Urgent Repair of a 17.3 cm Inflammatory Abdominal Aortic Aneurysm

We describe a case of delayed presentation of a very large infra-renal inflammatory abdominal aortic aneurysm. This case highlights the importance of early detection and surveillance of aneurysms in rural communities. Definitive management of symptomatic aneurysms is time critical, and any delay such as for the transfer of patients from a rural site can impact patient survival. We present an example of a rare variant of abdominal aortic aneurysm.

A graphical assessment of emergency surgical list efficiency to determine operating theatre capacity needs

BACKGROUND

Unlike elective lists, full utilisation of an emergency list is undesirable, as it could prevent patient access. Conversely, a perpetually empty emergency theatre is resource wasteful. Separately, measuring delayed access to emergency surgery from time of booking the urgent case is relevant, and could reflect either deficiencies in patient preparation or be because of an occupied (over-utilised) emergency theatre.

METHODS

We developed a graphical method recognising these two separate but linked elements of performance: (i) delayed access to surgery and (ii) operating theatre utilisation. In a plot of one against the other, data fell into one of four quadrants, with delays associated with high utilisation signifying the need for more emergency capacity. However, delays associated with low utilisation reflect process deficiencies in the emergency patient pathway. We applied this analysis to 73 consecutive lists (>300 cases) from two UK hospitals.

RESULTS

Although both hospitals experienced similar rates of delayed surgery (21.8% vs 21.0%; P=0.872), in one hospital 83% of these were associated with low emergency theatre utilisation (suggesting predominant process deficiencies), whereas in the other 73% were associated with high utilisation (suggesting capacity deficiency; P<0.0001). Increasing emergency capacity in the latter resulted in shorter delays (just 6.7% cases excessively delayed; P<0.0001 for effect of intervention).

CONCLUSIONS

This simple graphical analysis indicates whether more emergency capacity is necessary. We discuss potential applications in managing emergency surgery theatres.

Does the COVID-19 Pandemic Affect Morbidity and Mortality Rates of Emergency General Surgery? A Retrospective Study from a Single-Center Tertiary Greek Hospital

Background and Objectives: The outbreak of the COVID-19 pandemic had a major impact on all aspects of health care. Few up-to-date studies have actually assessed the impact of COVID-19 on emergency surgeries. The aim of this study was to provide an overview of the impact of the pandemic relating to the emergency surgery performed, as well as morbidity and mortality rates during the first year of the pandemic (March 2020–February 2021) and during the control period. In this period, the first propaedeutic surgery department and the third surgery department of the University General Hospital of Thessaloniki “AHEPA” in Greece provided continuous emergency general surgery services. Material and Methods: The study is in a retrospective cohort and included patients who were admitted to the Emergency Department and underwent emergency general surgery during the control period (n = 456), March 2019–February 2020 and during the first year of the pandemic (n = 223), March 2020–February 2021. Gender, age, type of surgical operation (morbidity), ICU need, the patient’s outcome, and days of hospitalization were compared. Results: A total of 679 emergency surgeries were included. Statistically significant differences emerged between the two time periods in the total number of emergency surgeries performed (p < 0.001). The most common type of surgery in the control period was associated with soft tissue infection while, during the pandemic period, the most common type of surgery was associated with the hepatobiliary system. In addition, the mortality rates nearly doubled during the pandemic period (2.2% vs. 4%). Finally, the mean age of our sample was 50.6 ± 17.5 and the majority of the participants in both time periods were males. Conclusions: The COVID-19 pandemic changed significantly the total number of emergency general surgeries performed. Mortality rates doubled and morbidity rates were affected between the control and pandemic periods. Finally, age, gender, length of hospitalization, intensive care unit hospitalization, and laparoscopy use in patients undergoing emergency surgery during the pandemic were stable.

Risk Factors for Surgical Site Infections in Patients Undergoing Emergency Surgery: A Single-centre Experience

BACKGROUND/AIM

Surgical site infections (SSI) are associated with increased morbidity and mortality, and they occur more frequently during unplanned emergency surgical (ES) procedures rather than elective. Our aim was to determine the incidence of SSI within our ES cohort and to identify risk factors for SSI.

PATIENTS AND METHODS

Data from consecutive patients undergoing ES in a single institution during a 5-year period were prospectively collected and analyzed.

