Emulating Target Trials With Real-World Data to Inform Health Technology Assessment: Findings and Lessons From an Application to Emergency Surgery

OBJECTIVES

International health technology assessment (HTA) agencies recommend that real-world data (RWD) are used in some circumstances to add to the evidence base about the effectiveness and cost-effectiveness of health interventions. The target trial framework applies the design principles of randomized-controlled trials to RWD and can help alleviate inevitable concerns about bias and design flaws with nonrandomized studies. This article aimed to tackle the lack of guidance and exemplar applications on how this methodology can be applied to RWD to inform HTA decision making.

METHODS

We use Hospital Episode Statistics data from England on emergency hospital admissions from 2010 to 2019 to evaluate the cost-effectiveness of emergency surgery for 2 acute gastrointestinal conditions. We draw on the case study to describe the main challenges in applying the target trial framework alongside RWD and provide recommendations for how these can be addressed in practice.

RESULTS

The 4 main challenges when applying the target trial framework to RWD are (1) defining the study population, (2) defining the treatment strategies, (3) establishing time zero (baseline), and (4) adjusting for unmeasured confounding. The recommendations for how to address these challenges, mainly around the incorporation of expert judgment and use of appropriate methods for handling unmeasured confounding, are illustrated within the case study.

CONCLUSIONS

The recommendations outlined in this study could help future studies seeking to inform HTA decision processes. These recommendations can complement checklists for economic evaluations and design tools for estimating treatment effectiveness in nonrandomized studies.

Postoperative pulmonary complications in severe acute respiratory syndrome coronavirus 2 infected patients who underwent emergency surgery

BACKGROUND

Recent studies suggest that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection increases the incidence of postoperative pulmonary complications (PPCs) and mortality. Consequently, patients with SARS-CoV-2 infection undergoing emergency surgery are more vulnerable to PPCs, yet few studies have evaluated PPCs in these patients.

METHODS

A retrospective analysis was conducted between January 2022 and February 2023 on the medical records of patients infected with SARS-CoV-2 who underwent emergency surgery. The study evaluated the incidence of PPCs and 30-day postoperative mortality in all enrolled patients.

RESULTS

A total of 41 patients were enrolled, among whom PPCs occurred in seven patients (17%). The incidence of PPCs was statistically significant in patients with underlying diabetes compared to those without (p = 0.01) and in patients with an American Society of Anesthesiologists (ASA) class 3 or higher compared to those with less than 3 (p = 0.005) (ASA classification uses a grading system of I (one) through V (five)). The 30-day mortality rate was 4.9%.

CONCLUSIONS

Our study demonstrates that the incidence of PPCs and 30-day mortality rates after emergency surgery in patients infected with SARS-CoV-2 are higher compared to prepandemic baseline rates. Given the significant interest and concern worldwide regarding severe infectious respiratory diseases, such as coronavirus disease 2019 (COVID-19), clinicians should focus on conducting research to identify ways to reduce the incidence of PPCs and mortality in patients with severe acute respiratory infections.

Adapting Patient and Public Involvement processes in response to the Covid-19 pandemic

BACKGROUND

The COVID-19 pandemic brought rapid and major changes to research, and those wishing to carry out Patient and Public Involvement (PPI) activities faced challenges, such as restrictions on movement and contact, illness, bereavement and risks to potential participants. Some researchers moved PPI to online settings during this time but remote consultations raise, as well as address, a number of challenges. It is important to learn from PPI undertaken in this period as face-to-face consultation may no longer be the dominant method for PPI.

METHODS

UK stay-at-home measures announced in March 2020 necessitated immediate revisions to the intended face-to-face methods of PPI consultation for the ESORT Study, which evaluated emergency surgery for patients with common acute conditions. PPI plans and methods were modified to all components being online. We describe and reflect on: initial plans and adaptation; recruitment; training and preparation; implementation, contextualisation and interpretation. Through first-hand accounts we show how the PPI processes were developed, experienced and viewed by different partners in the process.

DISCUSSION AND CONCLUSIONS

While concerns have been expressed about the possible limiting effects of forgoing face-to-face contact with PPI partners, we found important benefits from the altered dynamic of the online PPI environment. There were increased opportunities for participation which might encourage the involvement of a broader demographic, and unexpected benefits in that the online platform seemed to have a 'democratising' effect on the meetings, to the benefit of the PPI processes and outcomes. Other studies may however find that their particular research context raises particular challenges for the use of online methods, especially in relation to representation and inclusion, as new barriers to participation may be raised. It is important that methodological challenges are addressed, and researchers provide detailed examples of novel methods for discussion and empirical study.

