Structural or functional abnormality of sphincter of Oddi: an important factor for the recurrence of choledocholithiasis after endoscopic treatment

A high recurrence rate is undesirable after treatment of common bile duct (CBD) stones. A major risk factor identified for recurrence is that invasive techniques, including surgical or endoscopic treatments, will impair the biliary tract system either by direct incision of the CBD or by cutting or dilating the ampulla of Vater. During endoscopic treatment, two main assisted methods for lithotomy, sphincterotomy and papillary balloon dilation, can result in different degrees of damage to the structure and function of the sphincter of Oddi (SO), contributing to slowing of biliary excretion, cholestasis, biliary bacterial infection, and promotion of bile duct stone recurrence. In this review, the relationship between endoscopic lithotomy and structural impairment or functional abnormality of the SO will be summarized, and their relationship with the recurrence of CBD stones will also be analyzed. Further improvement of these endoscopic methods or exploration of some novel methods, such as endoscopic endoclip papilloplasty, temporary insertion of a self-expandable metal stent, and combined application of peroral cholangioscopy, may aid in providing more appropriate treatment for patients with choledocholithiasis, repair or protect the function and structure of SO, reduce or prevent the recurrence of bile duct stones, and improve patient outcomes.

Hepaticojejunostomy and long-term interventional treatment for recurrent biliary stricture after proximal bile duct injury: A case report

BACKGROUND

Proximal bile duct injury (BDI), which often occurs after laparoscopic cholecystectomy (LC), can lead to complex biliary stricture and recurrent cholangitis. This case report presented a 39-year-old woman who experienced proximal BDI during LC in 2017, leading to multiple episodes of cholangitis and subsequent hepaticojejunostomy in 2018. Despite these interventions, persistent biliary complications necessitated repeated hospital admissions and antibiotic treatment. Imaging studies revealed persistent stricture at the site of hepaticojejunostomy, prompting a series of percutaneous procedures, including balloon dilatation and biliary drainage. In August 2024, she underwent biodegradable biliary stenting, which significantly improved her condition. Subsequently, she remained clinically stable for 5 months without further episodes of cholangitis and had improved liver function tests. This case highlighted the complexities of managing postinjury biliary stricture, underscored the potential of biodegradable stents as an effective treatment option, and emphasized the need for a multidisciplinary approach in managing such complications. Long-term follow-up is essential for monitoring treatment effectiveness and preventing recurrence.

CASE SUMMARY

A 39-year-old female had a routine LC in 2017. The patient sustained a proximal BDI during the surgery. In the months that followed, recurrent bouts of cholangitis occurred. A hepaticojejunostomy biliary reconstruction was performed in 2018. However, hepatic cholangitis persisted. In 2021 and 2022, MRCP scans revealed biliary stasis, duct dilation, and a stricture at the hepaticojejunostomy site. A subsequent percutaneous transhepatic cholangiography (PTC) confirmed these findings and led to drain placement. The treatment included internal and external biliary drain placements, repeated balloon dilations of the stricture, percutaneous transhepatic cholangioscopy to extract intrahepatic lithiasis, and insertion of a biodegradable biliary stent. Since the first PTC intervention, there have been no hospital admissions for cholangitis. Liver function tests showed improvement, and for five months following the biodegradable stenting, the condition remained stable. Long-term surveillance with regular imaging and blood work has been emphasized. The final diagnosis is recurrent biliary stricture secondary to proximal BDI. Treatment, including hepaticojejunostomy, repeated PTC with balloon dilation, and biodegradable biliary stenting, has led to complete drainage of the biliary system. Ongoing follow-up remains crucial for monitoring the patient's progress and maintaining their health.

CONCLUSION

This case demonstrated how strictures and recurrent cholangitis complicate the management of BDI after LC. A customized and multidisciplinary approach to control chronic biliary disease was proven effective, as shown by the patient’s good outcome. This was achieved by integrating balloon dilatation sessions, biliary drainage, stone clearing, and biodegradable stent placement. Long-term follow-up and continued monitoring remain essential to ensure patient stability and prevent further complications.

Long-term outcomes of post-transplant biliary anastomotic strictures: Endoscopic therapy with plastic and metal stents

BACKGROUND

Biliary anastomotic stricture (BAS) occurs in approximately 14%-20% of patients post-orthotopic liver transplantation (post-OLT). Endoscopic retrograde cholangiopancreatography (ERCP) using multiple plastic stents (MPSs) or fully covered self-expandable metal stents (cSEMSs) represent the standard treatment for BAS post-OLT. Recently, cSEMSs have emerged as the primary option for managing BAS post-OLT.

AIM

To compare the resolution and recurrence of BAS rates in these patients.

METHODS

This retrospective cohort study was conducted in a single tertiary care center (Hospital Israelita Albert Einstein, São Paulo, Brazil). We reported the results of endoscopic therapy in patients with post-OLT BAS between 2012 and 2022. Patients were stratified into two groups according to therapy: (1) MPSs; and (2) cSEMSs. Primary endpoints were to compare stricture resolution and recurrence among the groups. The secondary endpoint was to identify predictive factors for stricture recurrence.

RESULTS

A total of 104 patients were included. Overall stricture resolution was 101/104 (97.1%). Stricture resolution was achieved in 83/84 patients (99%) in the cSEMS group and 18/20 patients (90%) in the MPS group (P = 0.094). Failure occurred in 3/104 patients (2.8%). Stricture recurrence occurred in 9/104 patients (8.7%). Kaplan-Meier analysis showed there was no difference in recurrence-free time among the groups (P = 0.201). A multivariate analysis identified the number of ERCP procedures (hazard ratio = 1.4; 95% confidence interval: 1.194-1.619; P < 0.001] and complications (hazard ratio = 2.8; 95% confidence interval: 1.008-7.724; P = 0.048) as predictors of stricture recurrence.

CONCLUSION

cSEMSs and MPSs were effective and comparable regarding BAS post-OLT resolution and recurrence. The number of ERCP procedures and complications were predictors of stricture recurrence.

Does pediatric trauma center designation matter for children in shock from gunshot wounds? A Trauma Quality Improvement Program analysis

BACKGROUND

Recent studies have demonstrated improved outcomes for severely injured pediatric trauma patients treated at pediatric trauma centers (PTCs). Nonetheless, specific injury patterns requiring immediate lifesaving intervention may offset the recognized benefits of PTC over adult trauma centers (ATCs). This study aims to compare the clinical outcomes of hypotensive pediatric trauma patients with gunshot wounds (GSWs), based on trauma center type. We hypothesize that outcomes are equivalent for this clinical scenario.

METHODS

The 2013-2021 Trauma Quality Improvement Program data set was used to identify all hypotensive pediatric patients (15 years or younger) with GSWs. Hypotension was defined per Pediatric Advanced Life Support Guidelines. Patients with an Abbreviated Injury Scale score of 6 in any region and transferred patients were excluded. In order to identify the association between PTC verification status and outcomes, Poisson regression models with robust standard errors were used.

RESULTS

A total of 687 patients met the criteria for analysis, and 236 (34%) cases were treated at PTCs. Pediatric trauma center patients were slightly younger (lower quartile, 10 vs. 12 years old; p = 0.037). There was no significant difference in Injury Severity Score or crude mortality rates (68.1% vs. 70.8%, p = 0.524). After adjusting for confounders, Poisson regression showed no reduction in in-hospital mortality, complications, failure to rescue, intensive care unit admission, or mechanical ventilation rates at PTCs compared with ATCs.

CONCLUSION

Gunshot wounds in children pose unique clinical challenges. Majority of cases are cared for at ATCs. Analysis of best available data did not demonstrate a benefit to managing these patients at a PTC. Conversely, ATCs were not superior, despite managing this scenario in both adults and children more often. These findings underscore the importance of ATCs in the care of this particular injury pattern and call attention to the recent pediatric readiness requirements for American College of Surgeons (ACS)-verified trauma centers to treat pediatric firearm injuries at both PTCs and ATC.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

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.

Predictive variables for intraoperative blood loss and surgical time in resection of malignant soft tissue tumors without reconstruction

BACKGROUND

Procedural techniques such as dissection and separation of blood vessels or nerves from the tumor for preserving limbs and functions involves high surgical difficulty. We hypothesized the relation of vessel and/or nerve preservation to surgical time and blood loss, accurately reflecting surgical difficulty. In this study, we elucidated the variables affecting surgical time and intraoperative bleeding in patients with malignant soft tissue tumors who did not undergo any reconstruction after tumor resection.

