The value of nanocarbon contrast methylene blue based on dye-based tracer technology in sentinel lymph node biopsy for breast cancer: a systematic review and meta-analysis

Objective

The purpose of this study was to compare the diagnostic value of nanocarbon suspensions and methylene blue injections in sentinel lymph node biopsies of patients with breast cancer based on the dye method.

Methods

A systematic search of the PubMed, Embase, Cochrane Library (Central) and Web of Science (SCI Expanded) databases was performed to determine the diagnostic value of carbon nanoparticles in Chinese databases (China National Knowledge Infrastructure (CNKI), VIP, Wanfang, Chinese Biomedical Literature Database (CBM)) for identifying methylene blue in sentinel lymph node biopsies of patients with breast cancer. The QUADAS2 quality evaluation tool of Review Manager 5.4 was used to evaluate the quality of the included studies. Meta-Disc 1.4 software was used to calculate the extracted valid data and perform a heterogeneity test. STATA 14.0 software was selected to conduct a sensitivity analysis, and Deek's publication bias test was used for the included studies.

Results

In 17 articles, the binding sensitivity of nanocarbons was 0.93 (0.90-0.95), the binding specificity was 0.98 (0.97-0.99), the binding sensitivity of methylene blue was 0.89 (0.85-0.92), and the binding specificity was 0.94 (0.92-0.95). The AUC value of the nanocarbon SROC was 0.9827 (SE = 0.0062), and the AUC value of methylene blue was 0.9495 (SE = 0.0139).

Conclusion

Nanocarbon versus methylene blue is a more satisfactory dye tracer for sentinel lymph node biopsy in breast cancer patients and should be considered a first-line diagnostic agent.

Source control in intra-abdominal infections: What you need to know

ABSTRACT

Providing optimal source control (SC) for intra-abdominal sepsis (IAS) is a critically important surgical principle, yet one that remains nebulous in terms of strict definitions and required conduct. The entire concept of SC has evolved in the last decades. Contemporary SC is not only surgical but also embraces minimally invasive percutaneous and medical therapies. We propose that adequate SC has evolved from the mere anatomical control of enteric leakage, cleansing of obvious contaminants and necrosis, to a more comprehensive anatomo-phyiological-biochemical model. While any breaches in the integrity of the gastrointestinal tract should be addressed urgently, SC should ultimately aim to control the generation and propagation of systemic biomediators, bacterial toxins, and toxic catabolites that perpetuate multisystem organ failure and death. Much urgently needs to be learned to understand and hopefully mitigate the dysbiotic influences of IAS on the human microbiome. Finally, the therapy offered should always be individualized, recognizing patient's unique pathophysiology, clinical condition, comorbidities, and predeclared preferences regarding invasive therapies and life-support.

The myth of iodine: A systematic review and meta-analysis on the relationship between iodine and thyroid nodule

BACKGROUND

Iodine is an essential trace element for thyroid hormone synthesis, and its role in thyroid health has been widely studied. While iodine deficiency is recognized as a risk factor for goiter, its association with thyroid nodules remains controversial. The aim of this systematic review and meta-analysis was to evaluate the relationship between iodine intake and the development of thyroid nodules.

METHODS

A systematic literature search was conducted in Medline (via PubMed), the Cochrane Library, and guideline registries (AWMF, GIN) for studies published between 2012 and 2023. Inclusion criteria focused on studies examining the association between iodine intake and thyroid nodule. Systematic review has been conducted whereas study quality was assessed using the checklists of Critical Appraisal Skills Programme (CASP). A meta-analysis was performed for studies reporting odds ratios based on WHO-defined iodine categories.

RESULTS

A total of 31 studies were included. Most studies (n = 23) were cross-sectional, limiting causal conclusions. The most used method for assessing iodine intake was urinary iodine concentration (UIC), though measurement approaches varied. N = 10 studies compared median UIC between groups with and without thyroid nodules, with n = 8 reporting significant differences. However, the iodine levels in both groups often remained within the WHO-defined adequate iodine range. N = 8 studies examined odds ratios for iodine intake and thyroid nodule risk, with n = 5 identifying iodine deficiency (< 100 μg/L) as a significant risk factor. However, results for more than adequate (> 200 μg/L) and excessive iodine intake (> 300 μg/L) were inconsistent. N = 3 studies suggested a U-shaped relationship between iodine and thyroid nodule prevalence, but meta-analysis findings did not confirm this hypothesis. The pooled odds ratio for iodine deficiency was 1.24 (95% CI [1.16-1.33], I2 = 0.00), while more than adequate and excessive iodine intake showed no significant association.

CONCLUSION

This systematic review and meta-analysis indicate that iodine deficiency increases moderately the risk of developing thyroid nodules, while more than adequate and excessive iodine intake does not show a consistent effect. However, the heterogeneity of study results and the predominance of cross-sectional designs limit definitive conclusions. Further prospective studies are needed to clarify the causal relationship between iodine intake and thyroid nodules.

Vacuum-assisted closure or primary closure with relaparotomy on-demand in patients with secondary peritonitis: a systematic review and meta-analysis

BACKGROUND

Secondary peritonitis is a serious condition with significant morbidity and mortality. Its management requires emergency laparotomy for source control. Vacuum-assisted closure (VAC) and primary abdominal closure (PAC) are the main strategies for managing the laparostomy after source control. Despite the increasing use of VAC, concerns persist regarding its complications and long-term outcomes compared with PAC.

METHODS

This systematic review followed PRISMA 2020 and MOOSE. The Cochrane Risk of Bias (RoB 2) tool, MINORS and GRADE framework assessed study quality and evidence certainty. The protocol was registered in PROSPERO (CRD42022304724). A comprehensive search of MEDLINE, Embase, and the Cochrane Library from January 2004 to August 2024 identified studies reporting postoperative outcomes following VAC or PAC after laparotomy for secondary peritonitis. The included studies had to report at least two key outcomes: mortality, postoperative complications, incisional hernia, secondary fascial closure, and hospital or intensive care unit (ICU) length of stay.

RESULTS

Thirty-three studies including 4,520 patients were analyzed. Mortality was 31.1% in VAC and 22.2% in PAC (p = 0.327). Postoperative complications were higher with VAC (71.0% vs. 39.3%, p = 0.001). Incisional hernia rates were similar (21.3% vs. 20.8%, p = 0.958). Secondary fascial closure rate was significantly lower with VAC (58.1% vs. 85.9%, p < 0.001). VAC patients had longer ICU stays (21.1 vs. 9.7 days, p = 0.04), while hospital stay did not differ. Most studies had a high risk of bias, and GRADE assessment showed low to very low evidence certainty.

CONCLUSION

VAC therapy was associated with more postoperative complications, a lower fascial closure rate, and a longer ICU length of stay compared with PAC. Thirty-day mortality rates did not differ between the approaches. However, most of studies included were subject to serious risk of bias and a low level of certainty in evidence.

Abnormal blood glucose on admission and outcomes in older patients with acute calculous cholecystitis

INTRODUCTION

We investigated the potential correlation between abnormal blood glucose on admission and clinical outcomes of acute calculus cholecystitis in older patients.

AREAS COVERED

We included older patients (≥65 years) diagnosed with acute calculus cholecystitis. The first plasma glucose measurement obtained at admission was used. Overall, 280 older patients were evaluated. The results showed that ABG was significantly associated with more severe systemic inflammatory responses (elevated white blood cell count and neutrophil-lymphocyte ratio), a higher incidence of moderate to severe ACC, and the need for invasive treatment (an increased proportion of percutaneous cholecystostomy and combined surgeries). The prolonged hospital stay, 30-day readmission rate and mortality rate of patients in the ABG group were significantly increased, and the incidence of severe postoperative complications (Clavien-Dindo≥grade III) was higher. Multivariate analysis confirmed that ABG was an independent predictor of the severity of ACC (TG18 classification) and 30-day re-admission rate.

EXPERT OPINION/COMMENTARY

In older patients with acute calculus cholecystitis, abnormal blood glucose on admission is associated with worse outcomes, serving as a novel quantifiable risk criterion to guide treatment selection, particularly for high-risk older adults ineligible for early surgery.

Evaluating The Glasgow Blatchford Score for Upper Gastrointestinal Bleeding Risk Stratification in A Community Hospital: A Retrospective Study

INTRODUCTION

Upper gastrointestinal bleeding (UGIB) is the most common emergency in gastroenterology. The Glasgow Blatchford Score (GBS) is a validated tool used for risk stratification. The cutoff values for GBS to predict the need for clinical intervention, endoscopic treatment, and mortality, are not consistent. To determine the relationship between mean GBS score and the need for hemostatic intervention, and blood transfusion, and to evaluate quality of care and proper allocation of resources at our midwestern community hospital.

METHODS

In this cross-sectional study, we retrospectively extracted records for patients ≥18 years who were admitted for UGIB and underwent esophagogastroduodenoscopy between July 2018 and July 2020. GBS was calculated for each observation. Multivariate analysis and a logistic regression model were performed to predict the GBS score, and the odds ratio, associated with the need for hemostatic intervention and blood transfusion while controlling for confounding factors.

RESULTS

The GBS sample mean score was 11.17. Those who required hemostatic intervention and blood transfusion scored significantly higher GBS (13.18 versus 10.79) and (13.57 versus 9.21), respectively. A GBS of >10 was associated with higher odds at 21.84 (CI: 10.324,46.185, P<0.001) and 5.085 (CI: 1.864, 13.872, P=0.001) for receiving blood transfusion and hemostatic intervention, respectively. A cutoff of 10 was 22.41% sensitive and 95.41% specific for requiring hemostatic interventions and 66.67% sensitive and 89.91% specific for receiving blood transfusion.