PATIENT AND PUBLIC CONTRIBUTION

We report a process which involved people with lived experience of emergency conditions and members of the public. A patient member was involved in the design and implementation, and two patients with lived experience contributed to the manuscript.

Comparing 30-Day Outcomes After Emergent Spine Procedures Performed "During Hours" vs "After Hours"

BACKGROUND

Spinal injuries, whether mechanical or neurological, frequently require urgent intervention. Superior outcomes are associated with earlier intervention, which often requires operating overnight and on weekends. However, operating after hours has been associated with increased risks of complications in selected studies. The authors sought to determine whether there are differences in outcomes for "after hours" surgery compared with "during hours" surgery for spinal emergencies.

METHODS

This is a single-center retrospective cohort study of spine surgery patients who underwent urgent surgery within 6 hours, from January 2015 through December 2019. Surgery was considered during hours if it started between 8 am and 5 pm Monday through Friday. After hours was defined as from 5 pm through 8 am on a weekday or Saturday or Sunday. We assessed 30-day outcome measures for differences between operations performed during hours or after hours.

RESULTS

There were 241 spine procedures performed (49 during hours and 192 after hours). There was no significant difference between the length of operation (145.3 vs 129.8 minutes, P = 0.29), estimated blood loss (303.9 vs 274.4 mL, P = 0.61), improvement in American Spinal Injury Association scale (0.26 vs 0.24 grade, P = 0.85), 30-day return to the operating room (OR; 14.3% vs 6.8%, P = 0.09), 30-day readmission (2.0% vs 6.3% P = 0.24), intensive care unit length of stay (4.6 vs 6.3 days, P = 0.27), hospital length of stay (13.5 days vs 14.2 days, P = 0.72), or 30-day mortality (4.1% vs 7.3%, P = 0.42) for cases performed during hours compared with those after hours, respectively. On multivariate analysis, prior malignancy (P = 0.008) and blue immediate status (P = 0.004) were predictors of 30-day mortality. However, "after hours" surgery was not a predictor of 30-day return to the OR, readmission, or mortality in either univariate or multivariate analysis.

CONCLUSIONS

Spine surgery must often be performed after hours. However, the time of day does not significantly impact the 30-day outcomes for emergent spine surgery.

LEVEL OF EVIDENCE: 3

Rare causes of abdominal pain: a primer for the admitting general surgeon

The broad uptake of the acute surgical unit (ASU) model of surgical care in Australia has resulted in general surgeons becoming increasingly involved in the management of patients with acute abdominal pain (AAP), some of whom will be labelled as having non-specific abdominal pain (NSAP) (Kinnear N, Jolly S, Herath M, et al. The acute surgical unit: An updated systematic review and meta-analysis. review. Int. J. Surg. 2021;94:106109; Lehane CW, Jootun RN, Bennett M, Wong S, Truskett P. Does an acute care surgical model improve the management and outcome of acute cholecystitis? ANZ J. Surg. 2010;80:438-42). NSAP patients lack a clear diagnosis of surgical pathology based on standard clinical, laboratory and imaging work-up, although they may require ASU admission for pain control and assessment. This article provides a review of uncommon conditions, presenting as AAP, that could possibly be mis-labelled as NSAP, with a focus on aspects of the presentation that may aid diagnosis and management including specific demographic features, clinical findings, key investigations and initial treatment priorities for ASU clinicians. Ultimately, most of the conditions discussed will not require surgical intervention, however, they require a diagnosis to be made and initial treatment planning before on-referral to the appropriate specialty. For the on-call general surgeon, some knowledge of these conditions and an index of suspicion are invaluable for the prompt diagnosis and efficient management of these patients.

Enhanced recovery after surgery protocols and emergency surgery: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

This systematic review and meta-analysis seeks to assess the modified protocols used and patient outcomes when enhanced recovery after surgery (ERAS) protocols are utilized in an emergency setting.

METHODS

PubMed, MEDLINE, EMBASE and Cochrane Central Registry of Controlled Trials were comprehensively searched until 13 March 2023. The Cochrane Risk of Bias Assessment Tool was used to assess for bias, along with funnel plot asymmetry. We present log risk ratios for dichotomous variables and raw mean differences for continuous variables.