RESULTS

A total of 838 consecutive patients were included. The median age was 52 (IQR=25-71) years and some 368 (44%) were female. 157 (18.7%) of those patients developed SSI. The most commonly isolated pathogen was E. Coli (55.4%) followed by Staphylococcus Aureus (40.1%). The 30-day mortality rate of patients who presented SSIs was 14.6% compared to 6.8% of patients without SSI (p=0.002). Multivariable analysis showed that the type of wound, American Society of Anesthesiology score, severity and duration of surgery >90 min were independent risk factors for the occurrence of SSI.

CONCLUSION

Identification of modifiable causative factors for SSI within an ES unit is paramount as they can critically impact postoperative outcomes.

Predictors of immediate neonatal outcome after cesarean section in Uganda

OBJECTIVE

To identify predictors of low Apgar score, immediate neonatal death, and stillbirth after cesarean section in Uganda.

METHODS

Records of cesarean sections performed at all 14 regional referral hospitals and also 14 first-level (district) hospitals in Uganda were reviewed. Both elective and emergency cases were included. Data comprised mother's age, indication, type of anesthesia, and immediate outcome of the newborn. To evaluate the relation of the predictor variables to outcome, regression analysis was performed.

RESULTS

A total of 37 585 cesarean sections were recorded. The indications for cesarean section that led to the highest neonatal mortality and stillbirth rates and lowest mean Apgar scores were uterine rupture and hemorrhage. Emergency surgery and general anesthesia had worse neonatal outcomes than elective surgery and spinal anesthesia. Compared with general anesthesia, spinal anesthesia was favorable for neonatal outcomes.

CONCLUSION

Elective surgical planning and scale-up of the use of spinal anesthesia may potentially reduce stillbirths and immediate neonatal deaths.

Necrotizing Soft Tissue Infection in the Elderly: Effect of Pre-Operative Factors on Mortality and Discharge Disposition

Background: Necrotizing soft tissue infections (NSTIs) are rapidly progressing, life-threatening diseases associated with substantial morbidity and mortality, especially in patients 65 years or older. We aimed to evaluate clinical factors associated with mortality and discharge disposition after NSTIs in elderly patients. Patients and Methods: Retrospective data were obtained from the 2007-2017 American College of Surgeons-National Surgical Quality (ACS-NSQIP) database. Patients aged 65 years or older with a post-operative diagnosis of an NSTI (defined as gas gangrene, necrotizing fasciitis, or Fournier gangrene) were included. Univariable and multivariable analyses were performed to identify independent clinical and demographic factors associated with mortality and with discharge disposition. Results: A total of 1,460 patients were included. Median age was 71 years, 43% were females. Overall, 30-day mortality was 18.5% and 30-day morbidity was 63.6%. The most important predictors of mortality included pre-operative septic shock (odds ratio [OR], 6.36; 95% confidence interval [CI], 3.61-11.18), pre-operative dialysis dependence (OR, 2.99; 95% CI, 1.77-5.05), coagulopathy (international normalized ratio [INR], >1.5, OR, 2.25; 95% CI, 1.51-3.37), hepatobiliary disease (bilirubin >1.0 mg/dL; OR, 2.05; 95% CI, 1.38-3.04) and aged 80 years or older (OR, 3.36; 95% CI, 2.08-5.44). Patients without any of these risk factors had a mortality of 7.3%. Predictors of discharge to inpatient rehabilitation or skilled care included age 80 years or older (OR, 2.49; 95% CI, 1.44-4.30), American Society of Anesthesiologists (ASA) ≥3 (OR, 2.05; 95% CI, 1.03-4.05)] and amputation as opposed to debridement (OR, 2.53; 95% CI,1.48-4.32). Conclusions: We identified several pre-operative clinical factors that were associated with increased post-operative mortality and discharge to post-acute care. The next steps should focus on determining if optimization of modifiable predictors would improve mortality.

Retrospective evaluation of gastrointestinal foreign bodies and presurgical predictors for enterectomy versus enterotomy in dogs (2013-2016): 82 cases

OBJECTIVE

To evaluate preoperative diagnostics in dogs with gastrointestinal foreign body (GIFB) obstruction and to identify clinical variables associated with the performance of simple enterotomy (EO) versus enterectomy (EC).