CONCLUSION

There is a clinical role to using the GBS even at a score higher than 2 to further stratify the severity of UGIB and determine the need for intervention. The sensitivity of a score of 10 on the GBS in this dataset was low. A cutoff with higher sensitivity is needed to stratify a life-threatening condition such as UGIB.

Comparative Study Between Various Scoring Systems in Predicting the Severity of Acute Pancreatitis

Background Acute pancreatitis (AP) is an acute inflammatory condition of the pancreas, peri-pancreatic tissues, and several organs, leading to multiple organ dysfunction syndrome and a higher risk of mortality. For many years, scoring systems that include biochemical, radiological, and clinical criteria for determining severity have been used. Though numerous studies have used various scoring methods to evaluate the severity of AP, this study has been conducted to compare four scoring systems: bedside index of severity in AP (BISAP), acute physiology and chronic health evaluation (APACHE II), Ranson's, and modified CT severity index (CTSI) based on clinical, biochemical, and radiological parameters. Materials and methods It was a prospective-comparative study. The study was conducted from December 2016 to August 2018 in the Department of General Surgery at Byramjee Jeejeebhoy Government Medical College (B.J.G.M.C.) and Sassoon Hospital, Pune, Maharashtra, India. A total of 75 participants were enrolled in the study.  Results The study population ranged from 18 to 68 years, with a mean age of 40.8±11.5 years. AP was most prevalent in the age group of 31-40 years (33.3% cases). Out of 75 patients in this study, 14 patients (18.7%) had severe AP (SAP), 18 patients (24%) had moderate SAP, and 43 patients (57.3%) had mild AP. Ten patients expired, with a mortality rate of 13.3%. It has been observed that the BISAP score had the best specificity (100%) and the CTSI score had the highest sensitivity (96.9%) among our study's four scores for predicting pancreatic necrosis. When predicting persistent organ failure, BISAP had the highest specificity, and Ranson and CTSI scored the highest sensitivity. The modified CTSI poorly predicted AP, patients' mortality, and SAP. Conclusion The BISAP score provides a straightforward and accurate way to analyze the seriousness of AP. Ranson's score is also a reliable indicator of ongoing organ failure among AP cases. The most reliable technique for predicting pancreatitis mortality is the APACHE II score.

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.

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.

Embryonal rhabdomyosarcoma at an unusual age and in an atypical site: a case report

BACKGROUND

Rhabdomyosarcoma is classified into histologic subtypes: embryonal, alveolar, pleomorphic, spindle, and mixed-type. Embryonal rhabdomyosarcoma is mainly a disease of children. It occurs rarely in adults. When rhabdomyosarcoma is found in adults, it usually exhibits worse outcomes than in pediatric patients.

CASE PRESENTATION

We present a case report of a 20-year-old Arab woman who presented with generalized musculoskeletal pain, unintended weight loss, and excessive night sweats. There was no remarkable history of medications, diseases, or surgeries. A positron emission tomography scan showed multiple osteolytic lesions with metabolic activity, as well as pleural effusion and soft tissue mass around the thoracic area. Following this, a bone marrow biopsy was performed and showed metastatic embryonal rhabdomyosarcoma according to immunochemistry stainings. Chemotherapy was started with 3 doses of vincristine, actinomycin D, and cyclophosphamide regimen for 3 months, after which a positron emission tomography scan showed a total disappearance of the soft tissue mass, but revealed metabolic activity of new foci. Therefore, the patient took another 3 doses of the vincristine, actinomycin D, and cyclophosphamide regimen, and received a total of 30 Gy of radiotherapy on the new foci.

CONCLUSION

This paper describes a case of a patient diagnosed with adult rhabdosmyosarcoma at an uncommon age and in an uncommon site; therefore, it is important to consider rhabdomyosarcoma in the differential diagnosis of patients given an abnormal presentation and unexplained findings. Early detection of the disease, which is difficult with nonspecific symptoms, is crucial for improving outcomes.

Vitamin D Deficiency and Mastalgia: A Prospective Controlled Study on Prevalence and the Therapeutic Impact of Supplementation

Objective

To investigate the relationship between vitamin D deficiency and mastalgia and assess the effectiveness of vitamin D supplementation in alleviating mastalgia symptoms.

Materials and Methods

A prospective investigational study conducted in an Indian tertiary teaching centre. Participants were included if the presented with mastalgia and controls without mastalgia were also were recruited. Exclusion criteria were malignant pathology; fibroadenoma; other benign breast diseases; or recent therapeutic vitamin D supplementation. Vitamin D deficiency was classified as <20 ng/mL. Women in the mastalgia group with deficiency received 60,000 IU weekly oral vitamin D for eight weeks. Symptom severity was evaluated using a visual analog scale (VAS) at baseline and follow-up intervals of 4, 8, and 12 weeks. Difference in serum vitamin D levels between groups and changes in VAS scores post-supplementation was assessed.

Results

A total of 200 women, including 100 with mastalgia and 100 without (control group), were recruited over two years.The mean serum vitamin D level was significantly lower in the mastalgia group (25.29±7.7 ng/mL) compared to controls (31.46±8.5 ng/mL, p<0.0001). Vitamin D deficiency was more prevalent in the mastalgia group (26% vs. 9%, p = 0.001). Post-supplementation, 46% of deficient patients in the mastalgia group reported symptom improvement, with 21% achieving complete resolution. However, 54% reported persistent symptoms despite achieving sufficient vitamin D levels.

Conclusion

Vitamin D deficiency is more prevalent in Indian women with mastalgia, and supplementation provides symptomatic relief for some patients. However, a significant proportion of patients continue to experience symptoms, suggesting other underlying factors contributing to mastalgia. Further research is needed to explore these factors and optimize management strategies.

Epidemiological analysis of intra-abdominal infections in Italy from the Italian register of complicated intra-abdominal infections-the IRIS study: a prospective observational nationwide study

BACKGROUND

Intra-abdominal infections (IAIs) are common and severe surgical emergencies associated with high morbidity and mortality. In recent years, there has been a worldwide increase in antimicrobial resistance associated with intra-abdominal infections, responsible for a significant increase in mortality rates. To improve the quality of treatment, it is crucial to understand the underlying local epidemiology, clinical implications, and proper management of antimicrobial resistance, for both community- and hospital-acquired infections. The IRIS study (Italian Register of Complicated Intra-abdominal InfectionS) aims to investigate the epidemiology and initial management of complicated IAIs (cIAIs) in Italy.

MATERIAL AND METHOD

This is a prospective, observational, nationwide (Italy), multicentre study. approved by the coordinating centre ethic committee (Local Research Ethics Committee of Pisa (Prot n 56478//2019). All consecutively hospitalized patients (older than 16 years of age) with diagnosis of cIAIs undergoing surgery, interventional drainage or conservative treatment have been included.

RESULTS

4530 patients included from 23 different Italian hospitals. Community Acquired infection represented the 70.9% of all the cases. Among appendicitis, we found that 98.2% of the cases were community acquired (CA) and 1.8% Healthcare-associated (HA) infections. We observed that CA represented the 94.2% and HA 5.8% of Gastro Duodenal perforation cases. The majority of HA infections were represented by colonic perforation and diverticulitis (28.3%) followed by small bowel occlusion (19%) and intestinal ischemia (18%). 27.8% of patients presented in septic shock. Microbiological Samples were collected from 3208 (70.8%) patients. Among 3041 intrabdominal sample 48.8% resulted positive. The major pathogens involved in intra-abdominal infections were found to be E.coli (45.6%). During hospital stay, empiric antimicrobial therapy was administered in 78.4% of patients. Amoxicillin/clavulanate was the most common antibiotic used (in 30.1% appendicitis, 30% bowel occlusion, 30.5% of cholecystitis, 51% complicated abdominal wall hernia, 55% small bowel perforation) followed by piperacillin/tazobactam (13.3% colonic perforation and diverticulitis, 22.6% cholecystitis, 24.2% intestinal ischemia, 28.6% pancreatitis). Empiric antifungal therapy was administered in 2.6% of patients with no sign of sepsis, 3.1% of patients with clinical sign of sepsis and 4.1% of patients with septic shock. Azoles was administered in 49.2% of patients that received empiric antifungal therapy. The overall mortality rate was 5.13% (235/4350). 16.5% of patients required ICU (748/4350). In accordance with mortality, it is important to highlight that 35.7% of small bowel perforation, 27.6% of colonic perforation and diverticulitis, 25.6% of intestinal ischemia and 24.6% of gastroduodenal complications required ICU.

CONCLUSION

Antibiotic stewardship programs and correct antimicrobial and antimycotic prescription campaigns are necessary to ulteriorly improve the adequacy of drug usage and reduce the resistances burden. This will help in improving the care and the cure of the next generations.

COVID-19 infection is a significant risk factor for death in patients presenting with acute cholecystitis: a secondary analysis of the ChoCO-W cohort study

BACKGROUND

During the coronavirus disease (COVID-19) pandemic, there has been a surge in cases of acute cholecystitis. The ChoCO-W global prospective study reported a higher incidence of gangrenous cholecystitis and adverse outcomes in COVID-19 patients. Through this secondary analysis of the ChoCO-W study data, we aim to identify significant risk factors for mortality in patients with acute cholecystitis during the COVID-19 pandemic, emphasizing the role of COVID-19 infection in patient outcomes and treatment efficacy."

METHODS

The ChoCO-W global prospective study reported data from 2546 patients collected at 218 centers from 42 countries admitted with acute cholecystitis during the COVID-19 pandemic, from October 1, 2020, to October 31, 2021. Sixty-four of them died. Nonparametric statistical univariate analysis was performed to compare patients who died and patients who survived. Significant factors were then entered into a logistic regression model to define factors predicting mortality.