RESULTS

Seven randomized trials were included, comprising 573 patients. Results of the primary outcomes when comparing ERAS to standard care are as follows; withdrawal of nasogastric tube (raw mean difference -1.87 CI: -2.386 to -1.359), time to first liquid diet (raw mean difference -2.56 CI: -3.435 to -1.669), time to first solid diet (raw mean difference -2.35 CI: -2.933 to -1.76), time to first flatus (raw mean difference -2.73 CI: -5.726 to 0.257), time to first stool passed (raw mean difference -1.83 CI: -2.307 to -1.349), time to removal of drains (raw mean difference -3.23 CI: -3.609 to -2.852), time to removal of urinary catheter (raw mean difference -1.57 CI: -3.472 to 0.334), mean pain score (raw mean difference -1.79 CI: -2.222 to -1.351) and length of hospital stay (raw mean difference -3.16 CI: -3.688 to -2.63).

CONCLUSIONS

The adoption of ERAS protocols in an emergency surgery setting was observed to enhance patient recovery, while not indicating any statistically significant increase in adverse outcomes.

Laparoscopic vs. Open Approach in Emergent Inguinal Hernia: Our Experience and Review of Literature

There is currently no consensus or homogeneous recommendation about the role of the laparoscopic approach in emergent inguinal hernia surgery. The aim of this manuscript is showing our experience and results of laparoscopic approach for emergent groin hernia repair comparing with open approach. A retrospective review of a prospectively maintained database between January 2011 and December 2021 of acute incarcerated groin hernia that were operated at Virgen del Rocio University Hospital. In this period, they were identified 463 patients with groin hernia that required an emergency repair. 454 patients underwent open surgery (group 1) and 36 patients underwent laparoscopic approach (TAPP procedure) (group 2). Median length stay was 1 day in lap group and 2 days in open approach. Reintervention was necessary in 20 cases (4.40%) from group 1 and one (2.27%) from group 2. In laparoscopic approach, no mortality was described but in open approach, 10 patients (2.20%) died. Globally, 58 cases (12.77%) from group 1 and six patients (16.66%) from group 2 presented any complication. Wound infection was higher in group of open repairs (5.94% vs. 2.77%). Non-surgical complications were higher in open approach (19 vs. 0). There is no statistical significance in any of these items. Laparoscopic approach is a safe, feasible and effective therapeutic option for the treatment of incarcerated groin hernia that require emergency surgery, but prospective and randomized comparative studies are needed to establish the best approach.

Informed consent process for emergency surgery: A scoping review of stakeholders' perspectives, challenges, ethical concepts, and policies

Background

A scoping review of literature about the informed consent process for emergency surgery from the perspectives of the patients, next of kin, emergency staff, and available guiding policies.

Objectives

To provide an overview of the informed consent process for emergency surgery; the challenges that arise from the perspectives of the patients, emergency staff, and next of kin; policies that guide informed consent for emergency surgery; and to identify any knowledge gaps that could guide further inquiry in this area.

Methods

We searched Google Scholar, PubMed/MEDLINE databases as well as Sheridan Libraries and Welch Medical Library from 1990 to 2021. We included journal articles published in English and excluded non-peer-reviewed journal articles, unpublished manuscripts, and conference abstracts. The themes explored were emergency surgery consent, ethical and theoretical concepts, stakeholders' perceptions, challenges, and policies on emergency surgery. Articles were reviewed by three independent reviewers for relevance.

Results

Of the 65 articles retrieved, 18 articles were included. Of the 18 articles reviewed, 5 addressed emergency informed consent, 9 stakeholders' perspectives, 7 the challenges of emergency informed consent, 3 ethical and theoretical concepts of emergency informed consent, and 3 articles addressed policies of emergency surgery informed consent.

Conclusion

There is poor satisfaction in the informed consent process in emergency surgery. Impaired capacity to consent and limited time are a challenge. Policies recommend that informed consent should not delay life-saving emergency care and patient's best interests must be upheld.

Giant duplication of the transverse colon in an adult: A case report and literature review

Intestinal duplication is a rare congenital malformation that can occur in any segment of the digestive tract. It is most commonly found in the ileum of infants and is rarely reported in adults, especially in the colon. Diagnosing intestinal duplication can be extremely challenging due to its diverse clinical manifestations and complex anatomical structure. Surgical intervention is currently considered the mainstay of treatment. In this report, we presented a case of giant duplication of the transverse colon in an adult.