DESIGN

Retrospective case control study from October 2013 to January 2016.

SETTING

Veterinary Teaching Hospital.

ANIMALS

Eighty-two client-owned dogs diagnosed at the time of surgery with GIFB obstruction.

MEASUREMENTS AND MAIN RESULTS

Data were collected from medical records regarding history, initial physical examination, clinicopathologic testing, diagnostic imaging, and surgical reports. Based on univariate analysis, dogs that required EC were ill (P < 0.0001) and anorexic (P = 0.0007) for a longer duration; had a higher vomiting severity score (P = 0.005); and had worse perfusion parameters (mucous membrane color [P = 0.028] and quality [P = 0.032], poorer pulse quality [P = 0.0015], relatively lower blood pressure [P = 0.0328], greater heart rates [P = 0.0011]). Dogs undergoing EC were more likely to have altered peritoneal detail on radiographs (P = 0.0014; odds ratio [OR] = 25.5; 95% confidence interval [CI]: 2.4, 275.7) and echogenic peritoneal effusion on ultrasound (P = 0.0101; OR = 12.5; 95% CI: 1.3, 120.9), compared to the EO group. Heart rate (adjusted P = 0.028; OR = 1.07; 95% CI: 1.0, 1.1) and vomiting severity score (adjusted P = 0.028; OR = 5.6; 95% CI: 1.2, 26.1) maintained significance after multiple logistic regression.

CONCLUSIONS

Multiple factors in the preoperative clinical evaluation were different between dogs undergoing EO versus EC for GIFB obstruction. However, many of these variables become insignificant with multiple logistic regression. The presence of an increased heart rate or increased vomiting severity score at presentation was independently associated with undergoing enterectomy. Prospective studies with greater number of animals are warranted to validate these results.

Trauma Team Activation: Which Surgical Capability Is Immediately Required in Polytrauma? A Retrospective, Monocentric Analysis of Emergency Procedures Performed on 751 Severely Injured Patients

There has been an ongoing discussion as to which interventions should be carried out by an “organ specialist” (for example, a thoracic or visceral surgeon) or by a trauma surgeon with appropriate general surgical training in polytrauma patients. However, there are only limited data about which exact emergency interventions are immediately carried out. This retrospective data analysis of one Level 1 trauma center includes adult polytrauma patients, as defined according to the Berlin definition. The primary outcome was the four most common emergency surgical interventions (ESI) performed during primary resuscitation. Out of 1116 patients, 751 (67.3%) patients (male gender, 530, 74.3%) met the inclusion criteria. The median age was 39 years (IQR: 25, 58) and the median injury severity score (ISS) was 38 (IQR: 29, 45). In total, 711 (94.7%) patients had at least one ESI. The four most common ESI were the insertion of a chest tube (48%), emergency laparotomy (26.3%), external fixation (23.5%), and the insertion of an intracranial pressure probe (ICP) (19.3%). The initial emergency treatment of polytrauma patients include a limited spectrum of potential life-saving interventions across distinct body regions. Polytrauma care would benefit from the 24/7 availability of a trauma team able to perform basic potentially life-saving surgical interventions, including chest tube insertion, emergency laparotomy, placing external fixators, and ICP insertion.

Robotics for Acute Care in Colorectal Surgery

Robotic surgery is growing exponentially in elective colorectal procedures, but utilization of robotics in urgent and emergency procedures remains low. Robotic surgery can be safely utilized for the management of several acute colorectal operations such as anastomotic leaks, perforated diverticulitis, and more. This chapter discusses safe access principles and planning, as well as technical aspects of these complex procedures, and the pathway to building a 24/7 robotic access culture.

