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Yankunze Y, Mwachiro MM, Lando JO, Bachheta N, Mangaoang D, Bekele A, Parker RK. Laparoscopy experience in East, Central, and Southern Africa: insights from operative case volume analysis. Surg Endosc 2024; 38:4415-4421. [PMID: 38890173 PMCID: PMC11289058 DOI: 10.1007/s00464-024-10960-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 05/24/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND With the primary objective of addressing the disparity in global surgical care access, the College of Surgeons of East, Central, and Southern Africa (COSECSA) trains surgeons. While sufficient operative experience is crucial for surgical training, the extent of utilization of minimally invasive techniques during COSECSA training remains understudied. METHODS We conducted an extensive review of COSECSA general surgery trainees' operative case logs from January 1, 2015, to December 31, 2020, focusing on the utilization of minimally invasive surgical procedures. Our primary objective was to determine the prevalence of laparoscopic procedures and compare this to open procedures. We analyzed the distribution of laparoscopic cases across common indications such as cholecystectomy, appendicitis, and hernia operations. Additionally, we examined the impact of trainee autonomy, country development index, and hospital type on laparoscopy utilization. RESULTS Among 68,659 total cases, only 616 (0.9%) were laparoscopic procedures. Notably, 34 cases were conducted during trainee external rotations in countries like the United Kingdom, Germany, and India. Gallbladder and appendix pathologies were most frequent among the 582 recorded laparoscopic cases performed in Africa. Laparoscopic cholecystectomy accounted for 29% (276 of 975 cases), laparoscopic appendectomy for 3% (76 of 2548 cases), and laparoscopic hernia repairs for 0.5% (26 of 5620 cases). Trainees self-reported lower autonomy for laparoscopic (22.5%) than open cases (61.5%). Laparoscopy usage was more prevalent in upper-middle-income (2.7%) and lower-middle-income countries (0.8%) compared with lower-income countries (0.5%) (p < 0.001). Private (1.6%) and faith-based hospitals (1.5%) showed greater laparoscopy utilization than public hospitals (0.5%) (p < 0.001). CONCLUSIONS The study highlights the relatively low utilization of minimally invasive techniques in surgical training within the ECSA region. Laparoscopic cases remain a minority, with variations observed based on specific diagnoses. The findings suggest a need to enhance exposure to minimally invasive procedures to ensure well-rounded training and proficiency in these techniques.
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Affiliation(s)
- Yves Yankunze
- Department of Surgery, Tenwek Hospital, PO Box 39, Bomet, 20400, Kenya
| | - Michael M Mwachiro
- Department of Surgery, Tenwek Hospital, PO Box 39, Bomet, 20400, Kenya
- College of Surgeons of East, Central, and Southern Africa, Arusha, Tanzania
| | - June Owino Lando
- Department of Surgery, Tenwek Hospital, PO Box 39, Bomet, 20400, Kenya
| | - Niraj Bachheta
- College of Surgeons of East, Central, and Southern Africa, Arusha, Tanzania
| | - Deirdre Mangaoang
- Institute of Global Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Abebe Bekele
- College of Surgeons of East, Central, and Southern Africa, Arusha, Tanzania
- University of Global Health Equity, Kigali, Rwanda
| | - Robert K Parker
- Department of Surgery, Tenwek Hospital, PO Box 39, Bomet, 20400, Kenya.
- Department of Surgery, Alpert Medical School of Brown University, Providence, RI, USA.