Outcomes of Emergency Groin Hernia Repair in the Elderly: A Systematic Review

Introduction: The number of surgeries for groin hernia (GH) among the elderly follows the increase in life expectancy of the population. The greater number and severity of comorbidities in this group increases the surgical risk, promoting discussion regarding the indication of elective surgery and the benefits of watchful waiting approach (WWA). The aim of the present study was to evaluate the outcomes of emergency hernia surgery among the elderly population. Materials and methods: A systematic review was performed in Pubmed and Scielo databases for the past early 10 years, until July 2022. The subject was groin hernia in the emergency setting focusing the elderly population. The PRISMA statement was followed and the classification of elderly was based on the World Health Organization's definition. Results: A total of 1,037 results were returned and we ended with nine original articles with emphasis in groin hernia in the emergency among the elderly population. In these subjects, the complications rate ranged between 21.2% and 28.9% and the mortality rate ranged between 1.2% and 6%. Cardiopulmonary disease, high ASA and Charlson's scales were associated with greater risk of complications and death. Conclusion: Emergency GH surgery in the elderly population carries an increased risk of complications and mortality. GH surgery is safe or, at least, less harmful when done electively. The risk and benefits of WWA and upfront surgery needs to be assessed and exposed to the patients. Our review sugest that elective surgery should be the option over WWA in this patient population.

Prophylactic effect of negative-pressure wound therapy and delayed sutures against incisional-surgical site infection after emergency laparotomy for colorectal perforation: A multicenter retrospective cohort study

Aim

The prophylactic effect of negative-pressure wound therapy against incisional surgical site infection after highly contaminated laparotomies has not been sufficiently explored. This study aimed to evaluate the prophylactic effect of negative-pressure wound therapy against incisional surgical site infection after emergency surgery for colorectal perforation.

Methods

This nationwide, multicenter, retrospective cohort study analyzed data from the 48 emergency hospitals certificated by the Japanese Society for Abdominal Emergency Medicine. Patients who underwent an emergency laparotomy for colorectal perforation between April 2015 and March 2020 were included in this study. Outcomes, including the incidence of incisional surgical site infection, were compared between patients who were treated with prophylactic negative-pressure wound therapy and delayed sutures (i.e., negative-pressure wound therapy group) and patients who were treated with regular wound management (i.e., control group) using 1:4 propensity score matching analysis.

Results

The negative-pressure wound therapy group comprised 88 patients, whereas the control group consisted of 1535 patients. Of them, 82 propensity score-matched pairs (negative-pressure wound therapy group: 82; control group: 328) were evaluated. The negative-pressure wound therapy group showed a lower incidence of incisional surgical site infection [18 (22.0%) in the negative-pressure wound therapy group and 115 (35.0%) in the control group, odds ratio, 0.52; 95% confidence interval, 0.30 to 0.92; p = 0.026].

Conclusions

The prophylactic use of negative-pressure wound therapy with delayed sutures was associated with a lower incidence of incisional surgical site infection after emergency surgery for colorectal perforation.

The impact of COVID-19 pandemic on access to medical services and its consequences on emergency surgery

Background

On March 9, 2020, the Italian Prime Minister announced the lockdown, which was officially closed on May 4. This extraordinary measure was necessary to contain the COVID-19 pandemic spread in Italy. During this phase, a significant decrease in patients' access to Emergency Department (ED) was observed. Delayed access to treatment determined a delay in the diagnosis of acute surgical conditions, as already documented in other clinical areas, with consequences on surgical outcome and survival. Aim of this study is to provide a detailed description of abdominal urgent-emergent conditions surgically treated and surgical outcomes during the lockdown in a tertiary referral Italian hospital, compared with historical data.

Methods

A retrospective review of urgent-emergent patients surgically treated in our department was conducted in order to compare patients' characteristics and surgical outcomes during the period March 9th-May 4th, 2020 with the same period of the previous year.

Results

152 patients were included in our study, 79 patients in 2020 group and 77 patients in 2019. We found no significant differences between the groups regarding ASA score, age, gender, and disease prevalence. Significant differences were found in symptom duration before ER access and abdominal pain as the main symptom in non-traumatic conditions. We also performed a sub-analysis on peritonitis which showed significant differences in: hospital length of stay, presence of colostomy vs. ileostomy, and fatal events in 2020. No differences were found in the use of laparoscopy.