METHODS

We included 153 patients with malignant oft tissue tumors in the trunk (n = 72), thigh (n = 68), and upper arm (n = 13) at nine institutions. We analyzed the possible predictive variables affecting surgical time and intraoperative bleeding.

RESULTS

Overall, the study included 153 patients (85 men and 68 women) with a mean age of 65 years. The tumors were primary soft tissue sarcoma (STS) (n = 114), local recurrent STS (n = 25), and soft tissue metastasis (n = 14). The median number of participating surgeons was three. The mean and median surgical time were 144.6 and 123 min, respectively. The mean and median intraoperative bleeding were 157.1 and 55 mL, respectively. Tumor size, depth, dissection and separation of blood vessels from the tumor, dissection and separation of nerve from the tumor, and the number of participating surgeons were significantly related to the surgical time and intraoperative bleeding.

CONCLUSIONS

The procedure of dissection and separation of blood vessels and nerves from the tumor were related to surgical time and intraoperative bleeding in patients with malignant soft tissue tumors, especially large and deep tumors.

Pancreaticoduodenectomy in a patient with severe portal hypertension: the role of preoperative TIPS

The complication rate for Pancreaticoduodenectomy (PD) is 40-50% in most published series and mortality can raise up to 4-5% even in high-volume centers. Severe portal hypertension secondary to liver disease is associated to high perioperative mortality and therefore is considered a contraindication for PD. No standardized management exists for surgically resectable patients with periampullary cancer and severe portal hypertension. The aim of this case study is to analyse the treatment alternatives in patients with periampullary cancer and severe portal hypertension and focus into the surgical treatment of these patients. We present the case of a 67 year-old patient case with a resectable ampullary cancer and portal hypertension managed with Preoperative Transjugular Intrahepatic Portosystemic Shunt (TIPS) to allow a PD. We present a literature review on the use of preoperative TIPS in patients who are candidates to PD. Neoadjuvant TIPS can be safely used in selected patients with severe portal hypertension who need a PD.

Exploring colorectal cancer patients' diagnostic pathways and general practitioners' assessment of the diagnostic processes: a Danish survey study

INTRODUCTION

Colorectal cancer (CRC) is among the most common cancers and the prognosis of CRC is highly dependent on stage at diagnosis. Although many cases are diagnosed swiftly, there is still room for improvement.

AIM

We aimed to explore CRC diagnostic pathways, encompassing (1) place of initial contact; (2) associations with symptom presentations, sex, and age with events in the diagnostic process and initial referrals and (3) the general practitioner's (GP's) evaluation of the diagnostic processes.

METHODS

All GPs in North-, Central-, and Southern Denmark were invited to fill in questionnaires for their listed patients diagnosed with cancer during the past two years.

RESULTS

Among 1,032 recorded CRC patients, 65% had their initial contact in general practice, 5% within the out-of hours service, 10% in the hospital, and 20% were diagnosed based on screening. A total of 27% of CRC patients over 40 who initially presented in general practice were treated or referred on suspicion of another disease first, and 9% were reported to have had hesitated in seeking medical attention. Some 37% presented solely non-specific symptoms, increasing the odds of the GP advising watchful waiting (OR 2.48; 95% CI 1.06-5.81), treating or referring on the suspicion of another illness first (OR 2.57; 95% CI 1.76-3.75), wait due to normal findings (OR 2.11; 95% CI 1.16-3.85), or referring to diagnostic imaging (OR 3.07; 95% CI 1.63-5.79). The GPs assessed nearly one fifth of the diagnostic processes as poor.

CONCLUSION

Most CRC patients are diagnosed with initial presentation in general practice. Having non-specific symptoms is common and challenges timely diagnosis.

From the operating room: Surgeons' views on difficult laparoscopic cholecystectomies

Backgrounds/Aims

Assessing surgical difficulty in laparoscopic cholecystectomy (LC) is challenging due to variations in surgeon proficiency and institutional protocols. This study evaluates surgeons' perspectives on procedural difficulty and examines how intraoperative findings and preoperative imaging contribute to refining difficulty assessment criteria.

Methods

A cross-sectional survey was conducted among 50 laparoscopic surgeons in India, providing insights into tolerances for surgical duration and blood loss, reasons for conversion, and predictors of complexity. Responses were analyzed using SPSS, with statistical significance set at p < 0.05.

Results

Among surveyed surgeons, 82.0% were male, and 78.0% worked in private institutions and 52.0% had performed over 1,000 LCs. Conversion to open surgery was primarily influenced by significant blood loss (68.0%) and biliary injury (94.0%). While 38.0% preferred surgeries under 60 minutes, 26.0% imposed no time constraints. Key intraoperative challenges included dense adhesions, cholecysto-enteric fistulas, and fibrosis. Less experienced surgeons reported greater challenges with scarring adhesions and anatomical variations, but no significant differences were found for other factors like edematous or necrotic changes. Preoperative imaging was considered essential by most surgeons.

Conclusions

This study underscores the limited reliability of traditional parameters for assessing difficulty in LC. Surgeons highlighted the importance of objective intraoperative findings and preoperative imaging in predicting surgical challenges. Factors such as adhesions, fibrosis, and anatomical variations significantly impact LC difficulty, with decisions regarding conversion to open surgery largely driven by individual judgment rather than experience. Standardized grading systems incorporating these factors could improve surgical planning, reduce complications, and enhance patient outcomes.

Stent placement can achieve same prognosis as endoscopic nasobiliary drainage in treatment of bile leakage after liver transplantation

BACKGROUND

Both stent placement and endoscopic nasobiliary drainage (ENBD) are commonly used for treating bile leakage following liver transplantation. However, little research has compared the advantages of both methods.

AIM

To compare the prognosis of stent placement and ENBD in treating bile leakage following liver transplantation.

METHODS

We retrospectively collected data for patients with bile leakage after liver transplantation in our center. The efficiency and prognosis were compared between the stent placement and ENBD groups.

RESULTS

We retrospectively collected data from 50 patients diagnosed with bile leakage within 1 month after liver transplantation. Forty patients underwent ENBD and nine received stent placement. Baseline patient characteristics, except white blood cell count, total bilirubin and direct bilirubin levels, were comparable between the two groups. Additionally, there was no significant difference in the rates of reconveyance or postoperative biliary stricture.

CONCLUSION

Stent placement and ENBD are recommended for treating bile leakage after liver transplantation, with similar efficacy and prognosis.

Development of an evaluation framework for robotic total mesorectal excision videos: a review and comparison of medical professional and public video resources

PURPOSE

This study aims to assess the quality of educational surgical videos for robotic total mesorectal excision (TME), across widely used open-source platforms, using a newly designed quality assessment checklist.

METHODS

The checklist was developed by using existing society guidelines, such as the European Academy of Robotic Colorectal Surgery, comprising four key sections: (i) usability of the platform, (ii) video component, (iii) intraoperative techniques and (iv) other information (including case presentation and outcomes). Videos were identified using the search terms 'Robotic TME' from surgical education platforms (WebSurg, C-SATS and Touch Surgery) and YouTube, between January 2016 and July 2024. All videos displaying robotic TME were reviewed and scored using the quality assessment tool (/12), and the videos across the platforms were subsequently compared.

RESULTS

A total of 113 videos were scored using the checklist: 63 surgical education platform (10 WebSurg and 53 C-SATS) and 50 YouTube videos. The total median checklist score achieved by WebSurg (9 [IQR 8-9] and YouTube videos (8 [IQR 7-10]) was significantly higher than CSAT-S videos (4 [IQR 4-5]; p < 0.001). The usability of platform scores for YouTube was significantly higher than WebSurg and C-SATS videos (p < 0.001). Scores for video components, intraoperative techniques and other information were higher across WebSurg and YouTube videos when compared to C-SATS (p < 0.001); however, there was no significant difference between WebSurg and YouTube for each domain.

CONCLUSION

The overall educational quality of online robotic TME videos was found to be generally heterogeneous, with WebSurg and YouTube videos demonstrating higher scores based on the checklist. A new quality assessment tool has been proposed for robotic TME videos, which has the potential to improve the reliability and value of published video research.