Laparoscopy in Emergency: Why Not? Advantages of Laparoscopy in Major Emergency: A Review

A laparoscopic approach is suggested with the highest grade of recommendation for acute cholecystitis, perforated gastroduodenal ulcers, acute appendicitis, gynaecological disorders, and non-specific abdominal pain (NSAP). To date, the main qualities of laparoscopy for these acute surgical scenarios are clearly stated: quicker surgery, faster recovery and shorter hospital stay. For the remaining surgical emergencies, as well as for abdominal trauma, the role of laparoscopy is still a matter of debate. Patients might benefit from a laparoscopic approach only if performed by experienced teams and surgeons which guarantee a high standard of care. More precisely, laparoscopy can limit damage to the tissue and could be effective for the reduction of the overall amount of cell debris, which is a result of the intensity with which the immune system reacts to the injury and the following symptomatology. In fact, these fragments act as damage-associated molecular patterns (DAMPs). DAMPs, as well as pathogen associated molecular patterns (PAMPs), are recognised by both surface and intracellular receptors of the immune cells and activate the cascade which, in critically ill surgical patients, is responsible for a deranged response. This may result in the development of progressive and multiple organ dysfunctions, manifesting with acute respiratory distress syndrome (ARDS), coagulopathy, liver dysfunction and renal failure. In conclusion, none of the emergency surgical scenarios preclude laparoscopy, provided that the surgical tactic could ensure sufficient cleaning of the abdomen in addition to resolving the initial tissue damage caused by the “trauma”.

A prognostic score predicting survival following emergency surgery in patients with metastatic colorectal cancer

BACKGROUND

Survival of patients with metastatic colorectal cancer (mCRC) varies. We aim to develop a prognostic score for mCRC after emergency surgery to guide treatment decisions.

METHODS

Newly diagnosed mCRC patients who presented with primary tumor-related complications and underwent emergency surgery between January 1999 and December 2013 were included. Univariate and multivariate Cox regression analyses were performed to identify covariates significantly associated with the time to death following surgery. A survival score was derived using the Cox regression equation.

RESULTS

The study cohort comprised 248 patients. Median patient age was 66 ± 13 years. Primary tumor was located in the left colon and rectum in 211 patients (85.1%) while 37 patients (14.9%) had primaries in the right colon. Liver, lung, and peritoneal metastases occurred in 161 patients (64.9%), 59 patients (23.8%), and 96 patients (38.7%), respectively. Majority of patients presented with either obstruction (174 patients, 70.1%) or perforation (52 patients, 21%). On multivariate analysis, age of 60 years or older (p = 0.007), carcinoembryonic antigen levels greater than 45 ng/ml (p = 0.022), presence of liver metastases (p = 0.024), and peritoneal carcinomatosis (p < 0.001) were found to be significantly associated with overall survival. A simplified score was derived with good survivors (score 0-2), moderate survivors (score 3-4), and poor survivors (score 5 and above) experiencing median survival of 7, 14, and 23 months, respectively (p < 0.001).

CONCLUSION

The management of mCRC presenting with an emergency is challenging. A prognostic score that estimates survival after emergency surgery may aid clinical decision-making.

Top Ten Tips Palliative Care Clinicians Should Know About Trauma and Emergency Surgery

There is growing interest in, and need for, integrating palliative care (PC) into the care of patients undergoing emergency surgery and those with traumatic injury. Thus, PC consults for these populations will likely grow in the coming years. Understanding the nuances and unique characteristics of these two acutely ill populations will improve the care that PC clinicians can provide. Using a modified Delphi technique, this article offers 10 tips that experts in the field, based on their broad clinical experience, believe PC clinicians should know about the care of trauma and emergency surgery patients.

Associations between surgical start time (regular vs after hours) and morbidity and mortality during hospitalization in dogs and cats

OBJECTIVE

To examine the relationship between after-hours (ie, nights and weekends) emergency general surgery and morbidity or mortality in dogs and cats during hospitalization.

DESIGN

Cross-sectional study from September 1, 2013 to May 31, 2017.

SETTING

University teaching hospital.

ANIMALS

Four hundred seventy-four dogs and 66 cats that underwent emergency general surgery (gastrointestinal, hepatobiliary, urogenital, soft tissue traumatic injury, splenectomy/excision of bleeding abdominal tumor, surgical revision, and negative exploratory categories) with the emergency surgery service. All patients were required to have complete medical records.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Study animals were grouped as exposed or not exposed to after-hours emergency surgery. They were further classified as either postoperatively dead or suffering morbidity (yes or no). Additional exposure factors (eg, age, sex, American Society of Anesthesiology [ASA] status) were investigated. Multivariable logistic regression was used to identify and quantify any associations with mortality or morbidity. In dogs, exposure to after-hours emergency general surgery was not associated with mortality or morbidity. In dogs, both mortality and morbidity were associated with ASA status. In cats, mortality was not examined because the number of dead cats was small (n = 5). The odds of morbidity were 3.4 times lower (1/0.29) in cats having emergency surgery after hours, compared to cats admitted during regular hours (odds ratio [OR], 0.29; 95% Confidence Interval (CI), 0.09-0.93; P = 0.03). No other investigated exposure factors were associated with morbidity in study cats.