Conclusions

While the overall number of ER accesses has decreased in 2020 group, the number of patients surgically treated in emergency-urgency conditions has not decreased. However, those patients waited significantly more before the hospital access. This diagnostic delay was associated with a more severe clinical condition and a consequent significantly worse prognosis.

Night-time surgery for type a aortic dissection: Immediate or delaying?

OBJECTIVES

This study aims to investigate whether surgery performed during night compared with daytime were associated with an increased risk of operative mortality of type A aortic dissection (TAAD) patients.

METHODS

A total of 2015 TAAD patients who underwent surgical repair were collected from two cardiovascular centers from Jan 2015 to Jan 2021. According to the start time of surgery, patients were divided into daytime group (06:01 a.m. to 06:00 p.m.) and night-time group (06:01 p.m. to 06:00 a.m.), and retrospective analyses were performed between them.

RESULTS

The operative mortality of night-time group (12.2%, 43/352) was dramatically higher than daytime group (6.9%, 115/1663; p = 0.001). There was significant difference between night-time and daytime groups in terms of 30-days mortality (5.8% vs 10.8%; p = 0.001) and in-hospital mortality (3.5% vs 6.0%; p = 0.03). The night-time group had a longer duration of intensive care unit stay (4 vs two; days; p < 0.001) and ventilation support (34 vs 19; hours; p < 0.001), compared with daytime group. The risk factors for operative mortality were night-time surgery (odds ratio [OR], 1.545; p = 0.027), age (odds ratio, 1.152; p < 0.001), total arch replacement (OR, 2.265; p < 0.001) and previous aortic surgery (OR, 2.376; p = 0.003).

CONCLUSION

Night-time surgical repair may be associated with higher operative mortality of patients with TAAD. Nevertheless, it is reasonable to offer emergency surgery at night-time for such patients who were more likely to present disastrous complications with delayed surgical intervention, as outcomes indicate acceptable operative mortality.

Use of preinjury antiplatelet and oral anticoagulant agents on outcomes following blunt trauma in an Asian population: a 1:2 propensity score matched study

BACKGROUND

Bleeding is a feared complication of antiplatelets (APTs) and oral anti-coagulants (OACs) use. Asians are at higher risk of bleeding from APT/OAC compared to Western population. Our study aims to investigate the impact of preinjury APT/OAC use on outcomes of moderate to severe blunt trauma.

METHODS

This is a retrospective cohort study from Jan 2017 - Dec 2019 of all patients with moderate to severe blunt trauma. A 1:2 propensity score matching (PSM) analysis was performed to address for confounding factors. Our primary outcome was in-hospital mortality. Our secondary outcomes were severity of head injury and need for emergency surgery within the first 24 hours.

RESULTS

There were 592 patients (APT/OAC n=72, no APT/OAC n=520) included in our study. The median age was 74 years in APT/OAC and 58 years in no APT/OAC. PSM resulted in 150 patients (APT/OAC n=50, no APT/OAC n=100). In the PSM cohort, more patients with APT/OAC use had ischemic heart disease (76% vs 0%, P<0.001). APT/OAC use was independently associated with higher in-hospital mortality (22.0% vs 9.0%, Odds ratio (OR) 3.00, 95% Confidence interval (CI): 1.05, 8.56, P=0.040) Severity of head injury (abbreviated injury scale in APT/OAC: 3.33 ± 1.53, vs 2.97 ± 1.43, P=0.380) and need for emergency surgery (APT/OAC 16.2% vs 11.0%, P=0.434) was comparable between APT/OAC and no APT/OAC.

CONCLUSIONS

Preinjury APT/OAC use was associated with higher in-hospital mortality. Severity of head injury and need for emergency surgery within 24 hours from admission were comparable between APT/OAC use and no APT/OAC use.

A Novel Clinical Nomogram for Predicting Overall Survival in Patients with Emergency Surgery for Colorectal Cancer

BACKGROUND

Long-term survival after emergency colorectal cancer surgery is low, and its estimation is most frequently neglected, with priority given to the immediate prognosis. This study aimed to propose an effective nomogram to predict overall survival in these patients.

MATERIALS AND METHODS

We retrospectively studied 437 patients who underwent emergency surgery for colorectal cancer between 2008 and 2019, in whom we analyzed the clinical, paraclinical, and surgical parameters.