RESULTS

The significant independent factors that predicted death in the logistic regression model with were COVID-19 infection (p < 0.001), postoperative complications (p < 0.001), and type (open/laparoscopic) of surgical intervention (p = 0.003). The odds of death increased 5 times with the COVID-19 infection, 6 times in the presence of complications, and it was reduced by 86% with adequate source control. Survivors predominantly underwent urgent laparoscopic cholecystectomy (52.3% vs. 23.4%).

CONCLUSIONS

COVID-19 was an independent risk factor for death in patients with acute cholecystitis. Early laparoscopic cholecystectomy has emerged as the cornerstone of treatment for hemodynamically stable patients.

Short-acting urapidil compared to long-acting phenoxybenzamine in the management of pheochromocytoma

PURPOSE

In patients with pheochromocytoma current guidelines recommend preoperative alpha-adrenoceptor blockade with selective or nonselective antagonists for at least 7-14 days. To date, no information exists about orally administered urapidil retard, a short-acting selective antagonist.

METHODS

The medical records of consecutive patients with pheochromocytoma between 2010 and 2023 were reviewed. Patients received phenoxybenzamine between 2010 and 2017, intravenous urapidil was given between 2017 and 2019. Orally administered urapidil retard has been used from 2019 until present.

RESULTS

Forty-nine patients with pheochromocytomas were included. Twenty-six patients received orally administered long-acting phenoxybenzamine and 23 patients were pretreated with short-acting intravenous (n = 8) or orally administered urapidil (n = 15). Treatment prior to surgery was significantly shorter with intravenously (3 days (IQR, 3-4), p = 0.015) or orally administered urapidil (2 days (IQR 2-3), p = 0.003) compared to phenoxybenzamine (7 days (IQR, 4-10)). Side effects were more often in the phenoxybenzamine group (17/26 vs 6/23, p = 0.02). The modified hemodynamic instability (HI) score was low and there was no significant difference between patients treated with phenoxybenzamine and those treated with intravenous or oral urapidil (29 (IQR 18.5-38); 26 (IQR 18-42); 31 (IQR 15-36) ns). No 30-day postoperative mortality or cardiovascular complications occurred in any of the three groups. The postoperative hospital stay was significantly shorter in the orally administered urapidil group compared to the phenoxybenzamine group (3 days (IQR 3-5)) vs 4 days (IQR 4-5)), p = 0.04).

CONCLUSION

Oral pretreatment with urapidil retard is well tolerated for patients with pheochromocytoma, enabling a safe intra- and postoperative course.

Is it time to say goodbye to drainage after axillary lymph node dissection in breast cancer? A randomized clinical trial of systemic tranexamic acid combined with topical epinephrine + xylocaine versus conventional drainage

Drainage after axillary lymph node dissection is a major cause of morbidity. We evaluated the outcomes of topical epinephrine with xylocaine + systemic tranexamic acid (EXT) after axillary lymph node dissection. The primary endpoint was the rate of seroma development. This resulted in reduced hospital stay with similar rates of seroma as drainage after axillary lymph node dissection; thereby making it possible to avoid drainage.

Examining the surgical backlog due to COVID-19 in Latin America and the Caribbean: insights from a scoping review

This scoping review assessed the surgical backlog in Latin America and the Caribbean (LAC) due to COVID-19 and identified mitigation strategies. We searched seven databases for citations from December 2019 to December 2022, focusing on LAC patients with cancelled or postponed procedures. We registered our protocol at Open Science Framework (https://osf.io/x2nd8) and adhered to PRISMA-ScR guidelines. We included 83 citations covering 23 LAC countries and 19 surgical specialities, with Brazil (67%, 56/83) and transplant surgery (24%, 20/83) being the most documented. Surgical backlogs were mainly reported at the hospital (44%, 37/83) and national levels (38%, 32/83). We identified 58 citations that reported a total of 42 strategies to mitigate the backlog, the most cited being establishing prioritisation criteria for surgical cases (41%, 24/58). Our findings highlight challenges across differing healthcare systems in LAC, including disparities in data availability, surgical capacity, and resource allocation. For instance, while countries like Brazil had extensive data on national surgical backlogs, others lacked comprehensive national-level data. Our review can help inform policymakers and healthcare stakeholders to implement targeted interventions to prepare LAC-based surgical systems for future health emergencies.

Non-occlusive mesenteric ischemia in critically ill patients: does bedside laparoscopy offer any real benefit?

Non-occlusive mesenteric ischemia in critically ill patients still has a poor prognosis. Despite several established risk factors, the interaction between clinical conditions and perfusion mismatch often leads to progressive organ failure. Workup is challenging because of the absence of typical abdominal signs and symptoms due to sedation, poor reactivity, need for ventilation, and confounding comorbidities. Moreover, imaging has poor specificity with findings often inconclusive. A bedside exploratory laparoscopy, as a complementary strategy, would allow for early and prompt diagnosis. Limits of a minimally invasive surgical rationale lie upon the effects of pneumoperitoneum induction, surgical stress, logistical resources, expertise, and costs.

Distribution and Antimicrobial Resistance of Complicated Intraabdominal Infection Pathogens in Two Tertiary Hospitals in Egypt

Background: Management of complicated intraabdominal infections (cIAIs) requires containment of the source and appropriate initial antimicrobial therapy. Identifying the local data is important to guide the empirical selection of antimicrobial therapy. In this study, we aimed to describe the pathogen distribution and antimicrobial resistance of cIAI. Methods: In two major tertiary care hospitals in Egypt, we enrolled patients who met the case definition of cIAI from October 2022 to September 2023. Blood cultures were performed using the BACTAlert system (BioMerieux, Marcy l'Etoile, France). A culture of aspirated fluid, resected material, or debridement of the infection site was performed. Identification of pathogens and antimicrobial susceptibility testing were conducted by the VITEK-2 system (BioMerieux, Marcy l'Etoile, France). Gram-negative resistance genes were identified by PCR and confirmed by whole bacterial genome sequencing using the Nextera XT DNA Library Preparation Kit and sequencing with the MiSeq Reagent Kit 600 v3 (Illumina, USA) on the Illumina MiSeq. Results: We enrolled 423 patients, 275 (65.01%) males. The median age was 61.35 (range 25-72 years). We studied 452 recovered bacterial isolates. Gram-negative bacteria were the vast majority, dominated by E. coli, followed by Klebsiella pneumoniae, Pseudomonas aeruginosa, Acinetobacter baumannii, and Proteus mirabilis (33.6%, 30.5%, 13.7%, 13%, and 5.4%, respectively). High rates of resistance were detected to third- and fourth-generation cephalosporins and fluoroquinolones. No resistance was detected to colistin. Resistance to amikacin and tigecycline was low among all isolates. Resistance to meropenem and ceftazidime/avibactam was moderate. ESBL genes were common in E. coli and K. pneumoniae. CTX-M15 gene was the most frequent. Among Enterobacterales, blaOXA-48 and blaNDM were the most prevalent carbapenemase genes. Pseudomonas aeruginosa isolates harbored a wide variety of carbapenemase genes (OXA, NDM, VIM, SIM, GIM, SPM, IMP, AIM), dominated by metallo-beta-lactamases. In 20.6% of isolates, we identified two or more resistance genes. Conclusion: High resistance rates were detected to third- and fourth-generation cephalosporins and fluoroquinolones. Amikacin and tigecyclines were the most active antimicrobials. Our data call for urgent implementation of antimicrobial stewardship programs and reinforcement of infection control.

2024 Clinical Practice Guideline Update by the Infectious Diseases Society of America on Complicated Intra-abdominal Infections: Risk Assessment in Adults and Children

This paper is part of a clinical practice guideline update on the risk assessment, diagnostic imaging, and microbiological evaluation of complicated intra-abdominal infections in adults, children, and pregnant people, developed by the Infectious Diseases Society of America. In this paper, the panel provides a recommendation for risk stratification according to severity of illness score. The panel's recommendation is based on evidence derived from systematic literature reviews and adheres to a standardized methodology for rating the certainty of evidence and strength of recommendation according to the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach.

Sentinel lymph node biopsy in early breast carcinoma using fluorescein sodium and methylene blue dye: A validation study

The availability of radioisotopes for sentinel lymph node biopsy (SLNB) in breast carcinoma is limited in low- and middle-income countries and thus the need for other reliable tracers exists. We aimed to validate the effectiveness of fluorescein sodium (FS) together with methylene blue dye (MBD) for patients with node-negative early breast carcinoma in a prospective cross-sectional study. Patients underwent SLNB using FS and MBD followed by axillary dissection to validate results. Sentinel lymph node (SLN) identification rate and false negative rate were assessed for all three tracers/combinations (MBD, FS, and MBD + FS). We concluded that SLNB using a combination of FS and MBD has an acceptable rate of SLN identification but the addition of FS provided no additional benefit.