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.

Serum calcium-based interpretable machine learning model for predicting anastomotic leakage after rectal cancer resection: A multi-center study

BACKGROUND

Despite the promising prospects of utilizing artificial intelligence and machine learning (ML) for comprehensive disease analysis, few models constructed have been applied in clinical practice due to their complexity and the lack of reasonable explanations. In contrast to previous studies with small sample sizes and limited model interpretability, we developed a transparent eXtreme Gradient Boosting (XGBoost)-based model supported by multi-center data, using patients' basic information and clinical indicators to forecast the occurrence of anastomotic leakage (AL) after rectal cancer resection surgery. The model demonstrated robust predictive performance and identified clinically relevant thresholds, which may assist physicians in optimizing perioperative management.

AIM

To develop an interpretable ML model for accurately predicting the occurrence probability of AL after rectal cancer resection and define our clinical alert values for serum calcium ions.

METHODS

Patients who underwent anterior resection of the rectum for rectal carcinoma at the Department of Digestive Surgery, Xijing Hospital of Digestive Diseases, Air Force Medical University, and Shaanxi Provincial People's Hospital, were retrospectively collected from January 2011 to December 2021,. Ten ML models were integrated to analyze the data and develop the predictive models. Receiver operating characteristic (ROC) curves, calibration curve, decision curve analysis, accuracy, sensitivity, specificity, positive predictive value, negative predictive value, and F1 score were used to evaluate model performance. We employed the SHapley Additive exPlanations (SHAP) algorithm to explain the feature importance of the optimal model.

RESULTS

A total of ten features were integrated to construct the predictive model and identify the optimal model. XGBoost was considered the best-performing model with an area under the ROC curve (AUC) of 0.984 (95%confidence interval: 0.972-0.996) in the test set (accuracy: 0.925; sensitivity: 0.92; specificity: 0.927). Furthermore, the model achieved an AUC of 0.703 in external validation. The interpretable SHAP algorithm revealed that the serum calcium ion level was the crucial factor influencing the predictions of the model.

CONCLUSION

A superior predictive model, leveraging clinical data, has been crafted by employing the most effective XGBoost from a selection of ten algorithms. This model, by predicting the occurrence of AL in patients after rectal cancer resection, has identified the significant role of serum calcium ion levels, providing guidance for clinical practice. The integration of SHAP provides a clear interpretation of the model's predictions.

Clinical significance of robot-assisted laparoscopic surgery for rectal cancer: a retrospective propensity score matching analysis

PURPOSE

Conventional laparoscopic surgery (CLS) for rectal cancer may sometimes be difficult. Robot-assisted laparoscopic surgery (RALS) is expected to overcome these technical challenges of CLS and provide better short-term outcomes. However, previous randomized controlled trials indicated that the safety and feasibility of RALS compared to CLS remain controversial; therefore, we assessed the safety and feasibility of RALS for rectal cancer compared with CLS.

METHODS

This study retrospectively reviewed 702 patients who had undergone anterior resection by CLS or RALS for rectal malignancies from January 2009 to December 2023. Among the patients, 313 and 75 were included in the CLS and RALS groups, respectively. Short- and midterm outcomes of the two groups were compared after performing propensity score matching analysis (PSM) to adjust for patient and tumor characteristics.

RESULTS

A total of 140 and 70 patients in the CLS and RALS groups, respectively, were matched using PSM. The bleeding amount and C-reactive protein (CRP) levels on postoperative days 1 and 3 were significantly lower, the operation time was longer, and the postoperative hospital stay was significantly shorter in the RALS group than in the CLS group. The Kaplan-Meier curves for cause-specific survival, relapse-free survival, and the cumulative incidence of local recurrence demonstrated no difference between the two groups.

CONCLUSION

RALS for rectal cancer provided superior outcomes to CLS in terms of the bleeding amount, postoperative CRP levels, and postoperative hospital stay. The midterm oncological outcomes in RALS were comparable to those in CLS.

Postpancreatectomy acute pancreatitis in pancreaticoduodenectomy and distal pancreatectomy: a retrospective cohort study on risk factors and clinical outcomes

BACKGROUND

Postpancreatectomy acute pancreatitis (PPAP) is a severe complication that can occur following pancreaticoduodenectomy (PD) or distal pancreatectomy (DP). Specific studies focus on the difference of PPAP in PD and DP are lacking.

METHODS

Patients who underwent PD or DP between 2019 and 2024 were retrospectively reviewed. Perioperative parameters and outcomes were collected. PPAP was defined in accordance with the criteria established by the International Study Group for Pancreatic Surgery (ISGPS).

RESULTS

The study cohort comprised 1,017 patients undergoing pancreatic resection: 670 PD and 347 DP. Among PD cases, PPAP occurred in 142 patients (21.19%) and was significantly associated with a higher incidence of postoperative pancreatic fistula (POPF) (82.39% vs. 37.12%, P < 0.0001), particularly in cases of grade B and C POPF (P < 0.0001). In DP cases, PPAP occurred in 17.58% of patients. In PD cases, patients with PPAP experienced increased morbidity (P < 0.0001), including a higher incidence of POPF (91.8% vs. 65.38%, P < 0.0001) and grade B POPF (39.34% vs. 11.54%, P < 0.0001). Compared to patients who had PD, those who had DP experienced a lower incidence of postoperative hyperamylasemia (POH) (30.55% vs. 43.88%, P < 0.0001).

CONCLUSION

PPAP represents a significant postoperative complication following pancreatic resection. Current evidence suggests associations between PPAP and morbidities in PD and DP cases. Notably, PPAP following DP appears to correlate with less severe clinical consequences compared to PD-associated PPAP.

Improving care and equity in the American trauma system: past, present and future

Trauma care in the USA is fragmented, unequal, and millions of people lack adequate access to a trauma center. These inequities are the result of historic precedent, racial and socioeconomic discrimination, and the economics of trauma care. The fixed location of trauma centers may also fail to meet the needs of moving and changing populations. Further, the current methods of trauma center formation perpetuate existing inequity by leaving the pursuit of trauma center creation up to hospitals, resulting in verification and designation processes that are mostly reliant on financial capability rather than community need. This particularly impacts those who are socioeconomically vulnerable, as existing trauma centers may not be accessible to their communities and new centers may not seek to serve them. On the contrary, already well-resourced communities increasingly receive duplicative care. A thorough understanding of the interplay between trauma center designation, socioeconomic and geographic disparities in trauma care-and potential levers for change-is crucial in trauma systems planning for more equitable trauma care.

Effect of high-quality nursing care on postoperative complications and quality of life for patients undergoing common bile duct exploration

BACKGROUND

Complications following common bile duct exploration for managing gallstones or choledocholithiasis negatively impact patients' quality of life. Occasionally, high-quality nursing care is necessary to either improve the outcome or to avoid life-threatening consequences.

AIM

This study aimed to evaluate the effect of high-quality nursing care on postoperative complications and quality of life for patients who underwent common bile duct exploration.

PATIENTS AND METHOD

A quasi-experimental research design was utilized. The study was conducted in the Hepatobiliary Surgical unit at Al-Rajhi Liver Hospital and the general surgery department at Assiut University Hospital. A purposive sample of sixty adult patients, whose ages ranged from 20 to 65 years, who underwent common bile duct exploration were included in the study. Patients were randomly divided into two equal groups (study and control) 30 patients for each.

TOOLS

Tool (I): patient's assessment form, Tool (II): Postoperative complications evaluation record, and Tool (III): Abdominal surgery impact scale.

RESULTS

Wound infection and T -Tube problems demonstrated a statistically significant difference between the two groups on follow-up as it occurred in (36.7%, and 26.7%) of the control group compared to (6.7%, and 3.3%) of the study group. Also, there was a significant improvement in total mean scores of QoL among the study group as it increased from 54.4 ± 22.11 on pre-intervention to 77.8 ± 6.15 post (P.value 0.001**).

CONCLUSION

High-quality nursing care proved to be effective in reducing the incidence of postoperative complications and improving quality of life among the study group compared to the control group.

RECOMMENDATIONS

Nevertheless, high-quality nursing care is crucial and should serve as the basis for routine nursing care for patients undergoing common bile duct exploration.