RESULTS

Only 30 patients (6.86%) survived until the end of the study. We identified the risk factors through the univariate Cox regression analysis and a multivariate Cox regression model. The model included the following eight independent prognostic factors: age > 63 years, Charlson score > 4, revised cardiac risk index (RCRI), LMR (lymphocytes/neutrophils ratio), tumor site, macroscopic tumoral invasion, surgery type, and lymph node dissection (p < 0.05 for all), with an AUC (area under the curve) of 0.831, with an ideal agreement between the predicted and observed probabilities. On this basis, we constructed a nomogram for prediction of overall survival.

CONCLUSIONS

The nomogram created, on the basis of a multivariate logistic regression model, has a good individual prediction of overall survival for patients with emergency surgery for colon cancer and may support clinicians when informing patients about prognosis.

Emergency hernia repair: a retrospective cross-sectional study on the treatment modalities and adherence to guidelines in a tertiary public hospital

BACKGROUND

Emergency presentations of hernias can pose significant morbidity. In addition, providing optimal surgical intervention can be challenging due to patient and disease factors with multiple treatment modalities available. Recently there have been several guidelines written to help standardize practices in hernia management. The aim of our study was to review emergency hernia operations at our tertiary level teaching hospital, the method of repair and how this matched to international guidelines.

METHODS

We performed a retrospective chart review of all the patients who underwent emergency hernia surgery for strangulated/incarcerated hernias in our department over a 3-year period. Adherence to guidelines was assessed looking at appropriateness of mesh utilization, as well as the appropriateness of antibiotic usage.

RESULTS

A total of 184 cases from April 1st 2018 to March 31st 2021 were included. Of these hernias 12% contained necrotic or perforated bowel, 42% contained viable incarcerated bowel, and 45% contained just incarcerated fat. The compliance to the appropriate use of mesh overall was 85%, with a variation by hernia type. The global compliance to appropriate antibiotic therapy was high, at 89.7%. With antibiotic use compliance being very high in clean wounds (95.6%), and dirty wounds (100%). But lower in clean/contaminated or contaminated wounds (36.8%).

CONCLUSION

Compliance at our hospital was globally good. Areas of decreased compliance seem to be mostly regarding mesh use and antibiotic use in potentially contaminated fields and the concept of risk of bacterial translocation versus actual contamination, as well as in mesh use in smaller umbilical hernias.

Victoria's surgical response to the COVID-19 pandemic: the first two years

Victoria suffered three major waves during the first two years of the COVID-19 pandemic. Melbourne became the longest locked down city in the world at 267 days. This narrative review documents the chronological waves of COVID-19 in Victoria and key themes influencing the State-wide surgical response. In 2020, Victoria needed to secure supplies of personal protective equipment (PPE) and later, recognizing the importance of aerosol transmission, introduced a respiratory protection program to protect health care workers (HCWs) with fit-tested N-95 masks. It established routine preoperative PCR testing for periods when community prevalence was high and developed strategies to restrict elective surgery when hospital capacity was limited. In 2021, three short-term outbreaks were contained and eliminated whilst vaccination of HCWs and the vulnerable was taking place. A third major wave (Delta) occurred July to November 2021, succeeded by another involving the Omicron variant from December 2021. Planned surgery waiting list numbers, and waiting times for surgery, doubled between March 2020 and March 2022. In early 2022, almost 300 patients underwent surgery when infected with Omicron, with a low mortality (2.6%), though mortality was significantly higher in the unvaccinated (7.3% versus 1.4%). In conclusion, the Victorian response to COVID-19 involved tight state-wide social restrictions, contact tracing, furlough, escalating PPE guidance and respiratory protection. HCW infections were greatly reduced in 2021 compared with 2020. Pre-operative PCR testing gave confidence for emergency and urgent elective surgery to proceed during pandemic waves. Other elective cases were performed as health system capacity allowed, without compromising outcomes.

Associations of abdominal discomfort and length of clinical signs with surgical procedure in 181 cases of canine small intestinal foreign body obstruction

BACKGROUND

Gastrointestinal foreign bodies are a common indication for abdominal exploratory surgery.

OBJECTIVES

The objective of this study was to evaluate the relationship of pre-operative abdominal discomfort and duration of clinical signs with surgical resolution of canine small intestinal foreign body obstructions (SIFBO).