Source Control and Antibiotics in Intra-Abdominal Infections

Intra-abdominal infections (IAIs) account for a major cause of morbidity and mortality, representing the second most common sepsis-related death with a hospital mortality of 23-38%. Prompt identification of sepsis source, appropriate resuscitation, and early treatment with the shortest delay possible are the cornerstones of management of IAIs and are associated with a more favorable clinical outcome. The aim of source control is to reduce microbial load by removing the infection source and it is achievable by using a wide range of procedures, such as definitive surgical removal of anatomic infectious foci, percutaneous drainage and toilette of infected collections, decompression, and debridement of infected and necrotic tissue or device removal, providing for the restoration of anatomy and function. Damage control surgery may be an option in selected septic patients. Intra-abdominal infections can be classified as uncomplicated or complicated causing localized or diffuse peritonitis. Early clinical evaluation is mandatory in order to optimize diagnostic testing and establish a therapeutic plan. Prognostic scores could serve as helpful tools in medical settings for evaluating both the seriousness and future outlook of a condition. The patient's conditions and the potential progression of the disease determine when to initiate source control. Patients can be classified into three groups based on disease severity, the origin of infection, and the patient's overall physical health, as well as any existing comorbidities. In recent decades, antibiotic resistance has become a global health threat caused by inappropriate antibiotic regimens, inadequate control measures, and infection prevention. The sepsis prevention and infection control protocols combined with optimizing antibiotic administration are crucial to improve outcome and should be encouraged in surgical departments. Antibiotic and antifungal regimens in patients with IAIs should be based on the resistance epidemiology, clinical conditions, and risk for multidrug resistance (MDR) and Candida spp. infections. Several challenges still exist regarding the effectiveness, timing, and patient stratification, as well as the procedures for source control. Antibiotic choice, optimal dosing, and duration of therapy are essential to achieve the best treatment. Promoting standard of care in the management of IAIs improves clinical outcomes worldwide. Further trials and stronger evidence are required to achieve optimal management with the least morbidity in the clinical care of critically ill patients with intra-abdominal sepsis.

Roadmap for integrating the AACN essentials with perioperative nursing

Faculty members teaching in pre-licensure nursing programs are entrusted with revising nursing education to meet the American Association of Colleges of Nursing's The Essentials: Core Competencies for Professional Nursing Education. Colleges of nursing faculty experience difficulty establishing enough clinical sites as healthcare facilities continue to overcome staffing challenges since the start of the COVID-19 pandemic. Perioperative nursing is an underutilized area despite the potential for students to attain valuable nursing competencies and experiences in perioperative areas. An opportunity exists for faculty, regardless of having perioperative nursing experience or not, to use perioperative environments for clinical experiences in didactic and simulation courses. Our aim is to provide a roadmap for nursing faculty to include perioperative nursing in the pre-licensure nursing curriculum. Perioperative education exemplars aligned with the American Association of Colleges of Nursing's The Essentials: Core Competencies for Professional Nursing Education domains are included for adoption in any college of nursing.

A systematic review and meta-analysis of diagnostic performance of fluorescein-guided sentinel lymph node biopsy in early breast cancer

BACKGROUND

Evaluation of axillary lymph nodes status in cN0 axilla is performed by sentinel lymph node biopsy (SLNB) utilizing a combination of radioactive isotope and blue dye or alternative to isotope like Indocyanine green (ICG). Both are very resource-intensive; which has prompted development of low-cost technique of Fluorescein Sodium (FS)-guided SLNB. This systematic review and meta-analysis evaluate the diagnostic performance of FS-guided SLNB in early breast cancer.

OBJECTIVES

The objective was to evaluate the diagnostic performance of FS for sentinel lymph node biopsy.

METHODS

Eligibility criteria: Studies where SLNB was performed using FS.

INFORMATION SOURCES

PubMed, EMBASE, Cochrane library and online clinical trial registers. Risk of bias: Articles were assessed for risk of bias using the QUADAS-2 tool.

SYNTHESIS OF RESULTS

The main summary measures were pooled Sentinel Lymph Node Identification Rate (SLN-IR) and pooled False Negative Rate (FNR) using random-effects model.

RESULTS

A total of 45 articles were retrieved by the initial systematic search. 7 out of the 45 studies comprising a total of 332 patients were included in the meta-analysis. The pooled SLN-IR was 93.2% (95% confidence interval [CI], 0.87-0.97; 87% to 97%). Five validation studies were included for pooling the false negative rate and included a total of 211 patients. The pooled FNR was 5.6% (95% confidence interval [CI], 2.9-9.07).

CONCLUSION

Fluorescein-guided SLNB is a viable option for detection of lymph node metastases in clinically node negative patients with early breast cancer. It achieves a high pooled Sentinel Lymph Node Identification Rate (SLN-IR) of 93% with a false negative rate of 5.6% for the detection of axillary lymph node metastasis.

Prognostic role of suPAR in acute pancreatitis: A protocol for systematic review

BACKGROUND

Acute pancreatitis (AP) is a common emergency condition with high morbidity, mortality, and socio-economic impact. Soluble urokinase plasminogen activator receptor (suPAR) is a potential biomarker for AP prognosis. This study systematically reviews the literature on suPAR's prognostic roles in assessing AP severity, organ failure, mortality, and other pathological markers.

METHODS

A comprehensive search of 5 databases up to March 19, 2023, was conducted, selecting cohort studies that examined suPAR's relationship with AP outcomes. Outcome variables included AP severity, organ failure, mortality, hospital stay length, and suPAR's association with other inflammatory markers. Our paper has been registered on Prospero (ID: CRD42023410628).

RESULTS

Nine prospective observational studies with 1033 AP patients were included. Seven of eight studies found suPAR significantly elevated in severe acute pancreatitis (P < .05). Four studies showed suPAR effectively predicted organ failure risk, and 4 studies concluded suPAR significantly predicted mortality (P < .05). The review had no high-risk studies, enhancing credibility.

CONCLUSION

suPAR is a valuable prognostic marker in AP, significantly predicting severity, organ failure, hospital stay length, and mortality. Further large-scale studies are needed to explore suPAR's role in other clinical outcomes related to AP disease course, to establish it as a mainstay of AP prognosis.

Management of intra-abdominal infections: recommendations by the Italian council for the optimization of antimicrobial use

Intra-abdominal infections (IAIs) are common surgical emergencies and are an important cause of morbidity and mortality in hospital settings, particularly if poorly managed. The cornerstones of effective IAIs management include early diagnosis, adequate source control, appropriate antimicrobial therapy, and early physiologic stabilization using intravenous fluids and vasopressor agents in critically ill patients. Adequate empiric antimicrobial therapy in patients with IAIs is of paramount importance because inappropriate antimicrobial therapy is associated with poor outcomes. Optimizing antimicrobial prescriptions improves treatment effectiveness, increases patients' safety, and minimizes the risk of opportunistic infections (such as Clostridioides difficile) and antimicrobial resistance selection. The growing emergence of multi-drug resistant organisms has caused an impending crisis with alarming implications, especially regarding Gram-negative bacteria. The Multidisciplinary and Intersociety Italian Council for the Optimization of Antimicrobial Use promoted a consensus conference on the antimicrobial management of IAIs, including emergency medicine specialists, radiologists, surgeons, intensivists, infectious disease specialists, clinical pharmacologists, hospital pharmacists, microbiologists and public health specialists. Relevant clinical questions were constructed by the Organizational Committee in order to investigate the topic. The expert panel produced recommendation statements based on the best scientific evidence from PubMed and EMBASE Library and experts' opinions. The statements were planned and graded according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) hierarchy of evidence. On November 10, 2023, the experts met in Mestre (Italy) to debate the statements. After the approval of the statements, the expert panel met via email and virtual meetings to prepare and revise the definitive document. This document represents the executive summary of the consensus conference and comprises three sections. The first section focuses on the general principles of diagnosis and treatment of IAIs. The second section provides twenty-three evidence-based recommendations for the antimicrobial therapy of IAIs. The third section presents eight clinical diagnostic-therapeutic pathways for the most common IAIs. The document has been endorsed by the Italian Society of Surgery.

Intra-abdominal infections survival guide: a position statement by the Global Alliance For Infections In Surgery

Intra-abdominal infections (IAIs) are an important cause of morbidity and mortality in hospital settings worldwide. The cornerstones of IAI management include rapid, accurate diagnostics; timely, adequate source control; appropriate, short-duration antimicrobial therapy administered according to the principles of pharmacokinetics/pharmacodynamics and antimicrobial stewardship; and hemodynamic and organ functional support with intravenous fluid and adjunctive vasopressor agents for critical illness (sepsis/organ dysfunction or septic shock after correction of hypovolemia). In patients with IAIs, a personalized approach is crucial to optimize outcomes and should be based on multiple aspects that require careful clinical assessment. The anatomic extent of infection, the presumed pathogens involved and risk factors for antimicrobial resistance, the origin and extent of the infection, the patient's clinical condition, and the host's immune status should be assessed continuously to optimize the management of patients with complicated IAIs.

A Case of Alveolar Rhabdomyosarcoma of the Nasal Cavity in an Adult: An Unusual Location

Rhabdomyosarcoma is a common soft tissue tumor in children but rare in adults. Alveolar rhabdomyosarcoma represents a subtype of rhabdomyosarcoma, extremely rare in adults, especially within the nasal cavities. Therapeutic protocols for adults are often based on those used in pediatric cases. We present the case of a 56-year-old female patient with a history of breast cancer who developed alveolar rhabdomyosarcoma of the nasal cavity, stage III, managed initially with chemotherapy resulting in partial response. Subsequently, the patient underwent concomitant chemoradiotherapy. The clinical course was marked by local remission with metastatic progression after 18 months. Alveolar rhabdomyosarcoma is uncommon in adults, and its therapeutic management remains non-standardized. However, it is typically based on initial chemotherapy followed by local treatment. Despite therapeutic advances, the prognosis remains poor.

Sentinel Lymph Node Biopsy after Neoadjuvant Chemotherapy in Breast Cancer Patients with Positive Nodes Using Low-Cost Dual Dye Technique: Identifying Factors Associated with Adequate False Negative Rate Threshold

Background

In this study, we evaluated the feasibility of the sentinel lymph node (SLN) identification rate (SLN-IR) of fluorescein-guided sentinel lymph node biopsy (SLNB) in combination with methylene blue dye (MBD) and factors which can lead to a false negative rate (FNR) threshold of 10%.