Endoscopic Use of N-Butyl-2-Cyanoacrylate in Refractory Pancreatic Duct Leak and Cystic Duct Leak: Is It Really a Last Resort?

Background/Objectives: The management of refractory pancreatic duct (PD) and cystic duct leaks may represent an endoscopic challenge. Standard endoscopic therapy involves pancreatic/biliary sphincterotomy and stenting during endoscopic retrograde cholangiopancreatography (ERCP). After conservative (fasting, parenteral nutrition, and use of somatostatin analogs) or conventional endoscopic treatments fail, a surgical approach is usually required, leading to higher mortality due to several technical complications. Previous evidence of the endoscopic use of N-butyl-2-cyanoacylate (NBCA) for treating pancreaticobiliary leaks is reported, although the evidence is scarce. Methods: Six patients with pancreaticobiliary leaks (three IT pancreatic leaks and three Class A sec. Strasberg post-cholecystectomy biliary leaks) refractory to previous treatment were treated with the endoscopic topical application of NBCA. All our patients gave informed consent. The procedures were all performed between December 2017 and February 2025 at a tertiary referral center for biliopancreatic endoscopy. Results: Therapeutic success, as shown both endoscopically and radiologically, was 100%, and no procedural complication was reported. In one patient with biliary leak, standard cannulation of the cystic duct stump with the guidewire was unsuccessful, requiring a peroral cholangioscopy (SpyGlass System DSII) to directly visualize the leakage site, allowing a precise closure of the wall defect with NBCA. Conclusions: NBCA injection could represent a safe and effective endoscopic option in refractory PD of the tail of the pancreas and cystic duct leaks. Larger and further studies are necessary to confirm these results.

Surgical and oncological outcomes in transverse colon carcinoma: does tumor sublocation make a difference?

BACKGROUND

Transverse colon carcinomas are often treated as a single entity in medical literature, despite differences in embryology, anatomy, physiology, genetics, and surgical treatment. We hypothesized that tumor sublocation affects demographics, oncological, surgical and quality of life outcomes.

METHODS

A retrospective analysis of patients who underwent surgery for transverse colon carcinomas between 2000 and 2018 was conducted. Tumor localization was determined by operative, pathological and imaging reports, and procedures were defined by the extent of vascular resection.

RESULTS

The study included 273 patients aged 69 years (SD 12.3), of whom 44% were female. The BMI was 28.8 kg/m2 (SD 6.2), and 61% were ASA class 3. Carcinomas were in the proximal (22%), the mid (42%), and the distal transverse colon (36%). Mid-transverse carcinomas exhibited the highest prevalence among female patients (53% vs. 35% proximal vs. 39% distal, p < 0.03). Proximal transverse carcinomas presented with a higher proportion of pathological stage II than mid and distal transverse carcinomas (68.3% vs. proximal vs. 44.3% mid-vs. 49% distal, p = 0.006). On multivariate analysis, anemia was more likely in mid than proximal (p = 0.009) and distal (p = 0.002) transverse colon cancers. Obstruction occurred more often in proximal than mid (p = 0.003), and hematochezia in distal than in mid (p < 0.001) and proximal (p = 0.014) transverse colon carcinomas. The 30-day mortality and morbidity and 5-year overall and disease-free survival rates were similar between the tumor sublocations.

CONCLUSION

Sublocations of the transverse colon carcinomas affect the symptoms of patients. Tumor sublocation does not impact the intraoperative, postoperative, or oncological outcomes and quality of life.

Surgeons' prioritization of emergency abdominal surgery and its impact on postoperative outcomes

BACKGROUND

Emergency general abdominal surgery (EGS) is associated with high morbidity and mortality. Timely intervention and effective triage systems are crucial to improve outcomes. This study evaluates the impact of surgeons' prioritization and adherence to a triage protocol on postoperative outcomes.

METHODS

Single-center retrospective analysis of patients undergoing EGS at Bern University Hospital from 03/2015-12/2022. Patients were categorized into four triage levels based on the urgency of surgery (level 1 within 1 h, level 2 within 6 h, level 3 within 12 h, and level 4 within 24 h). "Protocol violation" was defined in cases where the delay to surgery exceeded the triage level. Primary endpoint included complications according to Clavien-Dindo classification in patients with versus without "protocol violation".

RESULTS

A total of 1'947 patients were included. The mean overall delay from admission to surgery was in triage level 1 69.5 ± 127.5 min., in triage level 2 206.5 ± 178.0 min., in triage level 3 350.6 ± 282.6 min. and in triage level 4 693.4 ± 354.8 min.. Triage levels 1 and 2 correlated significantly with increased complication rates compared to triage level 3 and 4 (64% vs. 43% vs. 11% vs. 10%, p < 0.001). Similarly, mortality rates decreased significantly from triage level 1 through 4 (26% vs. 7% vs. 1% vs. 2%, p < 0.001). "Protocol violation" occurred in a total of 13% of patients with decreasing proportions from triage level 1 to 4 (37% vs. 13% vs. 12% vs. 0%, p < 0.001). "Protocol violation" did not statistically affect overall morbidity and mortality in most of the diagnoses. In patients with intestinal ischemia or abdominal abscesses, mortality was significantly higher in patients with "protocol violation". In contrast, in patients suffering from acute inguinal hernias or gastrointestinal bleeding, morbidity was significantly higher in patients without "protocol violation". A significantly shorter hospital length of stay (HLOS) was shown in triage level 2 and triage level 3 when patients were treated without "protocol violation" (8.6 ± 10.0 days vs. 13.5 ± 17.3 days, p = 0.022 and 5.3 ± 8.7 days vs. 6.4 ± 6.7 days, p < 0.001, respectively).

CONCLUSION

Surgeons' triage levels significantly correlated with mortality and morbidity. Moreover, "protocol violation" resulted in higher mortality in patients suffering from mesenteric ischemia and abdominal abscesses and resulted in prolonged HLOS. Further incorporating objective parameters into triage decisions in the EGS population may enhance prioritization accuracy, patient safety and resource utilization.

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.

Lived experience of student responders with leadership in a mass casualty simulation

BACKGROUND

Mass casualty situations create leadership opportunities for nurses and emergency responders, yet there is a notable gap in current literature regarding the benefits of interdisciplinary training on student leadership development.

PURPOSE

The purpose of this study was to explore the lived experience of leadership emergence within undergraduate nursing and emergency medical technician students in the context of a mass casualty incident simulation.

METHODS

Retrospective analysis of post-drill survey responses was conducted with 357 nursing and 99 EMT students during an MCIS. The study design was a qualitative, interpretive phenomenological study using the hermeneutic circle for analysis.

RESULTS

Three main themes emerged organically from the data: 1) A Good Leader Knows and Acts, 2) Leaders Inspire and Help, and 3) Respect and Trust Each Other.

CONCLUSION

This study contributes to current experiential learning and leadership education literature. An MCIS experience can be a valuable tool to cultivate the next generation of leaders, particularly in nursing and emergency responders.

The COMPARE Study: Comparing Perioperative Outcomes of Oncologic Minimally Invasive Laparoscopic, da Vinci Robotic, and Open Procedures: A Systematic Review and Meta-analysis of the Evidence

OBJECTIVE

To assess 30-day outcomes of da Vinci robotic-assisted (dV-RAS) versus laparoscopic or video-assisted thoracoscopic​​​​​ (lap/VATS) or open oncologic surgery.

BACKGROUND

Complex procedures in deep/narrow spaces especially benefit from dV-RAS. Prior procedure-specific comparisons are not generalizable.

METHODS

PubMed, Scopus, and EMBASE were systematically searched (latest: November 17, 2023) following Preferred Reporting Items for Systematic Reviews and Meta-Analyses and PROSPERO (Reg#CRD42023466759). Randomized, prospective, and database studies were pooled as odds ratios (ORs) or mean differences (MDs) in R using fixed effects or random effects (heterogeneity significant). ROBINS-I/RoB 2 were used to assess bias.