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Costa G, Garbarino GM, Lepre L, Liotta G, Mazzoni G, Gabrieli A, Costa A, Podda M, Sganga G, Fransvea P. Laparoscopic Treatment of Perforated Peptic Ulcer: A Propensity Score-Matched Comparison of Interrupted Stitches Repair versus Knotless Barbed Suture. J Clin Med 2024; 13:1242. [PMID: 38592114 PMCID: PMC10931710 DOI: 10.3390/jcm13051242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 01/26/2024] [Accepted: 02/19/2024] [Indexed: 04/10/2024] Open
Abstract
Background: Peptic ulcers result from imbalanced acid production, and in recent decades, proton pump inhibitors have proven effective in treating them. However, perforated peptic ulcers (PPU) continue to occur with a persistent high mortality rate when not managed properly. The advantages of the laparoscopic approach have been widely acknowledged. Nevertheless, concerning certain technical aspects of this method, such as the best gastrorrhaphy technique, the consensus remains elusive. Consequently, the choice tends to rely on individual surgical experiences. Our study aimed to compare interrupted stitches versus running barbed suture for laparoscopic PPU repair. Methods: We conducted a retrospective study utilizing propensity score matching analysis on patients who underwent laparoscopic PPU repair. Patients were categorised into two groups: Interrupted Stitches Suture (IStiS) and Knotless Suture (KnotS). We then compared the clinical and pathological characteristics of patients in both groups. Results: A total of 265 patients underwent laparoscopic PPU repair: 198 patients with interrupted stitches technique and 67 with barbed knotless suture. Following propensity score matching, each group (IStiS and KnotS) comprised 56 patients. The analysis revealed that operative time did not differ between groups: 87.9 ± 39.7 vs. 92.8 ± 42.6 min (p = 0.537). Postoperative morbidity (24.0% vs. 32.7%, p = 0.331) and Clavien-Dindo III (10.7% vs. 5.4%, p = 0.489) were more frequently observed in the KnotS group, without any significant difference. In contrast, we found a slightly higher mortality rate in the IStiS group (10.7% vs. 7.1%, p = 0.742). Concerning leaks, no differences emerged between groups (3.6% vs. 5.4%, p = 1.000). Conclusions: Laparoscopic PPU repair with knotless barbed sutures is a non-inferior alternative to interrupted stitches repair. Nevertheless, further research such as randomised trials, with a standardised treatment protocol according to ulcer size, are required to identify the best gastrorraphy technique.
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Affiliation(s)
- Gianluca Costa
- Surgery Center, Colorectal Surgery Research Unit, Fondazione Policlinico Universitario Campus Bio-Medico, University Campus Bio-Medico of Rome, 00128 Rome, Italy;
| | | | - Luca Lepre
- General and Emergency Surgery Unit, Santo Spirito in Sassia Hospital, ASL Roma 1, 00193 Rome, Italy;
| | - Gianluca Liotta
- General and Emergency Surgery Unit, Palestrina Hospital, ASL Roma 6, 00036 Palestrina, Italy
| | - Gianluca Mazzoni
- General Surgery Unit, G.B. Grassi Hospital, ASL Roma 3, 00122 Rome, Italy
| | - Alice Gabrieli
- Department of General Surgery, Cattinara University Hospital, Azienda Sanitaria Universitaria Giuliano Isontina, 34148 Trieste, Italy;
| | - Alessandro Costa
- UniCamillus School of Medicine, Saint Camillus International University of Health and Medical Sciences, 00131 Rome, Italy
| | - Mauro Podda
- Department of Surgical Science, University of Cagliari, 09124 Cagliari, Italy;
| | - Gabriele Sganga
- Emergency Surgery and Trauma, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Catholic University of Sacred Heart, 00135 Rome, Italy (P.F.)
| | - Pietro Fransvea
- Emergency Surgery and Trauma, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Catholic University of Sacred Heart, 00135 Rome, Italy (P.F.)