METHODS

We performed a retrospective study of 181 canine abdominal exploratory surgeries for confirmed SIFBO at two referral hospitals. Animals were categorized into five surgical groups (gastrotomy after manipulation into the stomach, enterotomy, resection-and-anastomosis [R&A], manipulated into colon, already in colon) and further grouped by whether entry into the gastrointestinal tract (GIT) was required.

RESULTS

Abdominal discomfort was noted in 107/181 cases (59.1%), but no significant differences in abdominal discomfort rates were present among the surgical groups or between GIT entry and no entry groups. Clinical sign duration was associated with surgical procedure; median durations were R&A = 3 days (range, 1-9), enterotomy = 2 days (range, 1-14), gastrotomy = 2 days (range, 1-6), already in colon = 1.5 days (range, 1-2), and manipulated into colon = 1 day (range, 1-7). In a pairwise comparison, differences in the duration of clinical signs were found for obstructions manipulated into the colon versus R&A, gastrotomy versus R&A, and in colon versus R&A. When patients were grouped according to GIT entry, cases with entry had a longer duration of clinical signs (median = 2 days [range, 1-14] versus 1 day [range, 1-7], respectively).

CONCLUSIONS

Abdominal discomfort was not associated with surgical complexity; however, the duration of clinical signs was associated with surgical complexity, with longer duration being associated with entry into the GIT and R&A. Despite statistical significance, the maximum difference of 2 days between surgical groups is unlikely to be clinically relevant.

Acute Lumbar Pyogenic Spondylitis With Multiple Abscesses Complicated by a Septic Shock That Required Emergency Surgical Open Drainage: A Case Report

We treated a patient with pyogenic spondylitis complicated by septic shock, who was saved by emergency surgery. The patient was a 75-year-old man with back pain, fever, and weakness in the lower limbs four days before. Upon admission to our hospital, he had tachycardia, tachypnea, fever, and fluctuating vital signs. His quick sequential organ failure assessment (SOFA) score was 2. Emergent magnetic resonance imaging showed scattered intramuscular abscesses and an epidural abscess. Gram-positive cocci were detected in a blood sample. He was diagnosed with pyogenic spondylitis complicated by sepsis. Intravenous antimicrobial therapy with cefepime, vancomycin, and clindamycin was added. However, he developed tachycardia and hypotension three hours after arrival at our hospital, so he received a blood transfusion and noradrenaline and underwent emergent surgical open drainage since percutaneous drainage was difficult to perform because of scattered abscesses. Paralysis of the proximal lower extremities was recovered after surgery. Postoperatively, the causative organism was found to be methicillin-susceptible Staphylococcus aureus and intravenous antimicrobial therapy for 81 days. Three years after surgery, the patient remains free of recurrence with improvement in the activity of daily living to the extent that he could walk. The outcome of our patient suggests that surgery may be a lifesaving measure in cases whose uncontrollable vital signs by pyogenic spondylitis are complicated by sepsis. Preoperative judgment is extremely important in difficult-to-control cases because surgical invasion can be lethal.

The Consequences of the COVID-19 Pandemic on Emergency Surgery for Colorectal Cancer

The aim of this study is to analyze the impact of the COVID-19 pandemic on the emergency treatment of patients with colorectal cancer in a university surgery clinic. Data from patients undergoing emergency surgery during the pandemic period (2020-2021) was taken into consideration and the results were analyzed and compared with the periods 2016-2017 and 2018-2019. A significant decrease in the number of patients undergoing emergency surgery was reported (p = 0.028). The proportion of patients who presented more severe symptoms at the hospital was significantly higher (p = 0.007). There was an increase in the average duration of surgical interventions compared to pre-pandemic periods (p = 0.021). An increase in the percentage of stomas performed during the pandemic was reported. The average duration of postoperative hospitalization was shorter during the pandemic. A postoperative mortality of 25.7% was highlighted. Conclusions: The pandemic generated by COVID-19 had significant consequences on the emergency treatment of patients with colon cancer. A smaller number of patients showed up at the hospital, and with more severe symptoms. In order to reduce the risk of infection with SARS-CoV-2 virus, the postoperative hospitalization period was shortened and a higher number of protective stomas were performed.