RESULTS

Of 56,314 unique references over 12 years from 22 countries, 230 studies (34 randomized, 74 prospective, and 122 database) comparing dV-RAS to lap/VATS or open surgery across 7 procedures, 4 specialties, representing 1,194,559 dV-RAS; 1,095,936 lap/VATS and 1,625,320 open cases were included. Operative time for dV-RAS was longer than lap/VATS [MD: 17.73 minutes (9.80, 25.67), P < 0.01] and open surgery [MD: 40.92 minutes (28.83, 53.00), P < 0.01], whereas hospital stay was shorter [lap/VATS MD: -0.51 days (-0.64, -0.38), P < 0.01; open MD: -1.85 days (-2.09, -1.62), P < 0.01] and blood loss was less versus open [MD: -293.44 mL (-359.53, -227.35)]. There were fewer dV-RAS conversions [OR: 0.44 (0.40, 0.49), P < 0.01], transfusions [OR: 0.79 (0.72, 0.88), P < 0.01], postoperative complications [OR: 0.90 (0.84, 0.96), P < 0.01], readmissions [OR: 0.91 (0.83, 0.99), P = 0.04], and deaths [OR: 0.86 (0.81, 0.92), P < 0.01] versus lap/VATS, and fewer transfusions [OR: 0.25 (0.21, 0.30), P < 0.01], postoperative complications [OR: 0.56 (0.52, 0.61), P < 0.01], readmissions [OR: 0.71 (0.63, 0.81), P < 0.01], operations [OR: 0.89 (0.81, 0.97), P < 0.01], and deaths [OR: 0.54 (0.47, 0.63), P < 0.01] versus open surgery. Blood loss [MD:- 12.26 mL (-29.44, 4.91), P = 0.16] and operations [OR: 1.03 (0.95, 1.11), P = 0.48] were similar for dV-RAS and lap/VATS. There was significant heterogeneity.

CONCLUSIONS

Da Vinci-RAS confers benefits across oncological procedures and study designs. These results provide clinical evidence to multispecialty-care decision-makers considering dV-RAS.

Short-term outcomes of laparoscopic common bile duct exploration for choledocholithiasis in elderly patients: A comparative single-centre study

INTRODUCTION

Laparoscopic common bile duct exploration (LCBDE) is an alternative to endoscopic retrograde cholangiopancreatography (ERCP) for the treatment of choledocholithiasis. However, its use in elderly patients has been limited, often avoided due to concerns about associated morbidity. This study aims to evaluate the success rate and outcomes of LCBDE in elderly patients.

METHODS

A retrospective study was conducted on patients with a confirmed diagnosis of choledocholithiasis via intraoperative cholangiography who underwent LCBDE from January 2009 to December 2022. Demographic, clinical, intraoperative, and postoperative data were collected. Patients were divided into two groups: those aged ≥70 years and those aged <70 years. Additionally, a subgroup analysis was performed on patients aged ≥80 years.

RESULTS

A total of 330 patients were included (<70 years = 168; ≥70 years = 162). The success rate of LCBDE in patients aged ≥70 years was similar to that in patients aged <70 years (95.7% vs. 97%; p = 0.514). No statistically significant differences were found in intraoperative outcomes, short-term complications, or mortality between the two groups. These results were consistent in the subgroup analysis of patients aged ≥80 years (n = 67) compared with those aged <70 years.

CONCLUSION

LCBDE is a safe and effective procedure for patients aged ≥70 years and could be considered a first-line therapeutic option for this group.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Lactated Ringer's solution versus saline fluid resuscitation for reducing progression to moderate-to-severe acute pancreatitis: a systematic review and meta-analysis

BACKGROUND

Fluid resuscitation represents a pivotal early therapeutic intervention in the management of acute pancreatitis (AP), yet a consensus on the optimal fluid type remains elusive. The present study endeavors to elucidate the differential effects of lactated Ringer's solution (LR) and normal saline (NS) in the initial treatment of AP.

METHODS

A comprehensive literature search was conducted through the PubMed, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL) databases, spanning from inception until July 2024. The primary outcome of interest was the likelihood of developing moderate-to-severe AP.

RESULTS

This meta-analysis synthesized evidence from six randomized controlled trials (RCTs) and four observational studies, involving a total of 1500 AP patients. Patients were stratified into two groups based on the administered fluid: LR (n = 689) and NS (n = 811). Our findings revealed that, compared to the NS group, patients in the LR group demonstrated a significantly lower risk of moderate-to-severe AP (OR 0.48; 95%Cl 0.34 to 0.67; P < 0.001; I2  = 0%), a shorter hospital stay (MD = -0.74, 95% confidence interval [CI] -1.20 to -0.28, P = 0.001; I2  = 0%), and a reduced intensive care unit (ICU) admission rate [relative risk (RR) = 0.42, 95% CI 0.20-0.89, P = 0.02; I2  = 0%]. Moreover, the LR group also showed a lower incidence of local complications (RR = 0.58, 95% CI 0.34-0.98, P = 0.04). Conversely, no statistically significant differences were observed between the two groups in terms of mortality, organ failure rates, Fluid administered 24 h, systemic inflammatory response syndrome (SIRS).

CONCLUSIONS

Our analysis underscores the superior efficacy of LR solution in comparison to NS. It provides compelling evidence of LR's ability to significantly mitigate the onset of moderate to severe pancreatitis. Additionally, our findings reveal that LR is associated with a reduced need for ICU admissions, a lower incidence of local complications, and a shorter overall hospital stay, thereby offering a more favorable clinical outcome. However, no notable differences were discerned in other complications. Subgroup analyses further suggest LR's potential to curb pancreatic necrosis and other indices, albeit these findings necessitate corroboration through extensive experimentation.

Real-time ancillary diagnostics for intraoperative assessment of intestinal viability in horses-looking for answers across species

Clinical intestinal viability assessment is associated with significant limitations, and there is an undisputable need for ancillary diagnostics during colic surgery. Human and companion animal surgeons struggle with similar intraoperative issues, yet there is little exchange between specialists. Therefore, this narrative review aimed to create an overview of real-time ancillary diagnostics with the potential for intraoperative intestinal viability assessment in horses. Most real-time ancillary diagnostics can be classified as either tissue perfusion or oxygenation assessments. Intestinal perfusion may be quantified using dark field microscopy, laser Doppler flowmetry, or fluorescence angiography (FA). In particular, indocyanine green FA has gained popularity in human medicine and is increasingly employed to predict intestinal injury. Intestinal oxygen saturation can be measured by pulse oximetry or mixed tissue oximetry. The latter can be conducted using visible light or near-infrared spectrophotometry, and these measurements correlate with clinical outcomes in various species. Other real-time diagnostics include thermography and techniques currently under development, such as laser speckle flowgraphy or photoacoustic imaging. The modalities discussed are minimally invasive and may be used for intraoperative assessments of the intestine. However, limitations include the occurrence of artifacts and the subjective nature of some modalities. Techniques such as indocyanine green FA and tissue oximetry are already available in veterinary practice and have the potential for use during colic surgery. However, blinded clinical trials are lacking in all species, and more research is needed to determine the accuracy and cutoff values in equine-specific intestinal lesions.

Visual Endoscopic Retrograde Appendicitis Therapy Vs Antibiotic Therapy for Treatment of Uncomplicated Acute Appendicitis

INTRODUCTION

Visual endoscopic retrograde appendicitis therapy (V-ERAT) involves a single-use video scope, allowing for real-time visualization of the appendiceal lumen during the procedure to treat uncomplicated acute appendicitis (AA). This study aims to compare V-ERAT to antibiotic therapy in treating uncomplicated AA.

METHODS

This multicenter, retrospective cohort study was conducted at 9 hospitals in China from August 2021 to July 2023. Propensity score matching was performed to minimize selection bias. A total of 692 uncomplicated AA patients were included, with 188 undergoing V-ERAT and 504 receiving antibiotic therapy. The primary outcome was treatment success rate. The secondary outcomes included recurrent appendicitis rate, the appendectomy rate during the initial hospitalization, length of initial hospitalization, time to disease recurrence, and overall adverse events.

RESULTS

The treatment success rate did not differ between the V-ERAT and antibiotic groups (93.6%; 95% confidence interval [CI] 89.1%-96.7% vs 90.5%; 95% CI, 87.6%-92.9%) ( P = 0.225). However, V-ERAT demonstrated a significantly lower risk of appendicitis recurrence compared with antibiotic therapy during the follow-up (log-rank P < 0.001), with a hazard ratio of 0.14 (95% CI, 0.07-0.29, P < 0.001). V-ERAT was associated with a lower appendectomy rate during the initial hospitalization (4.3%; 95% CI, 1.9%-8.2% vs 9.5%; 95% CI, 7.1%-12.4%) ( P = 0.027), a shorter length of initial hospitalization (3 [interquartile range (IQR), 3-4] vs 4 [IQR, 4-6] days, P < 0.001), and a longer time to recurrence (269 [IQR, 210-318] vs 70 [IQR, 21-103] days, P < 0.001). The overall adverse event rates did not differ between the 2 groups (log-rank P = 0.064).