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Costa G, Fransvea P, Lepre L, Liotta G, Mazzoni G, Biloslavo A, Bianchi V, Occhionorelli S, Costa A, Sganga G. Perforated peptic ulcer (PPU) treatment: an Italian nationwide propensity score-matched cohort study investigating laparoscopic vs open approach. Surg Endosc 2023:10.1007/s00464-023-09998-5. [PMID: 36944740 PMCID: PMC10030074 DOI: 10.1007/s00464-023-09998-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Accepted: 02/27/2023] [Indexed: 03/23/2023]
Abstract
BACKGROUND Perforated peptic ulcer (PPU) remain a surgical emergency accounting for 37% of all peptic ulcer-related deaths. Surgery remains the standard of care. The benefits of laparoscopic approach have been well-established even in the elderly. However, because of inconsistent results with specific regard to some technical aspects of such technique surgeons questioned the adoption of laparoscopic approach. This leads to choose the type of approach based on personal experience. The aim of our study was to critically appraise the use of the laparoscopic approach in PPU treatment comparing it with open procedure. METHODS A retrospective study with propensity score matching analysis of patients underwent surgical procedure for PPU was performed. Patients undergoing PPU repair were divided into: Laparoscopic approach (LapA) and Open approach (OpenA) groups and clinical-pathological features of patients in the both groups were compared. RESULTS A total of 453 patients underwent PPU simple repair. Among these, a LapA was adopted in 49% (222/453 patients). After propensity score matching, 172 patients were included in each group (the LapA and the OpenA). Analysis demonstrated increased operative times in the OpenA [OpenA: 96.4 ± 37.2 vs LapA 88.47 ± 33 min, p = 0.035], with shorter overall length of stay in the LapA group [OpenA 13 ± 12 vs LapA 10.3 ± 11.4 days p = 0.038]. There was no statistically significant difference in mortality [OpenA 26 (15.1%) vs LapA 18 (10.5%), p = 0.258]. Focusing on morbidity, the overall rate of 30-day postoperative morbidity was significantly lower in the LapA group [OpenA 67 patients (39.0%) vs LapA 37 patients (21.5%) p = 0.002]. When stratified using the Clavien-Dindo classification, the severity of postoperative complications was statistically different only for C-D 1-2. CONCLUSIONS Based on the present study, we can support that laparoscopic suturing of perforated peptic ulcers, apart from being a safe technique, could provide significant advantages in terms of postoperative complications and hospital stay.
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Affiliation(s)
- Gianluca Costa
- Surgery Center, Colorectal Surgery Research Unit - Fondazione Policlinico Universitario Campus Bio-Medico, University Campus Bio-Medico of Rome, Rome, Italy
| | - Pietro Fransvea
- Emergency Surgery and Trauma - Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Catholic University of Sacred Heart, Largo A. Gemelli 8, 00168, Rome, Italy.
| | - Luca Lepre
- General Surgery Unit, Santo Spirito in Sassia Hospital, ASL Roma 1, Rome, Italy
| | - Gianluca Liotta
- General and Emergency Surgery Unit, Azienda Ospedaliera San Camillo-Forlanini, Rome, Italy
| | - Gianluca Mazzoni
- General Surgery Unit, G.B. Grassi Hospital, ASL Roma 3, Rome, Italy
| | - Alan Biloslavo
- Department of General Surgery, Cattinara University Hospital, Azienda Sanitaria Universitaria Giuliano Isontina, Trieste, Italy
| | - Valentina Bianchi
- Emergency Surgery and Trauma - Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Catholic University of Sacred Heart, Largo A. Gemelli 8, 00168, Rome, Italy
| | - Savino Occhionorelli
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
- Department of Surgery, University Hospital Arcispedale Sant'Anna, Ferrara, Italy
| | - Alessandro Costa
- UniCamillus School of Medicine - Saint Camillus International University of Health and Medical Sciences, Rome, Italy
| | - Gabriele Sganga
- Emergency Surgery and Trauma - Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Catholic University of Sacred Heart, Largo A. Gemelli 8, 00168, Rome, Italy
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Donohue SJ, Reinke CE, Evans SL, Jordan MM, Warren YE, Hetherington T, Kowalkowski M, May AK, Matthews BD, Ross SW. Laparoscopy is associated with decreased all-cause mortality in patients undergoing emergency general surgery procedures in a regional health system. Surg Endosc 2022; 36:3822-3832. [PMID: 34477959 DOI: 10.1007/s00464-021-08699-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 08/24/2021] [Indexed: 01/29/2023]
Abstract
BACKGROUND The aim of this study was to evaluate the use of laparoscopic surgery for common emergency general surgery (EGS) procedures within an integrated Acute Care Surgery (ACS) network. We hypothesized that laparoscopy would be associated with improved outcomes. METHODS Our integrated health care system's EGS registry created from AAST EGS ICD-9 codes was queried from January 2013 to October 2015. Procedures were grouped as laparoscopic or open. Standard descriptive and univariate tests were performed, and a multivariable logistic regression controlling for open status, age, BMI, Charlson Comorbidity Index (CCI), trauma tier, and resuscitation diagnosis was performed. Laparoscopic procedures converted to open were identified and analyzed using concurrent procedure billing codes across episodes of care. RESULTS Of 60,604 EGS patients identified over the 33-month period, 7280 (12.0%) had an operation and 6914 (11.4%) included AAST-defined EGS procedures. There were 4813 (69.6%) surgeries performed laparoscopically. Patients undergoing a laparoscopic procedure tended to be younger (45.7 ± 18.0 years vs. 57.2 ± 17.6, p < 0.001) with similar BMI (29.7 ± 9.0 kg/m2 vs. 28.8 ± 8.3, p < 0.001). Patients in the laparoscopic group had lower mean CCI score (1.6 ± 2.3 vs. 3.4 ± 3.2, p ≤ 0.0001). On multivariable analysis, open surgery had the highest association with inpatient mortality (OR 8.67, 4.23-17.75, p < 0.0001) and at all time points (30-, 90-day, 1-, 3-year). At all time points, conversion to open was found to be a statistically significant protective factor. CONCLUSION Use of laparoscopy in EGS is common and associated with a decreased risk of all-cause mortality at all time points compared to open procedures. Conversion to open was protective at all time points compared to open procedures.