CONCLUSIONS

After-hours emergency surgery in dogs was not associated with increased risk of mortality and morbidity at the study facility. Feline patients having emergency surgery during regular hospital hours had a higher risk of morbidity; further investigation of modifiable risk factors is warranted.

[Surgical procedures at the city hospital for patients with Covid-19. A 9-month experience]

OBJECTIVE

To report our experience in surgical treatment of patients with COVID-19.

MATERIAL AND METHODS

There were 7815 patients with COVID-19 for the period from April 1, 2020 to December 31, 2020. During this period, 172 operations were performed in this group.

RESULTS

The most common procedures were tracheostomy (n=86, 50.0%), pleural puncture and drainage (n=20, 11.6%), caesarean section (n=22, 12.7%). There were 24 (14.0%) abdominal surgeries including 11 laparoscopies, 5 appendectomies, 3 bowel resections and others. Six lower limb amputations were carried out. We should emphasize common soft tissue hematomas and effusions. This complication is associated with anticoagulation recommended for patients with COVID-19.

CONCLUSION

Surgical interventions using personal protective equipment is a significant challenge. According to our experience, round-the-clock surgical care in a specialized hospital is required.

Elective versus nonelective brain tumor resections: a 5-year propensity score matching cost comparison analysis

OBJECTIVE

Elective surgical cases generally have lower costs, higher profit margins, and better outcomes than nonelective cases. Investigating the differences in cost and profit between elective and nonelective cases would help hospitals in planning strategies to withstand financial losses due to potential pandemics. The authors sought to evaluate the exact cost and profit margin differences between elective and nonelective supratentorial tumor resections at a single institution.

METHODS

The authors collected economic analysis data in all patients who underwent supratentorial tumor resection at their institution between January 2014 and December 2018. The patients were grouped into elective and nonelective cases. Propensity score matching was used to adjust for heterogeneity of baseline characteristics between the two groups.

RESULTS

There were 143 elective cases and 232 nonelective cases over the 5 years. Patients in the majority of elective cases had private insurance and in the majority of nonelective cases the patients had Medicare/Medicaid (p < 0.01). The total charges were significantly lower for elective cases ($168,800.12) compared to nonelective cases ($254,839.30, p < 0.01). The profit margins were almost 6 times higher for elective than for nonelective cases ($13,025.28 vs $2,128.01, p = 0.04). After propensity score matching, there was still a significant difference between total charges and total cost.

CONCLUSIONS

Elective supratentorial tumor resections were associated with significantly lower costs with shorter lengths of stay while also being roughly 6 times more profitable than nonelective cases. These findings may help future planning for hospital strategies to survive financial losses during future pandemics that require widespread cancellation of elective cases.

Characteristics of ovarian endometrioma during pregnancy

AIM

During pregnancy, the ovarian endometrioma generally decreases in size and occasionally ruptures. We evaluated (1) whether and how ovarian-endometrioma size changes from the first trimester to the postdelivery period, and (2) the type of endometrioma more likely to rupture during pregnancy.

METHODS

During an 18-year period (2000-2018), ultrasound in the first trimester revealed ovarian endometrioma in 149 pregnant women at our tertiary institute. Among these, we subjected 138 endometriomas in 145 patients to expectant management (wait-and-watch approach during pregnancy). We compared the cyst sizes in the first trimester and the postdelivery period, and defined a >1 cm diameter size-change as a significant increase/decrease. We analyzed four patients with rupture and characterized the predictors of rupture.

RESULTS

A comparison of cyst sizes in the first trimester and the postdelivery period revealed that the size of 94 (68%), 37 (27%), and 7 ovaries (5.0%), respectively, decreased, remained unchanged, and increased; in 56 ovaries (40%), apparent cysts were no longer present. Of the 145 patients, four (2.8%) required emergency surgery for cyst rupture. Adhesion to the surroundings, an increase in cyst size, large size (diameter of ≥6 cm), and compression due to the enlarged uterus in late pregnancy were factors clinically related to rupture.