DISCUSSION

V-ERAT seems to be a safe and effective alternative to antibiotic therapy in treating uncomplicated AA, significantly reducing the risk of appendicitis recurrence.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Influence of surgical start time on the quality of surgery for middle and low rectal cancer: a post hoc analysis of the real trial

BACKGROUND

Surgical start time is considered to influence the quality of surgery due to surgeon fatigue. High-quality studies on middle and low rectal cancer are lacking. The analysis aims to find out the influence of surgical start time on the quality of surgery for middle and low rectal cancer, and whether robotic surgery could avoid the influence.

MATERIALS AND METHODS

This study was a post hoc analysis of the REAL (robotic vs. laparoscopic surgery for middle and low rectal cancer) study, a multicenter, randomized, controlled, unblinded, parallel group, superiority trial. This analysis included the modified intention-to-treat population of the REAL study, who were divided into Group I (the surgeon's first surgery of the day), Group II (the surgeon's second surgery of the day), and Group III (the surgeon's third and subsequent surgeries of the day) based on surgical information registered in the REAL study. The primary outcome was the percentage of patients with a positive circumferential resection margin. The second outcomes were the macroscopic completeness of resection the incidence of intraoperative complications and 30-day postoperative complications.

RESULTS

A total of 1171 patients from the REAL study were included and divided into three groups: 547 (46.7%) in Group I (the surgeon's first surgery), 420 (35.9%) in Group II (the surgeon's second surgery), and 204 (17.4%) in Group III (the surgeon's third and subsequent surgeries). There was a lower percentage of circumferential resection margin (CRM)-positive patients in Group I (3.9%) than in Group II (6.6%, unadjusted P = 0.069) and Group III (8.1%, unadjusted P = 0.027, adjusted P = 0.081). Group I also had fewer intraoperative complications (5.3%) than Group II (8.3%, unadjusted P = 0.060) and Group III (9.3%, unadjusted P = 0.046, adjusted P = 0.138). Macroscopic completeness of resection was not significantly different among the three groups (complete rate: Group I vs. Group II, 94.9% vs. 92.4%, unadjusted P = 0.254; Group I vs. Group III, 94.9% vs. 92.6%, unadjusted P = 0.334; Group II vs. Group III, 92.4% vs. 92.6%, unadjusted P = 0.488). The incidence of 30-day postoperative complications showed no significant difference among the three groups (Group I vs. Group II, 18.5% vs. 20.0%, unadjusted P = 0.547; Group I vs. Group III, 18.5% vs. 22.1%, unadjusted P = 0.268; Group II vs. Group III, 20.0% vs. 22.1%, unadjusted P = 0.551). The quality of robotic surgery was not significantly influenced by surgical start time. For laparoscopic surgery, Group I had a lower CRM positivity rate (4.3%) than Group II (9.4%, unadjusted P = 0.029, adjusted P = 0.087) and Group III (10.4%, unadjusted P = 0.031, adjusted P = 0.047).

CONCLUSION

According to this post hoc analysis of the REAL study, for middle and low rectal cancer surgery, surgical start time could influence surgical quality by affecting surgeon fatigue. Surgeries start later in a day bring worse quality compared to those early in a day. Robotic surgery could reduce this influence to some extent, while laparoscopic surgery is more susceptible.

Minimal Invasive Pancreatoduodenectomy: A Comprehensive Systematic Review and Metanalysis of Randomized Controlled Clinical Trials

BACKGROUND

The role of a minimally invasive approach (MI) in patients who underwent pancreatoduodenectomy (PD) remained unclear.

METHODS

A systematic search of randomized controlled trials was conducted. A random-effects meta-analysis was conducted, reporting risk ratio (RR) or mean difference (MD). The primary endpoints were the morbidity, mortality, and R1 rate. The secondary endpoints were clinically relevant postoperative pancreatic fistula (POPF), postpancreatectomy hemorrhage (PPH), delayed gastric emptying (DGE), biliary fistula, reoperation, length of stay (LOS), time to functional recovery (TFR), and readmission.

RESULTS

The meta-analysis includes seven studies and 1428 patients: 618 (46.5%) in the OPD arm and 711 (53.5%) in minimally invasive pancreaticoduodenectomy (MIPD). The mortality rate was 2.9% for MIPD and 2.6% for OPD (RR 1.11 [range 0.53-2.29]). The major morbidity rate was 29.4% for MIPD and 25.6% for OPD (RR 1.11 [range 0.53-2.29]). The R1 rate was 6.2% for MIPD and 7% for OPD (RR 0.80 [0.54-1.20]). The operative time, comprehensive complication index score, POPF, PPH, DGE, biliary fistula, reoperation, readmission, LOS, TFR, and harvested lymph nodes were similar. Greater than 25% of heterogeneity was observed for major morbidity, operative time, POPF, LOS, TFR, and harvested lymph nodes. No publication bias was registered.

CONCLUSIONS

Minimally invasive pancreaticoduodenectomy was not superior to OPD and provided marginal advantages in short-term results. Further efforts should be addressed to clarify the impact of learning curve in MIPD results and the economic sustainability of MIPD, particularly robotic approach.

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

ABSTRACT

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

Computational fluid dynamics for vascular assessment in hepatobiliopancreatic surgery: a pilot study and future perspectives

INTRODUCTION

In major hepatobiliopancreatic surgery, an accurate preoperative planning is essential. Postoperative impaired blood supply due to arterial disease or variants can cause postoperative complications. Computational fluid dynamics has previously been successful in revealing distinct features of haemodynamic disturbances. The purpose of our study is to describe the feasibility of a computational fluid dynamics model to predict hepatic artery flow and its variations following gastroduodenal (GDA) or common hepatic (CHA) artery ligation.

MATERIAL AND METHODS

This is a pilot study including 20 patients undergoing robotic pancreaticoduodenectomy at a single centre. Preoperative images and intraoperative vascular flows were used to the computational model. Three scenarios of the hepatic artery were analysed: (1) without any clamps, (2) clamped GDA and (3) clamped CHA. Patients 1 to 15 were used to develop the model, and patients 15 to 20 were used for model validation. Finally, the model was tested in 3 abnormal cases: celiac trunk stenosis (2) and replaced right hepatic artery (1).

RESULTS

The selected methodology proved to be reproducible, with the CFD model demonstrating 100% accuracy in predicting blood flow redistribution after gastroduodenal artery (GDA) clamping and 80% accuracy following common hepatic artery (CHA) clamping. The model accurately simulated reversed GDA flow in cases of celiac trunk stenosis and displayed independent flow distribution in patients with anatomical variations, even without prior specific model training.

CONCLUSION

The developed computational model accurately predicts flow variations in the proper hepatic artery in case of gastroduodenal artery and common hepatic artery clamping. Further studies are needed to validate this methodology.

Balancing Ethics and Innovation: Can Artificial Intelligence Safely Transform Emergency Surgery? A Narrative Perspective

Background: Artificial intelligence (AI) is increasingly shaping the landscape of emergency surgery by offering real-time decision support, enhancing diagnostic accuracy, and optimizing workflows. However, its implementation raises significant ethical concerns, particularly regarding accountability, transparency, patient autonomy, and bias. Objective: This perspective paper, grounded in a narrative review, explores the ethical dilemmas associated with AI in emergency surgery and proposes future directions for its responsible and equitable integration. Methods: A comprehensive narrative review was conducted using PubMed, Scopus, Web of Science, and Google Scholar, covering the literature published from January 2010 to December 2024. We focused on peer-reviewed articles discussing AI in surgical or emergency care and highlighting ethical, legal, or regulatory issues. A thematic analysis was used to synthesize the main ethical challenges. Results: Key ethical concerns identified include issues of accountability in AI-assisted decision-making, the "black box" effect and bias in algorithmic design, data privacy and protection, and the lack of global regulatory coherence. Thematic domains were developed around autonomy, beneficence, justice, transparency, and informed consent. Conclusions: Responsible AI implementation in emergency surgery requires transparent and explainable models, diverse and representative datasets, robust consent frameworks, and clear guidelines for liability and oversight. Interdisciplinary collaboration is essential to align technological innovation with patient-centered and ethically sound clinical practice.

