = 1.16; 95% CI = 1.07-1.26; P < 0.001), teaching hospitals (OR = 1.93; 95% CI = 1.79-2.07; P < 0.001), eastern hospitals (OR = 1.24; 95% CI = 1.14-1.35; P < 0.001), coagulation disorders (OR = 1.32; 95% CI = 1.08-1.61), fluid and electrolyte disorders (OR = 2.46; 95% CI = 1.94-3.11), other neurological disorders (OR = 1.51; 95% CI = 1.20-1.89), paralysis (OR = 3.24; 95% CI = 1.95-5.38), and weight loss (OR = 2.34;95% CI = 1.26-4.35). In addition, urinary retention was associated with postoperative complications related to bladder or ureteral injury (OR = 6.12; 95% CI = 2.46-15.23), blood transfusion (OR = 1.51; 95% CI = 1.31-1.76), acute renal failure (OR = 4.74; 95% CI = 3.46-6.48), respiratory failure (OR = 2.21; 95% CI = 1.23-3.98), endometritis (OR = 1.32; 95% CI = 1.02-1.71), hemorrhage/hematoma ( OR = 2.52; 95% CI = 1.38-4.62), uterine rupture (OR = 1.75; 95% CI = 1.21-2.54), hysterectomy (OR = 2.30; 95% CI = 1.66-3.18), peritonitis (OR = 2.86; 95% CI = 1.03-7.92), severe puerperal infections (OR = 3.31; 95% CI = 2.60- 4.22), chorioamnionitis (OR = 1.78; 95% CI = 1.59-2.00). Notably, the presence of cephalopelvic disproportion (OR = 1.37; 95% CI = 1.11-1.67), breech or other fetal position abnormalities (OR = 1.10; 95% CI = 1.00-1.20), placenta previa (OR = 1.39; 95% CI = 1.06-1.84), multiple gestation (OR = 1.39; 95% CI = 1.23-1.58), anatomy of the bladder (OR = 3.93; 95% CI = 1.42-10.90), bladder catheter placement (OR = 22.57; 95% CI = 20.24-25.17) and intravenous infusion (OR = 1.22; 95% CI = 1.09-1.36) was associated with a significantly increased risk of urinary retention, while low cervical CS (OR = 0.62; 95% CI = 0.50-0.76), previous CS (OR = 0.87; 95% CI = 0.82-0.93) and prolapsed cord (OR = 0.52; 95% CI = 0.31-0.86) conferred some protective effect against it.

CONCLUSION

In this study, we identified an overall prevalence of 0.20% for urinary retention after CS and several risk factors, including advanced maternal age, Asian and Pacific Islander background, comorbidities, and delivery in large or teaching hospitals, particularly in the Eastern region. Protective factors included hospitals in the southern region, urban hospitals, obesity, and hypertension. Urinary retention was associated with increased postoperative complications, longer LOS, and higher healthcare costs. Several confounders also significantly influenced the incidence of urinary retention. To mitigate these risks, healthcare professionals should prioritize antenatal screening, manage comorbidities, and closely monitor high-risk patients during the postpartum period to reduce adverse outcomes.

Effect of age on major trauma profile and characterisation: Analysis from the national major trauma audit in Ireland

BACKGROUND

Major trauma (MT) is a significant cause of morbidity and mortality worldwide, with older adult patients facing unique challenges due to age-related vulnerabilities and higher risks of falls. This study aimed to investigate differences in trauma characteristics, injury mechanisms, and outcomes of older adults compared to all younger patients with MT on a national level.

METHODS

This retrospective cohort study analysed the national Major Trauma Audit data from 23,765 eligible patients with MT in Ireland of all ages and stratified into two age groups: those under 65 years (n = 12,620) and those aged 65 years or older (n = 11,145). The Major Trauma Audit follows the methodology of National Major Trauma Registry in the UK. Variables assessed included injury severity, comorbidities, length of stay (LOS), and mortality rates. Statistical comparisons were made between the two age groups.