CONCLUSIONS

Approximately two-thirds of ovarian endometriomas decreased in size during pregnancy (40% disappeared), 27% remained unchanged, and only 5% increased in size. However, 2.8% of pregnant women with endometrial cysts experienced rupture. We characterized risk factors for rupture; however, clinical application requires further evaluation.

Effects of Surgical Delay Due to COVID-19 on Women Requiring Emergency Gynaecological Surgery

In response to the coronavirus-19 (COVID-19) pandemic, the McGill University Health Centre introduced protocols to protect health care workers during emergency surgeries. These included waiting for a COVID-19 test result or waiting 20 minutes after aerosol-inducing procedures before proceeding with surgery. The following brief communication describes the impact of surgical delay on the outcomes of 3 emergency gynaecologic procedures: dilatation and curettage, laparoscopic salpingectomy, and laparoscopic cystectomy and detorsion. Our results show that delays associated with COVID-19 protocols did not negatively impact patients undergoing these surgeries.

Perforated colorectal cancers: clinical outcomes of 18 patients who underwent emergency surgery

Introduction

Although colon cancer perforations are rare among acute abdominal syndromes, it is a clinical picture with high mortality that requires urgent treatment.

Aim

In this study, the clinical results of patients who were operated in emergency conditions due to colorectal cancer perforation were evaluated.

Material and methods

The data of 18 patients treated for colorectal cancer perforation in our clinic between February 2014 and February 2017 were retrospectively reviewed. The following data were evaluated: demographic features of the patients, location of the tumour, metastasis, stage of the tumour, number of lymph nodes dissected, survival, type, and prognosis of the surgery.

Results

Eight (44%) of 18 patients with perforated colon cancers were female and 10 (56%) were male. The mean age was 65.2 (31-104) years. Four of the patients had liver metastasis only, and 5 had multiple metastases. All cases had sudden abdominal pain and acute abdominal clinical findings. Fourteen of the patients underwent full resection, and 4 of them underwent partial resection and trephine stoma (colostomy). Perioperative mortality was not observed. The long-term mortality rate in our study was 77.7% (n = 14), and the operative mortality rate was 44% (n = 8). Additional organ injuries occurred during resection in 2 patients.

Conclusions

Colorectal cancer perforation seen in advanced ages is one of the causes of acute abdominal syndrome, which can be fatal. The general condition of the patient and the size and localization of the perforation should be taken into consideration in the choice of treatment. Curative surgery can also be performed in perforated colorectal cancers. However, partial resection and trephine colostomy should be performed in patients with multiple metastases and poor general condition.

Quality of Colon Cancer Care in Patients Undergoing Emergency Surgery

Thirty percent of colon cancer diagnoses occur following emergency presentations, often with bowel obstruction or perforation requiring urgent surgery. We sought to compare cancer care quality between patients receiving emergency versus elective surgery. We conducted an institutional retrospective matched (46 elective:23 emergency; n = 69) case control study. Patients who underwent a colon cancer resection from January 2017 to February 2019 were matched by age, sex, and cancer stage. Data were collected through the National Surgical Quality Improvement Program and chart review. Process outcomes of interest included receipt of cross-sectional imaging, CEA testing, pre-operative cancer diagnosis, pre-operative colonoscopy, margin status, nodal yield, pathology reporting, and oncology referral. No differences were found between elective and emergency groups with respect to demographics, margin status, nodal yield, oncology referral times/rates, or time to pathology reporting. Patients undergoing emergency surgery were less likely to have CEA levels, CT staging, and colonoscopy (p = 0.004, p = 0.017, p < 0.001). Emergency cases were less likely to be approached laparoscopically (p = 0.03), and patients had a longer length of stay (p < 0.001) and 30-day readmission rate (p = 0.01). Patients undergoing emergency surgery receive high quality resections and timely post-operative referrals but receive inferior peri-operative workup. The adoption of a hybrid acute care surgery model including short-interval follow-up with a surgical oncologist or colorectal surgeon may improve the quality of care that patients with colon cancer receive after acute presentations. Surgeons treating patients with colon cancer emergently can improve their care quality by ensuring that appropriate and timely disease evaluation is completed.