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Affiliation(s)
- Sean J Donohue
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Caroline E Reinke
- Department of Surgery, Carolinas Medical Center, 1000 Blythe Blvd, Charlotte, NC, 28203, USA
| | - Susan L Evans
- Department of Surgery, Carolinas Medical Center, 1000 Blythe Blvd, Charlotte, NC, 28203, USA
| | - Mary M Jordan
- Department of Surgery, Carolinas Medical Center, 1000 Blythe Blvd, Charlotte, NC, 28203, USA
| | - Yancey E Warren
- Department of Surgery, Carolinas Medical Center, 1000 Blythe Blvd, Charlotte, NC, 28203, USA
| | - Timothy Hetherington
- Carolinas Medical Center, Center for Outcomes Research and Evaluation, Charlotte, NC, USA
| | - Marc Kowalkowski
- Carolinas Medical Center, Center for Outcomes Research and Evaluation, Charlotte, NC, USA
| | - Addison K May
- Department of Surgery, Carolinas Medical Center, 1000 Blythe Blvd, Charlotte, NC, 28203, USA
| | - Brent D Matthews
- Department of Surgery, Carolinas Medical Center, 1000 Blythe Blvd, Charlotte, NC, 28203, USA
| | - Samuel W Ross
- Department of Surgery, Carolinas Medical Center, 1000 Blythe Blvd, Charlotte, NC, 28203, USA.
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Villodre C, Taccogna L, Zapater P, Cantó M, Mena L, Ramia JM, Lluís F, Afonso N, Aguilella V, Aguiló J, Alados JC, Alberich M, Apio AB, Balongo R, Bra E, Bravo-Gutiérrez A, Briceño FJ, Cabañas J, Cánovas G, Caravaca I, Carbonell S, Carrera-Dacosta E, Castro EE, Caula C, Choolani-Bhojwani E, Codina A, Corral S, Cuenca C, Curbelo-Peña Y, Delgado-Morales MM, Delgado-Plasencia L, Doménech E, Estévez AM, Feria AM, Gascón-Domínguez MA, Gianchandani R, González C, Hevia RJ, González MA, Hidalgo JM, Lainez M, Lluís N, López F, López-Fernández J, López-Ruíz JA, Lora-Cumplido P, Madrazo Z, Marchena J, de la Cuadra MB, Martín S, Casas MI, Martínez P, Mena-Mateos A, Morales-García D, Mulas C, Muñoz-Forner E, Naranjo A, Navarro-Sánchez A, Oliver I, Ortega I, Ortega-Higueruelo R, Ortega-Ruiz S, Osorio J, Padín MH, Pamies JJ, Paredes M, Pareja-Ciuró F, Parra J, Pérez-Guarinós CV, Pérez-Saborido B, Pintor-Tortolero J, Plua-Muñiz K, Rey M, Rodríguez I, Ruiz C, Ruíz R, Ruiz S, Sánchez A, Sánchez D, Sánchez R, Sánchez-Cabezudo F, Sánchez-Santos R, Santos J, Serrano-Paz MP, Soria-Aledo V, Tallón-Aguilar L, Valdivia-Risco JH, Vallverdú-Cartié H, Varela C, Villar-Del-Moral J, Zambudio N. Simplified risk-prediction for benchmarking and quality improvement in emergency general surgery. Prospective, multicenter, observational cohort study. Int J Surg 2022; 97:106168. [PMID: 34785344 DOI: 10.1016/j.ijsu.2021.106168] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 10/24/2021] [Accepted: 11/03/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Emergency General Surgery (EGS) conditions account for millions of deaths worldwide, yet it is practiced without benchmarking-based quality improvement programs. The aim of this observational, prospective, multicenter, nationwide study was to determine the best benchmark cutoff points in EGS, as a reference to guide improvement measures. METHODS Over a 6-month period, 38 centers (5% of all public hospitals) attending EGS patients on a 24-h, 7-days a week basis, enrolled consecutive patients requiring an emergent/urgent surgical procedure. Patients were stratified into cohorts of low (i.e., expected morbidity risk <33%), middle