RESULTS

Older adults represent 47 % of the total Irish patient population with MT, with a significantly higher proportion of females (56 %) compared to younger patients (31 %) (P<0.001). Falls of less than two meters were the leading mechanism of injury for older adults (82 %), while road traffic accidents (RTA) were more common among younger patients (25 %). Severe injuries were observed in 34 % of both age groups, but <10 % of older adults were received by a trauma team. Comorbidities were significantly more prevalent in older adults (75 %) compared to 39 % in younger patients, (P<0.001). Median hospital LOS was twelve days for older adults, compared to seven days for younger patients. Mortality rates were significantly higher among the older patient population, who were also more likely to be discharged to long-term care, (P<0.001).

CONCLUSION

In comparison to younger patients, the present study highlights that older adults who experience major trauma are frequently under-triaged as suspected MT, leading to delays in care, inadequate treatment, or worse clinical outcomes.

Modern Treatment of Skeletal Metastases: Multidisciplinarity and the Concept of Oligometastasis in the Recent Literature

Bone metastases are a major concern in cancer management since they significantly contribute to morbidity and mortality. Metastatic lesions, commonly arising from breast, prostate, lung, and kidney cancers, affect approximately 25% of cancer patients, leading to severe complications such as pain, fractures, and neurological deficits. This narrative review explores contemporary approaches to bone metastases, emphasizing a multidisciplinary strategy and the evolving concept of oligometastatic disease. Oligometastases, defined by limited metastatic spread (1-5 lesions), offer a potential window for curative treatment through aggressive interventions, including stereotactic ablative radiotherapy and resection surgery. Tumor boards, integrating systemic therapies with local interventions, are crucial to optimize treatment. Despite promising results, gaps remain in defining optimal treatment sequences and refining patient selection criteria. Future research should focus on personalized approaches, leveraging biomarkers and advanced imaging to enhance outcomes and the quality of life in patients with bone metastases.

Improving Empiric Antibiotic Selection for Patients Hospitalized With Abdominal Infection: The INSPIRE 4 Cluster Randomized Clinical Trial

Importance

Empiric extended-spectrum antibiotics are routinely prescribed for over a million patients hospitalized annually with abdominal infection despite low likelihoods of infection with multidrug-resistant organisms (MDROs).

Objective

To evaluate whether computerized provider order entry (CPOE) prompts providing patient- and pathogen-specific MDRO infection risk estimates can reduce empiric extended-spectrum antibiotics for non-critically ill patients admitted with abdominal infection.

Design, Setting, and Participants

This 92-hospital cluster randomized clinical trial assessed the effect of an antibiotic stewardship bundle with CPOE prompts vs routine stewardship on antibiotic selection during the first 3 hospital days (empiric period) in non-critically ill adults hospitalized with abdominal infection. The trial population included adults (≥18 years) treated with empiric antibiotics for abdominal infection in non-intensive care units (ICUs). The trial periods included a 12-month baseline from January to December 2019 and an intervention period from January to December 2023.

Intervention

CPOE prompts recommending standard-spectrum antibiotics in patients prescribed extended-spectrum antibiotics during the empiric period if the patient's estimated absolute risk of MDRO abdominal infection was less than 10%, coupled with feedback and education.

Main Outcomes and Measures

The primary outcome was empiric extended-spectrum antibiotic days of therapy. Safety outcomes: days to ICU transfer and hospital length of stay. Analyses compared differences between baseline and intervention periods across strategies.