In-Hospital Predictors of Need for Ventilatory Support and Mortality in Chest Trauma: A Multicenter Retrospective Study

Chest trauma management often requires the use of invasive and non-invasive ventilation. To date, only a few studies investigated the predictors of the need for ventilatory support. Data on 1080 patients with chest trauma managed in two different centers were retrospectively analyzed. Univariate and multivariate analyses were performed to identify the predictors of tracheal intubation (TI), non-invasive mechanical ventilation (NIMV), and mortality. Rib fractures (p = 0.0001) fracture of the scapula, clavicle, or sternum (p = 0.045), hemothorax (p = 0.0035) pulmonary contusion (p = 0.0241), and a high Injury Severity Score (ISS) (p ≤ 0001) emerged as independent predictors of the need of TI. Rib fractures (p = 0.0009) hemothorax (p = 0.0027), pulmonary contusion (p = 0.0160) and a high ISS (p = 0.0001) were independent predictors of NIMV. The center of trauma care (p = 0.0279), age (p < 0.0001) peripheral oxygen saturation in the emergency department (p = 0.0010), ISS (p < 0.0001), and Revised Trauma Score (RTS) (p < 0.0001) were independent predictors of outcome. In conclusion, patients who do not require TI, while mandating ventilatory support with selected types of injuries and severity scores, are more likely to be subjected to NIMV. Trauma team expertise and the level of the trauma center could influence patient outcomes.

Uncorrected Preoperative Infection Causing the Death of a Patient with a Thoracic Aortic Aneurysm

Background

A thoracic aortic aneurysm (TAA) is a known condition seen in cardiovascular practice. A TAA rupture and postoperative infection may result in death. Preoperative infections leading to death are extremely rare.

Case Study

A 62-year-old Chinese female was admitted to The First Hospital of Hebei Medical University with a two-day history of abdominal pain. She was diagnosed with a TAA rupture and underwent immediate surgery. The preoperative urine analysis indicated that the positive bacteria and white blood cell count suggested a urinary tract bacterial infection. The patient was administered the empiric antibiotics, cefazolin; however, her blood pressure continued to drop during the perioperative period and she died of uncorrectable acidosis 8 h after the operation. On the second day after death, both the blood and urine cultures were positive for Pseudomonas aeruginosa.

Conclusion

Given that this patient with a TAA rupture died of uncorrected acidosis caused by preoperative infection, it is important to evoke the diagnosis in the context of TAA. Routine laboratory indicators are valuable factors for surgeons and physicians in assessing a patient's condition and improving their prognosis.

[Surgical treatment of COVID-19 patients during the pandemic]

OBJECTIVE

To analyze the results of emergency surgery in COVID-19 patients with viral pneumonia.

MATERIAL AND METHODS

A retrospective study included 75 COVID-19 patients who underwent emergency surgical interventions. Comorbidities included cardiac diseases, nonspecific lung diseases, type 2 diabetes, kidney diseases, overweight, and cancer. Various combinations of these diseases were also noted.

RESULTS

We carried out emergency surgeries for abdominal, thoracic, soft tissue and venous diseases. Postoperative mortality was 42.6%. The best results were obtained after minimally invasive interventions without mechanical ventilation. Extended surgery with mechanical ventilation was followed by fast progression of pneumonia according to clinical and CT data.

CONCLUSION

Surgical interventions undoubtedly worsen prognosis of treatment in patients with COVID-19. Emergency minimally invasive surgery without mechanical ventilation can reduce the risk of unfavorable outcomes in patients with viral pneumonia, especially in case of concomitant cancer and other severe comorbidities.

[Pudov Surgical care in a multi-field hospital during the new coronavirus infection pandemic (SARS-COVID-19): a 5-year experience]

OBJECTIVE

To analyze the 5-year experience of surgical care in a multi-field hospital during the coronavirus pandemic and before infection.

MATERIAL AND METHODS

We assessed «non-traumatic» surgery and the main indicators in a multi-field hospital during the coronavirus pandemic and surgical work in the «pre-COVID» period.

RESULTS

The number of discharged patients was the same between 2018 and 2021. In 2020-2021, mortality increased by 2.8 times, the number of deceased patients - by 2.5 times, hospitalizations for emergency surgical indications - by 2.1 times. Elective care decreased by 2.5 times. The number of adverse vascular events increased by 3 times.

CONCLUSION

Acute increase in emergency surgery and decrease in elective care create the prerequisites for growth of «neglect» with subsequent postoperative complications. We observed significant increase in mortality. It is advisable to create a backup emergency surgical service in infectious disease hospitals to provide care in obviously infected patients.