and high risk using the novel m-LUCENTUM calculator. RESULTS A total of 7258 patients were included; age (mean ± SD) was 51.1 ± 21.5 years, 43.2% were female. Benchmark cutoffs in the low-risk cohort (5639 patients, 77.7% of total) were: use of laparoscopy ≥40.9%, length of hospital stays ≤3 days, any complication within 30 days ≤ 17.7%, and 30-day mortality ≤1.1%. The variables with the greatest impact were septicemia on length of hospital stay (21 days; adjusted beta coefficient 16.8; 95% CI: 15.3 to 18.3; P < .001), and respiratory failure on mortality (risk-adjusted population attributable fraction 44.6%, 95% CI 29.6 to 59.6, P < .001). Use of laparoscopy (odds ratio 0.764, 95% CI 0.678 to 0.861; P < .001), and intraoperative blood loss (101-500 mL: odds ratio 2.699, 95% CI 2.152 to 3.380; P < .001; and 500-1000 mL: odds ratio 2.875, 95% CI 1.403 to 5.858; P = .013) were associated with increased morbidity. CONCLUSIONS This study offers, for the first time, clinically-based benchmark values in EGS and identifies measures for improvement.
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Affiliation(s)
- C Villodre
- Hospital Gran Canaria Doctor Negrín, Las Palmas de Gran Canarias, Spain Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain Hospital Lluís Alcanyís de Xàtiva, Valencia, Spain Hospital Universitario de Badajoz, Badajoz, Spain Hospital Universitario de Bellvitge, Barcelona, Spain Hospital Marina Baixa, Alicante, Spain Hospital Juan Ramón Jiménez, Infanta Elena, Huelva, Spain Hospital Infanta Cristina, Parla, Madrid, Spain Hospital Universitario de Canarias, Tenerife, Spain Hospital Reina Sofía de Córdoba, Córdoba, Spain H. Ramón y Cajal, Madrid, Spain Hospital Parc Taulí de Sabadell, Barcelona, Spain Hospital General Universitario de Alicante, Alicante, Spain Complejo Hospitalario Universitario de Vigo, Hospital Pontevedra, Spain Hospital Trueta de Girona, Girona, Spain Hospital Universitario Rio Hortega, Valladolid, Spain Hospital Mutua Terrassa, Barcelona, Spain Consorci Hospitalari de Vic, Barcelona, Spain POVISA, Pontevedra, Spain Hospital Universitario Nuestra Señora de Candelaria, Tenerife, Spain Hospital Universitario Basurto, Bizkaia, Spain Hospital Universitario Marqués de Valdecilla, Santander, Spain Hospital de Viladecans, Barcelona, Spain Hospital Clínico de Valencia, Valencia, Spain Hospital Universitario Insular de Gran Canaria, Las Palmas, Spain Hospital Vírgen de la Macarena, Sevilla, Spain Hospital Cabueñes, Gijón, Spain Complejo Hospitalario de Jaén, Jaén, Spain Hospital Universitari Sant Joan de Reus, Tarragona, Spain Hospital Universitario Infanta Sofía, Madrid, Spain Complejo Hospitalario Torrecárdenas, Almería, Spain Hospital Sant Pau i Santa Tecla, Tarragona, Spain Hospital General Rafael Méndez de Lorca, Murcia, Spain Hospital Vírgen del Rocío, Sevilla, Spain Hospital Morales Meseguer, Murcia, Spain Hospital del Vinalopó, Alicante, Spain Hospital Universitario del Vinalopó, Alicante, Spain Hospital Universitario Virgen de las Nieves, Granada, Spain Department of Surgery, General University Hospital of Alicante, Alicante, Spain Department of Clinical Pharmacology, General University Hospital of Alicante, Alicante, Spain Computing, BomhardIP, Alicante, Spain Department of Clinical Documentation, General University Hospital of Alicante, Alicante, Spain Institute of Health and Biomedical Research of Alicante, ISABIAL, Alicante, Spain