Methods

This was a prospective cross-sectional non-randomized validation study in patients with post-neoadjuvant chemotherapy (NACT) clinically node negative axilla who were node positive prior to start of NACT. Patients underwent validation of SLNB using fluorescein (and blue LED light) and MBD. Axillary dissection was performed irrespective of SLNB histology. SLIN-IR and FNR were assessed and compared with various molecular subtypes.

Results

The SLNs were identified in 102 out of 120 (85%) post-NACT patients. The median number of sentinel lymph nodes identified was 2 (range 1-3). The SLN-IR using MBD was 85%, FD was 82.5%, and combined MBD FD was 85%. Two or more SLNs were removed in 72 patients and 11 patients had tumor in the rest of the axilla, resulting in an FNR of 17.4%. An FNR was 25% in case only one SLN was found, and it was 11.42% if two or more than two SLNs were excised.

Conclusions

This cohort study found that use of low-cost dual dyes in patients with positive axillary disease, rendered cN0 with NACT, with 2 or more negative SLNs with SLNB alone, results in an FNR of 11.4%. Her 2 positive and TNBC with 2 or more negative SLNs are associated with an FNR of <10%. However, the number of such patients was small and further studies with larger sample size are warranted to confirm these findings.

Development and validation of a nomogram to predict postsurgical intra-abdominal infection in blunt abdominal trauma patients: A multicenter retrospective study

BACKGROUND

Intra-abdominal infection is a common complication of blunt abdominal trauma. Early detection and intervention can reduce the incidence of intra-abdominal infection and improve patients' prognoses. This study aims to construct a clinical model predicting postsurgical intra-abdominal infection after blunt abdominal trauma.

METHODS

This study is a retrospective analysis of 553 patients with blunt abdominal trauma from the Department of General Surgery of 7 medical centers (2011-2021). A 7:3 ratio was used to assign patients to the derivation and validation cohorts. Patients were divided into 2 groups based on whether intra-abdominal infection occurred after blunt abdominal trauma. Multivariate logistic regression and least absolute shrinkage and selection operator regression were used to select variables to establish a nomogram. The nomogram was evaluated, and the validity of the model was further evaluated by the validation cohort.

RESULTS

A total of 113 were diagnosed with intra-abdominal infection (20.4%). Age, prehospital time, C-reactive protein, injury severity score, operation duration, intestinal injury, neutrophils, and antibiotic use were independent risk factors for intra-abdominal infection in blunt abdominal trauma patients (P < .05). The area under the receiver operating curve (area under the curve) of derivation cohort and validation cohort was 0.852 (95% confidence interval, 0.784-0.912) and 0.814 (95% confidence interval, 0.751-0.902). The P value for the Hosmer-Lemeshow test was .135 and .891 in the 2 cohorts. The calibration curve demonstrated that the nomogram had a high consistency between prediction and practical observation. The decision curve analysis also showed that the nomogram had a better potential for clinical application. To facilitate clinical application, we have developed an online at https://nomogramcgz.shinyapps.io/IAIrisk/.

CONCLUSION

The nomogram is helpful in predicting the risk of postoperative intra-abdominal infection in patients with blunt abdominal trauma and provides guidance for clinical decision-making and treatment.

Predictive value of the Ranson and BISAP scoring systems for the severity and prognosis of acute pancreatitis: A systematic review and meta-analysis

BACKGROUND

To systematically assess and compare the predictive value of the Ranson and Bedside Index of Severity in Acute Pancreatitis (BISAP) scoring systems for the severity and prognosis of acute pancreatitis (AP).

METHODS

PubMed, Embase, Cochrane Library, and Web of Science were systematically searched until February 15, 2023. Outcomes in this analysis included severity and prognosis [mortality, organ failure, pancreatic necrosis, and intensive care unit (ICU) admission]. The revised Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool was used to evaluate the quality of diagnostic accuracy studies. The threshold effect was evaluated for each outcome. The sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR), and the area under the summary receiver operating characteristic (SROC) curve (AUC) as well as 95% confidence intervals (CI) were calculated. The DeLong test was used for AUC comparisons. For the outcome evaluated by over 9 studies, publication bias was assessed using the Deeks' funnel plot asymmetry test.

RESULTS

Totally 17 studies of 5476 AP patients were included. For severity, the pooled sensitivity of the Ranson and BISAP was 0.95 (95%CI: 0.87, 0.98) and 0.67 (95%CI: 0.27, 0.92); the pooled specificity of the Ranson and BISAP was 0.74 (0.52, 0.88) and 0.95 (95%CI: 0.85, 0.98); the pooled AUC of the Ranson and BISAP was 0.95 (95%CI: 0.93, 0.97) and 0.94 (95%CI: 0.92, 0.96) (P = 0.480). For mortality, the pooled sensitivity of the Ranson and BISAP was 0.89 (95%CI: 0.73, 0.96) and 0.77 (95%CI: 0.58, 0.89); the pooled specificity of the Ranson and BISAP was 0.79 (95%CI: 0.68, 0.87) and 0.90 (95%CI: 0.86, 0.93); the pooled AUC of the Ranson and BISAP was 0.91 (95%CI: 0.88, 0.93) and 0.92 (95%CI: 0.90, 0.94) (P = 0.480). For organ failure, the pooled sensitivity of the Ranson and BISAP was 0.84 (95%CI: 0.76, 0.90) and 0.78 (95%CI: 0.60, 0.90); the pooled specificity of the Ranson and BISAP was 0.84 (95%CI: 0.63, 0.94) and 0.90 (95%CI: 0.72, 0.97); the pooled AUC of the Ranson and BISAP was 0.86 (95%CI: 0.82, 0.88) and 0.90 (95%CI: 0.87, 0.93) (P = 0.110). For pancreatic necrosis, the pooled sensitivity of the Ranson and BISAP was 0.63 (95%CI: 0.35, 0.84) and 0.63 (95%CI: 0.23, 0.90); the pooled specificity of the Ranson and BISAP was 0.90 (95%CI: 0.77, 0.96) and 0.93 (95%CI: 0.89, 0.96); the pooled AUC of the Ranson and BISAP was 0.87 (95%CI: 0.84, 0.90) and 0.93 (95%CI: 0.91, 0.95) (P = 0.001). For ICU admission, the pooled sensitivity of the Ranson and BISAP was 0.86 (95%CI: 0.77, 0.92) and 0.63 (95%CI: 0.52, 0.73); the pooled specificity of the Ranson and BISAP was 0.58 (95%CI: 0.55, 0.61) and 0.84 (95%CI: 0.81, 0.86); the pooled AUC of the Ranson and BISAP was 0.92 (95%CI: 0.81, 1.00) and 0.86 (95%CI: 0.67, 1.00) (P = 0.592).

CONCLUSION

The Ranson score was an applicable tool for predicting severity and prognosis of AP patients with reliable diagnostic accuracy in resource and time-limited settings. Future large-scale studies are needed to verify the findings.

Risk factors for intraoperative hypertensive crisis in patients with pheochromocytomas and sympathetic paragangliomas

PURPOSE

To identify presurgical and surgical risk factors for intraoperative hypertensive crisis in patients with pheochromocytomas and sympathetic paragangliomas (PGLs) (PPGLs).

METHODS

Retrospective multicenter cohort study of patients with PPGLs from 18 tertiary hospitals. Intraoperative hypertensive crisis was defined as systolic blood pressure (SBP) greater than 200 mmHg lasting more than 1 min and postoperative hypertensive crisis as SBP greater than 180 mmHg or diastolic blood pressure (DBP) greater than 110 mmHg.

RESULTS

A total of 296 surgeries were included. Alpha presurgical blockade was employed in 93.2% of the cases and beta-adrenergic in 53.4%. Hypertensive crisis occurred in 20.3% ( n  = 60) of the surgeries: intraoperative crisis in 56 and postoperative crisis in 6 cases (2 cases had both types of crises). We identified as risk factors of intraoperative hypertensive crisis, absence of presurgical glucocorticoid therapy (odds ratio [OR] 3.48; 95% confidence interval [CI] 1.19-10.12) higher presurgical SBP (OR 1.22 per each 10 mmHg, 95% CI 1.03-1.45), a larger tumor size (OR 1.09 per each 10 mm, 95% CI 1.00-1.19) and absence of oral sodium repletion (OR 2.59, 95% CI 1.25-5.35). Patients with hypertensive crisis had a higher rate of intraoperative bleeding ( P  < 0.001), of intraoperative hemodynamic instability ( P  < 0.001) and of intraoperative hypotensive episodes ( P  < 0.001) than those without hypertensive crisis.

CONCLUSION

Intraoperative hypertensive crisis occurs in up to 20% of the PPGL resections. Patients not pretreated with glucocorticoid therapy before surgery, with larger tumors and higher presurgical SBP and who do not receive oral sodium repletion have a higher risk for developing hypertensive crisis during and after PPGL surgery.

[Laparoscopic surgery for advanced peritonitis]

OBJECTIVE

To determine the criteria for choosing surgical access in patients with advanced peritonitis considering its local and general manifestations.

MATERIAL AND METHODS

We analyzed treatment outcomes in 588 patients with advanced peritonitis. The most common causes of peritonitis were destructive forms of acute appendicitis (273 cases), perforated gastroduodenal ulcers (165 cases), acute cholecystitis (59 cases). To determine the criteria for choosing surgical access in advanced peritonitis, we analyzed treatment outcomes considering MPI, SPP and WSES SSS score.

RESULTS

The choice of surgical access in advanced peritonitis can only symbolically be standardized according to modern scoring systems (MPI, SPP, WSES SSS). Laparotomy is necessary for MPI score ≥30 and SPP score > 10 (WSES SSS score > 8). Regardless of MPI, SPP, WSES SSS scores, the absolute contraindications for laparoscopic surgery are dense non-removable fibrin deposits, interintestinal abscesses, purulent recesses, intra-abdominal pressure > 20 mm Hg or small intestine dilation> 3 cm, sepsis or septic shock (qSOFA score 2-3), previous open abdominal surgery, unstable hemodynamics, technical difficulties. Conversion should be used at any doubt.