Does transanal total mesorectal excision (taTME) result in better quality of life and functional outcomes than traditional TME does? A retrospective propensity score-adjusted cohort study

PURPOSE

The improved prognosis of rectal cancer through modern therapeutic approaches raises questions regarding quality of life (QoL) and functional outcomes. In this study, we compared post-transanal total mesorectal excision (taTME) short- and long-term QoL and functional outcomes with those after abdominal TME (abTME).

METHODS

Prospective data from patients who underwent elective taTME or abTME for stage I-III rectal cancer followed by anastomosis were retrospectively propensity score-adjusted. The primary endpoint, QoL, was assessed with the European Organization for Research and Treatment of Cancer core questionnaire (EORTC QLQ-C30). Functional outcomes were the secondary endpoints.

RESULTS

Among 494 patients during 2013-2022, 187 patients who underwent taTME and 62 patients who underwent abTME were included. QoL was worse after taTME at isolated time points: overall QoL (after 3 years: 72 vs. 82 points, p = 0.017) and QLQ-total (after 3 years: 81 vs. 87 points, p = 0.028; after 4 years: 82 vs. 89 points, p = 0.012). After propensity score matching, the between-group differences were still significant but smaller: overall QoL - 6 points, p = 0.021; QLQ-total - 5 points, p = 0.026.

CONCLUSION

The differences reported at isolated time points have questionable clinical relevance. Therefore, taTME and traditional abTME seem to have comparable long-term QoL and functional outcomes.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT06505863, https://clinicaltrials.gov/search?id=NCT06505863 .

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

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

Quality improvement program for the severely injured

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

Applicability and results of the versius surgical robotic system in colorectal surgery: a systematic review of the literature

Minimally invasive surgery has become the standard of care in colorectal surgery. However, the laparoscopic approach still presents technical challenges, especially when performing intracorporeal anastomosis or total mesorectal excision. Current literature underscores the potential of robotic-assisted surgery in overcoming these challenges. Among emerging robotic platforms, the Versius Surgical Robotic System, shows promises. However, its relatively recent introduction means there is a lack of data on its performances in colorectal surgery. This systematic review aimed to evaluate the current evidence on the use of Versius Surgical Robotic System in colorectal surgery. Following PRISMA 2020 guidelines, MEDLINE, CENTRAL, and EMBASE were systematically searched for original studies reporting on the use of the Versius Surgical Robotic System for colorectal surgery. Out of 199 publications screened, nine studies met the inclusion criteria for qualitative analysis. Most included studies were observational and monocentric studies, with the only large-scale, multicentric prospective data derived from the Versius surgical registry. A total of 561 colorectal procedures were reported, including oncological and benign disease, comprising 159 right hemicolectomies, 37 left colon or sigmoid resection, 253 low anterior resection and 64 abdominoperineal resections. The proportion of conversion to open surgery was 7.0% in the largest series and severe complications, defined as Clavien-Dindo grade 3 or higher was reported in 5.3% of cases. For right hemicolectomies, the mean operative time ranged from 160 to 221 min, with no conversion to open surgery reported and only one case requiring surgical revision. Intracorporeal anastomosis was reported in only one case. Regarding low anterior resection, the mean operative time ranged from 214 to 319 min, with a conversion rate to open of 6.9% and an incidence of severe complications of 6.0% in the largest series. Based on available literature there are no major safety concerns for the use of the Versius Surgical Robotic System for colorectal surgery. However, future well-conducted studies are needed to enable quantitative comparisons between different robotic platforms.

Brief insight regarding the use of transanal, laparoscopic, and robotic total mesorectal excision for rectal cancer

In this article, we provide an important commentary on the original study Lu et al, which offers insight into the surgical efficacy of transanal total mesorectal excision (TaTME) vs laparoscopic total mesorectal excision (LapTME) in the management of low-lying locally advanced rectal cancer (LARC). We focus specifically on the rate of postoperative complications between the two using existing data from the literature. We additionally introduce robotic total mesorectal excision (RTME) and look at its postoperative complications relative to the TaTME and LapTME. LARC has been conventionally approached by open surgery. However, minimally invasive techniques have emerged over the past two decades as alternatives to open total mesorectal excision, namely robotic, laparoscopic, and transanal. Each approach has its supporters, but conflicting data on resection outcomes and complications has fueled ongoing debate over the optimal minimally invasive technique for low/mid-LARC. This article aims to extend on the data regarding the use of TaTME and RTME in the treatment of low/mid-LARC and further elaborate on their comparative efficacy relative to LapTME.

Comparison of surgical outcomes between robotic and laparoscopic surgery for mid-low rectal cancer: a meta-analysis of randomized controlled trials

The surgical treatment of mid-low rectal cancer poses greater technical challenges, and whether robotic surgery provides superior safety and efficacy compared to laparoscopic surgery remains controversial. The aim of this meta-analysis was to compare the surgical outcomes of robotic and laparoscopic surgery for mid-low rectal cancer. We searched the PubMed, Cochrane, and Web of Science databases for randomized controlled trials (RCTs) comparing robotic and laparoscopic surgery for mid-low rectal cancer, published up to November 30, 2024. A total of four RCTs were finally included, comprising 1952 patients with mid-low rectal cancer. For patients with mid-low rectal cancer, robotic surgery was associated with longer operative time, a lower rate of conversion to open surgery, a higher lymph node yield, a lower rate of positive circumferential resection margin, and a lower rate of reoperation within 30 days postoperatively compared with laparoscopic surgery. However, there were no significant differences between the two surgical approaches in the estimated blood loss, the postoperative hospital stay, the rates of overall and severe postoperative complications, the time to first autonomous urination and to first flatus, and the rate of readmission within 30 days postoperatively between the two surgical approaches. Robotic surgery demonstrated certain advantages in reducing conversion rates and improving pathological outcomes for mid-low rectal cancer, but its clinical superiority remains limited, with no significant differences observed in multiple critical clinical outcomes compared with laparoscopic surgery, along with prolonged operative time. These findings indicate that, for mid-low rectal cancer, robotic surgery is a technically more refined option but does not confer absolute advantages over laparoscopic surgery.

Role of pelvimetry in predicting surgical outcomes and morbidity in rectal cancer surgery: A retrospective analysis

BACKGROUND

Rectal cancer has increased in incidence, and surgery remains the cornerstone of multimodal treatment. Pelvic anatomy, particularly a narrow pelvis, poses challenges in rectal cancer surgery, potentially affecting oncological outcomes and postoperative complications.

AIM

To investigate the relationship between radiologically assessed pelvic anatomy and surgical outcomes as well as the impact on local recurrence following rectal cancer surgery.

METHODS

We retrospectively analyzed 107 patients with rectal adenocarcinoma treated with elective rectal surgery between January 1, 2017, and September 1, 2022. Pelvimetric measurements were performed using computed tomography (CT)-based two-dimensional methods (n = 77) by assessing the pelvic inlet area in mm², and magnetic resonance imaging (MRI)-based three-dimensional techniques (n = 52) using the pelvic cavity index (PCI). Patient demographic, clinical, radiological, surgical, and pathological characteristics were collected and analyzed in relation to their pelvimetric data.

RESULTS

When patients were categorized based on CT measurements into narrow and normal/wide pelvis groups, a significant association was observed with male sex, and a lower BMI was more common in the narrow pelvis group (P = 0.002 for both). A significant association was found between a narrow pelvic structure, indicated by low PCI, and increased surgical morbidity (P = 0.049). Advanced age (P = 0.003) and male sex (P = 0.020) were significantly correlated with higher surgical morbidity. Logistic regression analysis identified four parameters that were significantly correlated with local recurrence: older age, early perioperative readmission, longer operation time, and a lower number of dissected lymph nodes (P < 0.05). However, there were no significant differences between the narrow and normal/wide pelvis groups in terms of the operation time, estimated blood loss, or overall local recurrence rate (P > 0.05).