Results

Among 92 hospitals with 198 480 patients, mean (SD) age was 60 (19) years and 118 723 (59.8%) were female. The trial included 93 476 and 105 004 patients hospitalized with abdominal infection during the baseline and intervention periods, respectively. Receipt of any empiric extended-spectrum antibiotics for the routine care group was 48.2% (22 519 of 46 725) during baseline and 50.5% (27 452 of 54 384) during intervention vs 47.8% (22 367 of 46 751) and 37.6% (19 010 of 50 620) for the CPOE bundle group. The group receiving CPOE prompts had a 35% relative reduction (rate ratio, 0.65; 95% CI, 0.60-0.71; P < .001) in empiric extended-spectrum antibiotic days of therapy vs routine care (raw absolute reduction between baseline and intervention periods was -169 for the CPOE bundle vs -20 for routine care). Hospital length of stay was noninferior to routine care (0.1 days longer during intervention; mean [SD], baseline, 5.4 [3.4] days vs intervention, 5.5 [3.5] days; hazard ratio [HR], 1.02; 90% CI, 0.99-1.06), and mean days to ICU transfer in the CPOE group was indeterminate (both groups 0.2 days longer during intervention; HR, 1.10; 90% CI, 0.99-1.23).

Conclusions and Relevance

CPOE prompts recommending empiric standard-spectrum antibiotics (coupled with education and feedback) for patients admitted with abdominal infection who have low risk for MDRO infection significantly reduced extended-spectrum antibiotics without increasing ICU transfers or length of stay.

Trial Registration

ClinicalTrials.gov Identifier: NCT05423743.

Sigmoid Resection vs Conservative Treatment After Diverticulitis: Prespecified 4-Year Analysis of the LASER Randomized Clinical Trial

Importance

Laparoscopic elective sigmoid resection is a treatment option for patients with recurring, persistent painful, or complicated diverticulitis, but outcomes of surgery compared with conservative treatment are unclear in long-term follow-up.

Objective

To compare quality-of-life (QOL), complication, and recurrence outcomes of surgery vs conservative treatment in patients with recurring, persistent painful, or complicated diverticulitis.

Design, Setting, and Participants

The open-label Laparoscopic Elective Sigmoid Resection Following Diverticulitis (LASER) randomized clinical trial was conducted in 6 Finnish hospitals. Ninety patients with recurring, persistent painful, or complicated diverticulitis were randomized (1:1) to elective sigmoid resection or conservative treatment from September 2014 to October 2018. Herein, outcomes are reported at 4-year follow-up using the intention-to-treat principle. Data analysis for this 4-year follow-up was performed from October 2023 to November 2024.

Interventions

Laparoscopic elective sigmoid resection vs conservative treatment.

Main Outcomes and Measures

Secondary outcomes, such as Gastrointestinal Quality of Life Index (GIQLI) scores, complications, and recurrences, within 4 years are reported using intention-to-treat and post hoc per-protocol analyses.

Results

Of 90 enrolled patients (28 male [31%] with mean [SD] age of 54.11 [11.9] years; 62 female [69%] with mean [SD] age of 57.13 [7.6] years), 45 were randomized to elective sigmoid resection and 45 to conservative treatment. Among those randomized to conservative treatment, 14 of 44 (32%) underwent sigmoid resection within 4 years (patients with lower QOL on average). The mean (SD) GIQLI score was 115.3 (17.8) in the surgery group vs 109.8 (19.8) in the conservative treatment group (mean difference, 5.54 [95% CI, -2.98 to 14.06]) at 4 years. Recurrence of diverticulitis occurred in 6 of 38 patients (16%) (4 [10%] after surgery) in the surgery group vs 34 of 37 patients (92%) in the conservative treatment group. Severe postoperative complications occurred in 4 patients (10%) in the surgery group vs 5 patients (11%) in the conservative treatment group.

Conclusions and Relevance

High crossover rates from conservative treatment to surgery indicate that patients with low QOL in the conservative treatment group often require surgical intervention; elective sigmoid resection did not improve QOL compared with conservative treatment in 4-year follow-up, even though it was effective in preventing recurrences of diverticulitis and did not lead to increased rates of postoperative complications. Upfront surgery may be preferable in patients with low QOL, but initial conservative treatment is an option for patients with near-normal QOL.

Trial Registration

ClinicalTrials.gov Identifier: NCT02174926.