CONCLUSION

Careful patient selection, surgical experience and training in laparoscopic technique are decisive factors for wider use of laparoscopic approach in patients undergoing emergency abdominal surgery.

Therapeutic effect of adipose-derived mesenchymal stem cells in a porcine model of abdominal sepsis

BACKGROUND

The term sepsis refers to a complex and heterogeneous syndrome. Although great progress has been made in improving the diagnosis and treatment of this condition, it continues to have a huge impact on morbidity and mortality worldwide. Mesenchymal stem cells are a population of multipotent cells that have immunomodulatory properties, anti-apoptotic effects, and antimicrobial activity. We studied these capacities in a porcine model of peritoneal sepsis.

METHODS

We infused human adipose-derived mesenchymal stem cells (ADSCs) into a porcine model of peritoneal sepsis. Twenty piglets were treated with antibiotics alone (control group) or antibiotics plus peritoneal infusion of ADSCs at a concentration of 2 × 106 cells/kg or 4 × 106 cells/kg (low- and high-dose experimental groups, respectively). The animals were evaluated at different time points to determine their clinical status, biochemical and hematologic parameters, presence of inflammatory cytokines and chemokines in blood and peritoneal fluid, and finally by histologic analysis of the organs of the peritoneal cavity.

RESULTS

One day after sepsis induction, all animals presented peritonitis with bacterial infection as well as elevated C-reactive protein, haptoglobin, IL-1Ra, IL-6, and IL-1b. Xenogeneic ADSC infusion did not elicit an immune response, and peritoneal administration of the treatment was safe and feasible. One day after infusion, the two experimental groups showed a superior physical condition (e.g., mobility, feeding) and a significant increase of IL-10 and TGF-β in blood and a decrease of IL-1Ra, IL-1b, and IL-6. After 7 days, all animals treated with ADSCs had better results concerning blood biomarkers, and histopathological analysis revealed a lower degree of inflammatory cell infiltration of the organs of the peritoneal cavity.

CONCLUSIONS

Intraperitoneal administration of ADSCs as an adjuvant therapy for sepsis improves the outcome and diminishes the effects of peritonitis and associated organ damage by regulating the immune system and reducing intra-abdominal adhesions in a clinically relevant porcine model of abdominal sepsis.

Surgical treatment of spondylodiscitis in critically ill septic patients

PURPOSE

Surgical procedures in critically ill patients with spondylodiscitis are challenging and there are several controversies. Here, we present our experience with offering surgical intervention early in critically ill septic patients with spondylodiscitis.

METHOD

After we introduced a new treatment paradigm offering early but limited surgery, eight patients with spondylodiscitis complicated by severe sepsis and multiple organ failure underwent urgent surgical treatment over a 10-year period. Outcome was assessed according to the Barthel index at 12-month follow-up and at the last available follow-up (mean 89 months).

RESULTS

There were 7 men and 1 woman, with a mean age of 62 years. The preoperative ASA score was 5 in 2 patients, and 4 in 6 patients. Six of them presented with high-grade paresis, and in all of them, spondylodiscitis with intraspinal and/or paravertebral abscesses was evident in MR imaging studies. All patients underwent early surgery (within 24 h after admission). The median time in intensive care was 21 days. Out of the eight patients, seven survived. One year after surgery, five patients had a good outcome (Barthel index: 100 (1); 80 (3); and 70 (1)). At the last follow-up (mean 89 months), 4 patients had a good functional outcome (Barthel index between 60 and 80).

CONCLUSION

Early surgical treatment in critically ill patients with spondylodiscitis and sepsis may result in rapid control of infection and can provide favorable long-term outcome. A general strategy of performing only limited surgery is a valid option in such patients who have a relatively high risk for surgery.

Damage Control Surgery and Transfer in Emergency General Surgery

Selective non traumatic emergency surgery patients are targets for damage control surgery (DCS) to prevent or treat abdominal compartment syndrome and the lethal triad. However, DCS is still a subject of controversy. As a concept, DCS describes a series of abbreviated surgical procedures to allow rapid source control of hemorrhage and contamination in patients with circulatory shock to allow resuscitation and stabilization in the intensive care unit followed by delayed return to the operating room for definitive surgical management once the patient becomes physiologic stable. If appropriately applied, the DCS morbidity and mortality can be significantly reduced.

From the floret to the canopy: High temperature tolerance during flowering

Heat waves induced by climate warming have become common in food-producing regions worldwide, frequently coinciding with high temperature (HT)-sensitive stages of many crops and thus threatening global food security. Understanding the HT sensitivity of reproductive organs is currently of great interest for increasing seed set. The responses of seed set to HT involve multiple processes in both male and female reproductive organs, but we currently lack an integrated and systematic summary of these responses for the world's three leading food crops (rice, wheat, and maize). In the present work, we define the critical high temperature thresholds for seed set in rice (37.2°C ± 0.2°C), wheat (27.3°C ± 0.5°C), and maize (37.9°C ± 0.4°C) during flowering. We assess the HT sensitivity of these three cereals from the microspore stage to the lag period, including effects of HT on flowering dynamics, floret growth and development, pollination, and fertilization. Our review synthesizes existing knowledge about the effects of HT stress on spikelet opening, anther dehiscence, pollen shedding number, pollen viability, pistil and stigma function, pollen germination on the stigma, and pollen tube elongation. HT-induced spikelet closure and arrest of pollen tube elongation have a catastrophic effect on pollination and fertilization in maize. Rice benefits from pollination under HT stress owing to bottom anther dehiscence and cleistogamy. Cleistogamy and secondary spikelet opening increase the probability of pollination success in wheat under HT stress. However, cereal crops themselves also have protective measures under HT stress. Lower canopy/tissue temperatures compared with air temperatures indicate that cereal crops, especially rice, can partly protect themselves from heat damage. In maize, husk leaves reduce inner ear temperature by about 5°C compared with outer ear temperature, thereby protecting the later phases of pollen tube growth and fertilization processes. These findings have important implications for accurate modeling, optimized crop management, and breeding of new varieties to cope with HT stress in the most important staple crops.

The Significance of Preoperative Neutrophil-to-Lymphocyte Ratio (NLR), Platelet-to-Lymphocyte Ratio (PLR), and Systemic Inflammatory Index (SII) in Predicting Severity and Adverse Outcomes in Acute Calculous Cholecystitis

The prediction of severity in acute calculous cholecystitis (AC) is important in therapeutic management to ensure an early recovery and prevent adverse postoperative events. We analyzed the value of the neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and systemic inflammatory index (SII) to predict advanced inflammation, the risk for conversion, and postoperative complications in AC. Advanced AC was considered the cases with empyema, gangrene, perforation of the gallbladder, abscesses, or difficulties in achieving the critical view of safety. A 3-year retrospective was performed on 235 patients admitted in emergency care for AC. The NLR was superior to the PLR and SII in predicting advanced inflammation and risk for conversion. The best predictive value was found to be at an NLR "cut-off" value of >4.19, with a sensitivity of 85.5% and a specificity of 66.9% (AUC = 0.824). The NLR, SII, and TG 13/18 correlate well with postoperative complications of Clavien-Dindo grade IV (p < 0.001 for all variables) and sepsis. For predicting early postoperative sepsis, TG 13/18 grading >2 and NLR > 8.54 show the best predicting power (AUC = 0.931; AUC = 0.888, respectively), although not significantly higher than that of the PLR and SII. The NLR is a useful biomarker in assessing the severity of inflammation in AC. The SII and PLR may be useful in the prediction of systemic inflammatory response.

Clinical usefulness of scoring systems to predict severe acute pancreatitis: A systematic review and meta-analysis with pre and post-test probability assessment

BACKGROUND

Scoring systems for severe acute pancreatitis (SAP) prediction should be used in conjunction with pre-test probability to establish post-test probability of SAP, but data of this kind are lacking.

OBJECTIVE

To investigate the predictive value of commonly employed scoring systems and their usefulness in modifying the pre-test probability of SAP.

METHODS

Following PRISMA statement and MOOSE checklists after PROSPERO registration, PubMed was searched from inception until September 2022. Retrospective, prospective, cross-sectional studies or clinical trials on patients with acute pancreatitis defined as Revised Atlanta Criteria, reporting rate of SAP and using at least one score among Bedside Index for Severity in Acute Pancreatitis (BISAP), Acute Physiology and Chronic Health Examination (APACHE)-II, RANSON, and Systemic Inflammatory Response Syndrome (SIRS) with their sensitivity and specificity were included. Random effects model meta-analyses were performed. Pre-test probability and likelihood ratio (LR) were combined to estimate post-test probability on Fagan nomograms. Pooled severity rate was used as pre-test probability of SAP and pooled sensitivity and specificity to calculate LR and generate post-test probability. A priori hypotheses for heterogeneity were developed and sensitivity analyses planned.

RESULTS

43 studies yielding 14,116 acute pancreatitis patients were included: 42 with BISAP, 30 with APACHE-II, 27 with Ranson, 8 with SIRS. Pooled pre-test probability of SAP ranged 16.6%-25.3%. The post-test probability of SAP with positive/negative score was 47%/6% for BISAP, 43%/5% for APACHE-II, 48%/5% for Ranson, 40%/12% for SIRS. In 18 studies comparing BISAP, APACHE-II, and Ranson in 6740 patients with pooled pre-test probability of SAP of 18.7%, post-test probability when scores were positive was 48% for BISAP, 46% for APACHE-II, 50% for Ranson. When scores were negative, post-test probability dropped to 7% for BISAP, 6% for Ranson, 5% for APACHE-II. Quality, design, and country of origin of the studies did not explain the observed high heterogeneity.