The Role of Dual-Energy Computed Tomography in Locating Gastrointestinal Tract Perforations

Objective With each passing day, dual-energy computed tomography (DECT) is being used more frequently in the evaluation of abdominal pathologies. In this article, we aimed to assess the role of dual-energy CT in locating gastrointestinal perforations, which are among the causes of acute abdomen. Materials and methods All patients who underwent DECT due to acute abdomen in a COVID-19 designated hospital between June 1st, 2020 and December 31st, 2020, who were found to have gastrointestinal tract (GIT) perforation and underwent surgery were included in the study. DECT results and intraoperative findings of the patients were compared. Results Thirteen patients (nine males and four females) who underwent DECT for acute abdomen and were diagnosed with perforation in the gastrointestinal system were included in the study. The mean age of the patients was 57.6 years (range: 11-85 years). Two patients had gastric perforation, three had duodenal perforations, and one patient had a perforation in the gallbladder wall. Two patients were diagnosed with jejunal perforations, one patient with Meckel's diverticulum, and three patients with colorectal perforation. Although free air was detected in the abdomen of one patient, perforation could not be located. In patients with GIT perforation who were operated on following DECT imaging, the perforation location shown on DECT correlated 100% with the perforation locations detected during surgery. Conclusion DECT is significantly effective in planning surgical treatment and determining the foci of perforation in GIT perforations.

Anaesthesia for ruptured ectopic pregnancy at district level

In South Africa, deaths as a result of ectopic pregnancies are increasing despite the overall improvements in maternal mortality. These deaths occur predominantly in district hospitals, with the final cause of death being hypovolaemic shock in almost all cases. In most cases, no anaesthesia was attempted despite the district hospitals having the clinical skills, equipment and infrastructure to provide a caesarean delivery service. It appears that there is a skills gap between the provision of anaesthesia for caesarean delivery and that of ruptured ectopic pregnancy. There is a growing recognition of the urgent need to prioritise the provision of emergency surgical care in rural settings. This should be viewed not as a luxury but as an absolute necessity. In this study, we aim to discuss the pathophysiology of a patient with a ruptured ectopic pregnancy briefly, outline district hospital requirements for safe surgery and then discuss a simple, safe method for the provision of anaesthesia in patients deemed too unstable to transfer to a referral facility.

Damage control surgery for spontaneous perforation of pyometra with septic shock: a case report

Background

Although spontaneous perforation of pyometra is very rare, it sometimes causes severe peritonitis, leading to lethal conditions. Damage control surgery reportedly improves the survival of critically ill patients; however, there has been no report describing damage control surgery for ruptured pyometra.

Case presentation

An 83‐year‐old postmenopausal woman with generalized peritonitis and septic shock was admitted and underwent emergency laparotomy. Abbreviated surgery was carried out because of progressing septic shock, and planned reoperation was carried out 2 days after the initial surgery. Histopathological examination revealed the perforation of pyometra with no evidence of malignancy. The patient was discharged on the 32nd postoperative day in stable condition.

Conclusion

We report a case of spontaneous perforation of pyometra with severe septic shock successfully treated by damage control surgery. Damage control surgery is a useful treatment option for hemodynamically unstable patients with diseases in the field of obstetrics and gynecology.

Accessory extensor pollicis longus tendon in emergency surgery

Background

A true accessory extensor tendon of the thumb seems to be rare. We found a variation of the accessory extensor pollicis longus (EPL) tendon while performing an emergency surgical procedure. Identification of this accessory tendon during emergency surgery has not been previously reported.

Case presentation: A 43-year-old man presented to our hospital after sustaining a work-related injury involving a saw. During the operation, the tendons of the EPL, accessory EPL, and extensor pollicis brevis were severed. The lacerated tendon and tendon sheath were repaired, and the wrist and thumb were positioned in extension. The patient’s postoperative activity returned to normal without the need for a second tendon release operation.

Conclusions

Surgeons should be aware of this anatomic anomaly of the EPL tendon. Presentation of our case increases clinicians’ chances of preoperatively detecting this anomaly, which can improve surgical outcomes.