CONCLUSION

MRI-based pelvimetry may be valuable in predicting surgical difficulty and morbidity in rectal cancer surgery, as indicated by the PCI. The observed correlation between low PCI and increased surgical morbidity suggests the potential importance of a preoperative MRI-based pelvimetric evaluation. In contrast, CT-based pelvimetry did not show significant differences in predicting surgical outcomes or cancer recurrence, indicating that the utility of pelvimetry alone may be limited in these respects.

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

Abdominal drainage to prevent intraperitoneal abscess after appendectomy for complicated appendicitis

RATIONALE

This is the third update of a Cochrane review first published in 2015 and last updated in 2021. Appendectomy, the surgical removal of the appendix, is performed primarily for acute appendicitis. People who undergo appendectomy for complicated appendicitis, defined as gangrenous or perforated appendicitis, are more likely to suffer postoperative complications in comparison to uncomplicated appendicitis. The routine use of abdominal drainage to reduce postoperative complications after appendectomy for complicated appendicitis is controversial.

OBJECTIVES

To evaluate the benefits and harms of abdominal drainage in reducing intraperitoneal abscess after appendectomy (irrespective of open or laparoscopic) for complicated appendicitis; to compare the effects of different types of surgical drains; and to evaluate the optimal time for drain removal.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, two other databases, and five trials registers, together with reference checking, citation searching, and contact with study authors, to identify studies for inclusion in the review. The latest search date was 12 October 2023.

ELIGIBILITY CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs in people with complicated appendicitis comparing (1) use of drain versus no drain, (2) open drain versus closed drain, or (3) different schedules for drain removal. We excluded studies in which not all participants received antibiotics after appendectomy.

OUTCOMES

Our critical outcome was intraperitoneal abscess. Important outcomes were wound infection, morbidity, mortality, and hospital stay.

RISK OF BIAS

We used the Cochrane RoB 1 tool to assess the risk of bias in RCTs and quasi-RCTs.

SYNTHESIS METHODS

We synthesised the results for each outcome in a meta-analysis using the random-effects model, except for the Peto odds ratio, which only has a fixed-effect model. We planned to use the Synthesis Without Meta-analysis (SWiM) approach to report studies when it was not possible to undertake a meta-analysis of effect estimates. We used GRADE to assess the certainty of evidence for each outcome.

INCLUDED STUDIES

We included eight studies (five RCTs and three quasi-RCTs) with a total of 739 paediatric and adult participants, of which 370 participants were randomised to the drainage group and 369 participants to the no-drainage group. The studies were conducted in North America, Asia, and Africa and published between 1973 and 2023. The majority of participants had perforated appendicitis with local or general peritonitis. All participants received antibiotic regimens after open or laparoscopic appendectomy. All studies were at overall high risk of bias.

SYNTHESIS OF RESULTS

Use of drain versus no drain We assessed the certainty of the evidence for 30-day mortality as moderate due to imprecision. We assessed the certainty of the evidence for all other outcomes as very low, downgraded mainly due to high risk of bias, inconsistency, and imprecision. The evidence is very uncertain regarding the effects of abdominal drainage versus no drainage on intraperitoneal abscess at 30 days (risk ratio (RR) 1.08, 95% confidence interval (CI) 0.55 to 2.12; 7 studies, 671 participants; very low-certainty evidence), wound infection at 30 days (RR 1.76, 95% CI 0.89 to 3.45; 7 studies, 696 participants), and morbidity at 30 days (RR 1.84, 95% CI 0.14 to 24.50; 2 studies, 124 participants) in paediatric and adult participants undergoing open or laparoscopic appendectomy for complicated appendicitis. Approximately 113 (57 to 221 participants) out of 1000 participants in the drainage group developed intraperitoneal abscess, compared with 104 out of 1000 participants in the no-drainage group. There were seven deaths in the drainage group (N = 291) compared with one in the no-drainage group (N = 290); abdominal drainage probably increases the risk of 30-day mortality (Peto odds ratio 4.88, 95% CI 1.18 to 20.09; 6 studies, 581 participants; moderate-certainty evidence) in paediatric and adult participants undergoing open appendectomy for complicated appendicitis. Abdominal drainage may increase hospital stay by 1.58 days (95% CI 0.86 to 2.31; 5 studies, 516 participants; very low-certainty evidence) in paediatric and adult participants undergoing open or laparoscopic appendectomy for complicated appendicitis, but the evidence is very uncertain. Open drain versus closed drain No studies compared open drain versus closed drain for complicated appendicitis. Early versus late drain removal No studies compared early versus late drain removal for complicated appendicitis.

AUTHORS' CONCLUSIONS

The evidence is very uncertain whether abdominal drainage prevents intraperitoneal abscess, wound infection, or morbidity in paediatric and adult participants undergoing open or laparoscopic appendectomy for complicated appendicitis. Abdominal drainage may increase hospital stay in paediatric and adult participants undergoing open or laparoscopic appendectomy for complicated appendicitis, but the evidence is very uncertain. Consequently, there is no evidence for any clinical improvement with the use of abdominal drainage in people undergoing open or laparoscopic appendectomy for complicated appendicitis. The increased risk of mortality with drainage comes from eight deaths observed in paediatric and adult participants undergoing open appendectomy for complicated appendicitis. Larger studies are needed to more reliably determine the effects of drainage on mortality outcomes.

FUNDING

This Cochrane review was funded by the National Natural Science Foundation of China (Grant No. 81701950, 82172135), Natural Science Foundation of Chongqing (Grant No. CSTB2022NSCQ-MSX0058, cstc2021jcyj-msxmX0294), Medical Research Projects of Chongqing (Grant No. 2018MSXM132, 2023ZDXM003, 2024jstg028), and the Kuanren Talents Program of the Second Affiliated Hospital of Chongqing Medical University.

REGISTRATION

Registration: not available. Protocol and previous versions available via doi.org/10.1002/14651858.CD010168, doi.org/10.1002/14651858.CD010168.pub2, doi.org/10.1002/14651858.CD010168.pub3, and doi.org/10.1002/14651858.CD010168.pub4.

Non-programmed rehospitalizations after cholecystectomy

Cholecystectomy is one the most frequent procedures in digestive surgery. While the operation is generally associated with low rates of morbidity and mortality, frequency of occurrence can vary considerably according to surgical indication, time elapsed between symptom appearance and surgical intervention, anatomical area under treatment, and the experience of the different centers. Rehospitalization after cholecystectomy remains potentially problematic in numerous units, due in part to the ongoing development of day hospital treatment and short-term hospitalization. The objective of this update is to assess not only the rate, causes and risk factors of non-programmed hospitalizations subsequent to cholecystectomy, but also the available ways and means of prevention and management in the patient's best interests.

The feasibility and safety of deeply inserted enema tubes for acute malignant left-hemicolon obstruction: an alternative solution in developing countries

Background and aims

Disposable enema kits are commonly used for bowel preparation, with the anal tube typically positioned near the rectal ampulla. This study assesses the feasibility and safety of deeply inserting an enema tube in cases of acute malignant left-hemicolon obstruction.

Methods

A retrospective analysis was conducted on 42 patients who underwent emergency endoscopic decompression via a deeply inserted enema tube for acute malignant left-hemicolon obstruction from January 2021 to September 2024 at a single center, the Endoscopy Centre of the Affiliated Hospital of Putian University. This analysis covered intubation duration, the success rate of intubation, the obstruction relief rate, as well as associated adverse events.

Results

Thirty-six patients achieved successful tube placement, attaining a one-time success rate of 85.7% (36/42). Following successful intubation, the abdominal circumference decreased to a mean of (85.2 ± 3.0)% of the original value on the subsequent day (P < 0.01). Abdominal plain films depicted a significant reduction in both the quantity of gas-fluid levels and the maximal transverse diameter of the proximally obstructed colon [(4.5 ± 1.2) cm versus (7.4 ± 0.8) cm, P < 0.01]. Within 48 hours, C-reactive protein (CRP) levels plummeted by over 50%, and bowel sounds normalized within 2 - 5 days. During surgery, the bowel exhibited only slight or negligible dilation and edema, with no conspicuous fecal residues detected in the colonic cavity. Furthermore, no severe tube-related adverse events occurred either during or after intubation.

Conclusion

The application of deeply inserted enema tubes proves to be both feasible and safe in treating acute malignant left-hemicolon obstruction, thus presenting itself as a viable alternative approach in developing countries.