CONCLUSIONS

The most commonly used scoring systems to predict SAP perform poorly and do not aid in decision-making.

Acute pancreatitis: A review of diagnosis, severity prediction and prognosis assessment from imaging technology, scoring system and artificial intelligence

Acute pancreatitis (AP) is a potentially life-threatening inflammatory disease of the pancreas, with clinical management determined by the severity of the disease. Diagnosis, severity prediction, and prognosis assessment of AP typically involve the use of imaging technologies, such as computed tomography, magnetic resonance imaging, and ultrasound, and scoring systems, including Ranson, Acute Physiology and Chronic Health Evaluation II, and Bedside Index for Severity in AP scores. Computed tomography is considered the gold standard imaging modality for AP due to its high sensitivity and specificity, while magnetic resonance imaging and ultrasound can provide additional information on biliary obstruction and vascular complications. Scoring systems utilize clinical and laboratory parameters to classify AP patients into mild, moderate, or severe categories, guiding treatment decisions, such as intensive care unit admission, early enteral feeding, and antibiotic use. Despite the central role of imaging technologies and scoring systems in AP management, these methods have limitations in terms of accuracy, reproducibility, practicality and economics. Recent advancements of artificial intelligence (AI) provide new opportunities to enhance their performance by analyzing vast amounts of clinical and imaging data. AI algorithms can analyze large amounts of clinical and imaging data, identify scoring system patterns, and predict the clinical course of disease. AI-based models have shown promising results in predicting the severity and mortality of AP, but further validation and standardization are required before widespread clinical application. In addition, understanding the correlation between these three technologies will aid in developing new methods that can accurately, sensitively, and specifically be used in the diagnosis, severity prediction, and prognosis assessment of AP through complementary advantages.

Typhoid Intestinal Perforation Prognostic Score in Poor-Resource Settings

Background

Mortality from peritonitis due to typhoid intestinal perforation (TIP) in sub-Saharan Africa is high.

Objectives

This study aimed to determine the predictive factors of mortality, propose a prognostic score, and determine the appropriate surgical treatment for TIP in low-resource settings.

Materials and Methods

This was a retrospective data collection of peritonitis due to TIP admitted at Zinder National Hospital from 2014 to 2021. To build a typhoid intestinal perforation prognostic score (TIPPS), patients were randomised into two groups: a score-building group and a validation group. Univariate and multivariate analyses were performed to identify risk factors of mortality. The value of P <0.05 was assigned significant for all analyses.

Results

TIP accounted for 52.4% (n = 1132) of all cases of peritonitis (n = 2159). The median age was 12 years. Rural provenance represented 72.2% (n = 817). Deaths accounted for 10.5% (n = 119). The factors influencing mortality were respiratory rate ≥24/min (odds ratio [OR] = 2.6, P = 0.000), systolic blood pressure <90 mmHg (OR = 0.31, P = 0.002), serum creatinine >20 mg/L (OR = 2.6, P ≤ 0.009), haemoglobin (OR = 2.1, P = 0.000), comorbidity (OR = 3.5, P = 0.001), the American Society of Anesthesiologists score IV&V (OR = 3.3, P = 0.000), admission and management delay > 72 h (OR = 3.2, P = 0.001), and a number of perforations (OR = 2.4, P = 0.0001). These factors were used to build a "TIPPS" score, which ranged from 8 to 20. The risk of mortality was associated with increased TIPPS. The performance of this score was good in the two groups (area under receiver operating characteristic > 0.83). According to the severity and mortality risk of TIP, we classified TIPS into four grades: grade I (low risk: 8-10), grade II (moderate risk: 11-13), grade III (high risk: 14-16) and grade IV (very high risk: 17-20).

Conclusion

The TIPPS is simple. It can describe the severity of the disease and can predict the risk of death. The study highlights the importance and impact of timely and adequate perioperative resuscitation in more complicated cases.

Severe Acute Pancreatitis Prediction: A Model Derived From a Prospective Registry Cohort

Background Severe acute pancreatitis (SAP) has a mortality rate as high as 40%. Early identification of SAP is required to appropriately triage and direct initial therapies. The purpose of this study was to develop a prognostic model that identifies patients at risk for developing SAP of patients managed according to a guideline-based standardized early medical management (EMM) protocol. Methods This single-center study included all patients diagnosed with acute pancreatitis (AP) and managed with the EMM protocol Methodist Acute Pancreatitis Protocol (MAPP) between April 2017 and September 2022. Classification and regression tree (CART®; Professional Extended Edition, version 8.0; Salford Systems, San Diego, CA), univariate, and logistic regression analyses were performed to develop a scoring system for AP severity prediction. The accuracy of the scoring system was measured by the area under the receiver operating characteristic curve. Results A total of 516 patients with mild (n=436) or moderately severe and severe (n=80) AP were analyzed. CART analysis identified the cutoff values: creatinine (CR) (1.15 mg/dL), white blood cells (WBC) (10.5 × 109/L), procalcitonin (PCT) (0.155 ng/mL), and systemic inflammatory response system (SIRS). The prediction model was built with a multivariable logistic regression analysis, which identified CR, WBC, PCT, and SIRS as the main predictors of severity. When CR and only one other predictor value (WBC, PCT, or SIRS) met thresholds, then the probability of predicting SAP was >30%. The probability of predicting SAP was 72% (95%CI: 0.59-0.82) if all four of the main predictors were greater than the cutoff values. Conclusions Baseline laboratory cutoff values were identified and a logistic regression-based prognostic model was developed to identify patients treated with a standardized EMM who were at risk for SAP.

Prediction of outcome using CD14++CD16-, CD14++CD16+ and CD14+CD16++ monocyte subpopulations in patients with complicated intra-abdominal infections

There is still no study investigating the prognostic performance of CD14++CD16-, CD14++CD16+ and CD14+CD16++ monocyte subpopulations in complicated intra-abdominal infections (cIAIs); therefore, we aimed to evaluate the association between monocyte subtypes and outcome in such patients. A single-center prospective study was conducted at a University Hospital Stara Zagora between November 2018 and August 2021. Preoperatively and on the 3rd postoperative day (POD), we measured the levels of CD14++CD16-, CD14++CD16+ and CD14+CD16++ monocytes in peripheral blood using flow cytometry in 62 patients with cIAIs and 31 healthy controls. Nine of the 62 patients died during hospitalization. Survivors had higher pre-surgery percentages of CD14++CD16- classical monocytes and higher percentage of these cells predicted favorable outcome in ROC analysis (AUROC = 0.781, p = 0.008). The CD14++CD16+ intermediate monocyte percentages were higher in non-survivors both pre- and postoperatively but only the higher preoperative values predicted a lethal outcome (AUROC = 0.722, p = 0.035). For CD14+CD16++ non-classical monocytes, non-survivors had lower percentages on day 3 post-surgery and low percentage was predictive of lethal outcome (AUROC = 0.752, p = 0.046). Perioperative levels of monocyte subpopulations in peripheral blood show a great potential for prognostication of outcome in patients with cIAIs.

Source control in emergency general surgery: WSES, GAIS, SIS-E, SIS-A guidelines

Intra-abdominal infections (IAI) are among the most common global healthcare challenges and they are usually precipitated by disruption to the gastrointestinal (GI) tract. Their successful management typically requires intensive resource utilization, and despite the best therapies, morbidity and mortality remain high. One of the main issues required to appropriately treat IAI that differs from the other etiologies of sepsis is the frequent requirement to provide physical source control. Fortunately, dramatic advances have been made in this aspect of treatment. Historically, source control was left to surgeons only. With new technologies non-surgical less invasive interventional procedures have been introduced. Alternatively, in addition to formal surgery open abdomen techniques have long been proposed as aiding source control in severe intra-abdominal sepsis. It is ironic that while a lack or even delay regarding source control clearly associates with death, it is a concept that remains poorly described. For example, no conclusive definition of source control technique or even adequacy has been universally accepted. Practically, source control involves a complex definition encompassing several factors including the causative event, source of infection bacteria, local bacterial flora, patient condition, and his/her eventual comorbidities. With greater understanding of the systemic pathobiology of sepsis and the profound implications of the human microbiome, adequate source control is no longer only a surgical issue but one that requires a multidisciplinary, multimodality approach. Thus, while any breach in the GI tract must be controlled, source control should also attempt to control the generation and propagation of the systemic biomediators and dysbiotic influences on the microbiome that perpetuate multi-system organ failure and death. Given these increased complexities, the present paper represents the current opinions and recommendations for future research of the World Society of Emergency Surgery, of the Global Alliance for Infections in Surgery of Surgical Infection Society Europe and Surgical Infection Society America regarding the concepts and operational adequacy of source control in intra-abdominal infections.

Practical Management of Adult Ultra-Rare Primary Retroperitoneal Soft Tissue Sarcoma: A Focus on Perivascular Epithelioid Tumours and Extraosseous Ewing Sarcoma

With the exception of well-differentiated liposarcoma, dedifferentiated liposarcoma, leiomyosarcoma, solitary fibrous tumour, malignant peripheral nerve sheath tumour, and undifferentiated pleomorphic sarcoma, the majority of the ≈70 histologic subtypes of retroperitoneal sarcoma are defined as 'ultra-rare' sarcomas, with an incidence of ≤1-5/1,000,000 persons/year. For most of these ultra-rare RPS subtypes, diagnosis and treatment follows international guidelines for the management of more common RPS histologies, with en bloc surgical resection as the mainstay of curative treatment, and enrolment in clinical trials where possible. Because the treatment of RPS is heavily driven by histology, the surgeon must be familiar with specific issues related to the diagnosis and management of ultra-rare sarcoma subtypes. Expert radiological and surgeon reviews are required to differentiate similarly presenting tumours where surgery can be avoided (e.g., angiomyolipoma), or where upfront systemic therapy is indicated (e.g., extraosseous Ewing's sarcoma). Thus, the management of all retroperitoneal sarcomas should occur at a sarcoma referral centre, with a multidisciplinary team of experts dedicated to the surgical and medical management of these rare tumours. In this focused review, we highlight how diagnosis and management of the ultra-rare primary RPS histologies of malignant perivascular epithelioid cell tumour (PEComa), extraosseous Ewing sarcoma (EES), extraosseous osteosarcoma (EOS), and rhabdomyosarcoma (RMS) critically diverge from the management of more common RPS subtypes.

The unrestricted global effort to complete the COOL trial

BACKGROUND

Severe complicated intra-abdominal sepsis (SCIAS) has an increasing incidence with mortality rates over 80% in some settings. Mortality typically results from disruption of the gastrointestinal tract, progressive and self-perpetuating bio-mediator generation, systemic inflammation, and multiple organ failure. A further therapeutic option may be open abdomen (OA) management with negative peritoneal pressure therapy (NPPT) to remove inflammatory ascites and attenuate the systemic damage from SCIAS, although there are definite risks of leaving the abdomen open whenever it might possibly be closed. This potential therapeutic paradigm is the rationale being assessed in the Closed Or Open after Laparotomy (COOL trial) ( https://clinicaltrials.gov/ct2/show/NCT03163095 ). Initially, the COOL trial received Industry sponsorship; however, this funding mandated the use of a specific trademarked and expensive NPPT device in half of the patients allocated to the intervention (open) arm. In August 2022, the 3 M/Acelity Corporation without consultation but within the terms of the contract canceled the financial support of the trial. Although creating financial difficulty, there is now no restriction on specific NPPT devices and removing a cost-prohibitive intervention creates an opportunity to expand the COOL trial to a truly global basis. This document describes the evolution of the COOL trial, with a focus on future opportunities for global growth of the study.

METHODS

The COOL trial is the largest prospective randomized controlled trial examining the random allocation of SCIAS patients intra-operatively to either formal closure of the fascia or the use of the OA with an application of an NPPT dressing. Patients are eligible if they have free uncontained intraperitoneal contamination and physiologic derangements exemplified by septic shock OR severely adverse predicted clinical outcomes. The primary outcome is intended to definitively inform global practice by conclusively evaluating 90-day survival. Initial recruitment has been lower than hoped but satisfactory, and the COOL steering committee and trial investigators intend with increased global support to continue enrollment until recruitment ensures a definitive answer.

DISCUSSION

OA is mandated in many cases of SCIAS such as the risk of abdominal compartment syndrome associated with closure, or a planned second look as for example part of "damage control"; however, improved source control (locally and systemically) is the most uncertain indication for an OA. The COOL trial seeks to expand potential sites and proceed with the evaluation of NPPT agnostic to device, to properly examine the hypothesis that this treatment attenuates systemic damage and improves survival. This approach will not affect internal validity and should improve the external validity of any observed results of the intervention.

TRIAL REGISTRATION

National Institutes of Health ( https://clinicaltrials.gov/ct2/show/NCT03163095 ).

The unrestricted global effort to complete the COOL trial

BACKGROUND

Severe complicated intra-abdominal sepsis (SCIAS) has an increasing incidence with mortality rates over 80% in some settings. Mortality typically results from disruption of the gastrointestinal tract, progressive and self-perpetuating bio-mediator generation, systemic inflammation, and multiple organ failure. A further therapeutic option may be open abdomen (OA) management with negative peritoneal pressure therapy (NPPT) to remove inflammatory ascites and attenuate the systemic damage from SCIAS, although there are definite risks of leaving the abdomen open whenever it might possibly be closed. This potential therapeutic paradigm is the rationale being assessed in the Closed Or Open after Laparotomy (COOL trial) ( https://clinicaltrials.gov/ct2/show/NCT03163095 ). Initially, the COOL trial received Industry sponsorship; however, this funding mandated the use of a specific trademarked and expensive NPPT device in half of the patients allocated to the intervention (open) arm. In August 2022, the 3 M/Acelity Corporation without consultation but within the terms of the contract canceled the financial support of the trial. Although creating financial difficulty, there is now no restriction on specific NPPT devices and removing a cost-prohibitive intervention creates an opportunity to expand the COOL trial to a truly global basis. This document describes the evolution of the COOL trial, with a focus on future opportunities for global growth of the study.

METHODS

The COOL trial is the largest prospective randomized controlled trial examining the random allocation of SCIAS patients intra-operatively to either formal closure of the fascia or the use of the OA with an application of an NPPT dressing. Patients are eligible if they have free uncontained intraperitoneal contamination and physiologic derangements exemplified by septic shock OR severely adverse predicted clinical outcomes. The primary outcome is intended to definitively inform global practice by conclusively evaluating 90-day survival. Initial recruitment has been lower than hoped but satisfactory, and the COOL steering committee and trial investigators intend with increased global support to continue enrollment until recruitment ensures a definitive answer.

DISCUSSION

OA is mandated in many cases of SCIAS such as the risk of abdominal compartment syndrome associated with closure, or a planned second look as for example part of "damage control"; however, improved source control (locally and systemically) is the most uncertain indication for an OA. The COOL trial seeks to expand potential sites and proceed with the evaluation of NPPT agnostic to device, to properly examine the hypothesis that this treatment attenuates systemic damage and improves survival. This approach will not affect internal validity and should improve the external validity of any observed results of the intervention.

TRIAL REGISTRATION

National Institutes of Health ( https://clinicaltrials.gov/ct2/show/NCT03163095 ).

The Impact of Facial Personal Protective Equipment on Speech Intensity

IMPORTANCE

Facial personal protective equipment (FPPE) filters small particles in the operating room (OR) but also affects speech production, diminishing the effective transfer of information among OR team members.

OBJECTIVE

The aim of the study is to assess the attenuating effects of different combinations of layered FPPE on speech intensity, including potential differences in the effect of talkers with varying backgrounds and speaking volumes.

STUDY DESIGN

We recruited 30 speakers from health and nonhealth occupations with English as either their first or second language. All participants spoke unmasked, at varying voice levels into a portable Zoom H4n device 12 inches from the microphone. These no-mask recordings were played from a Styrofoam head, fitted with 7 combinations of FPPE commonly worn in the COVID-19 era, with the attenuated signals assessed for digital average signal levels. We submitted these attenuation values to an omnibus mixed analysis of variance and performed a spectral analysis on signal attenuation stratified by typical speech frequency bands.

RESULTS

Signal attenuation was strongly determined by FPPE combination, regardless of talker sex, first language, and occupation ( P < 0.01, η 2p = 0.881). The effects of vocal output were also significant ( P < 0.01, η 2p = 0.881). Soft talkers experienced particularly high attenuation at frequency bands higher than 2,000 Hz. The signal of the softest talkers, when asked to speak loudly, was similar to the loud talkers' signal.

CONCLUSIONS

Layered FPPE in the OR protects the surgical team from small particle exposure but may increase communication failures. Our data can help OR staff choose FPPE and alter their vocal volume accordingly.

Effectiveness of intraoperative peritoneal lavage with saline in patient with intra-abdominal infections: a systematic review and meta-analysis

Background

Intraoperative peritoneal lavage (IOPL) with saline has been widely used in surgical practice. However, the effectiveness of IOPL with saline in patients with intra-abdominal infections (IAIs) remains controversial. This study aims to systematically review randomized controlled trials (RCTs) evaluating the effectiveness of IOPL in patients with IAIs.

Methods

The databases of PubMed, Embase, Web of Science, Cochrane library, CNKI, WanFang, and CBM databases were searched from inception to December 31, 2022. Random-effects models were used to calculate the risk ratio (RR), mean difference, and standardized mean difference. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) was used to rate the quality of the evidence.

Results

Ten RCTs with 1318 participants were included, of which eight studies on appendicitis and two studies on peritonitis. Moderate-quality evidence showed that the use of IOPL with saline was not associated with a reduced risk of mortality (0% vs. 1.1%; RR, 0.31 [95% CI, 0.02–6.39]), intra-abdominal abscess (12.3% vs. 11.8%; RR, 1.02 [95% CI, 0.70–1.48]; I2 = 24%), incisional surgical site infections (3.3% vs. 3.8%; RR, 0.72 [95% CI, 0.18–2.86]; I2 = 50%), postoperative complication (11.0% vs. 13.2%; RR, 0.74 [95% CI, 0.39–1.41]; I2 = 64%), reoperation (2.9% vs. 1.7%; RR,1.71 [95% CI, 0.74–3.93]; I2 = 0%) and readmission (5.2% vs. 6.6%; RR, 0.95 [95% CI, 0.48–1.87]; I2 = 7%) in patients with appendicitis when compared to non-IOPL. Low-quality evidence showed that the use of IOPL with saline was not associated with a reduced risk of mortality (22.7% vs. 23.3%; RR, 0.97 [95% CI, 0.45–2.09], I2 = 0%) and intra-abdominal abscess (5.1% vs. 5.0%; RR, 1.05 [95% CI, 0.16–6.98], I2 = 0%) in patients with peritonitis when compared to non-IOPL.

Conclusion

IOPL with saline use in patients with appendicitis was not associated with significantly decreased risk of mortality, intra-abdominal abscess, incisional surgical site infection, postoperative complication, reoperation, and readmission compared with non-IOPL. These findings do not support the routine use of IOPL with saline in patients with appendicitis. The benefits of IOPL for IAI caused by other types of abdominal infections need to be investigated.