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Poillucci G, Podda M, Pisanu A, Mortola L, Dalla Caneva P, Massa G, Costa G, Savastano R, Cillara N. Risk factors for postoperative morbidity following appendectomy in the elderly: a nationwide prospective cohort study. Eur J Trauma Emerg Surg 2021; 47:1729-1737. [PMID: 31309237 DOI: 10.1007/s00068-019-01186-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 07/08/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND A limited number of studies investigating perioperative risk factors associated with emergency appendectomy in elderly patients have been published to date. Whether older age may be associated with poorer outcomes following appendectomy is still a matter of debate. The primary aim of this study was to determine the predictors of postoperative morbidity following appendectomy in patients aged ≥ 65 years. METHODS Data regarding all elderly patients who underwent emergency appendectomy from January 2017 to June 2018 admitted 36 Italian surgical departments were prospectively collected and analyzed. Baseline demographics and perioperative variables were evaluated. Uni- and multivariate analyses adjusted for differences between groups were carried out to determine possible predictors of adverse outcomes after appendectomy. RESULTS Between January 2017 and June 2018, 135 patients aged ≥ 65 years with a diagnosis of AA met the study inclusion criteria. Twenty-six patients (19.3%) were diagnosed with some type of postoperative complication. Decreasing the preoperative hemoglobin level showed a statistically significant association with postoperative complications (OR 0.77, CI 0.61-0.97, P = 0.03). Preoperative creatinine level (P = 0.02, OR 2.04, CI 1.12-3.72), and open appendectomy (P = 0.03, OR 2.67, CI 1.11-6.38) were significantly associated with postoperative morbidity. After adjustment, the only independent predictor of postoperative morbidity was preoperative creatinine level (P = 0.04, OR 2.01, CI 1.05-3.89). CONCLUSIONS In elderly patients with AA, perioperative risk assessment in the emergency setting must be as accurate as possible to identify modifiable risk factors that can be addressed before surgery, such as preoperative hemoglobin and creatinine levels.
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Affiliation(s)
- Gaetano Poillucci
- Department of General Surgery "Paride Stefanini", Policlinico Universitario Umberto I, Sapienza University, Rome, Italy
| | - Mauro Podda
- Department of General, Emergency and Minimally Invasive Surgery, Policlinico Universitario "D. Casula", University of Cagliari, SS 554, Km 4,500, 09042, Monserrato, Italy.
| | - Adolfo Pisanu
- Department of General, Emergency and Minimally Invasive Surgery, Policlinico Universitario "D. Casula", University of Cagliari, SS 554, Km 4,500, 09042, Monserrato, Italy
| | - Lorenzo Mortola
- Department of Surgery, Policlinico Universitario "D. Casula", University of Cagliari, Monserrato, Italy
| | - Patrizia Dalla Caneva
- Department of Surgery, Policlinico Universitario "D. Casula", University of Cagliari, Monserrato, Italy
| | - Giulia Massa
- Surgical and Medical Department of Translational Medicine, Sant'Andrea Teaching Hospital, Sapienza University, Rome, Italy
| | - Gianluca Costa
- Surgical and Medical Department of Translational Medicine, Sant'Andrea Teaching Hospital, Sapienza University, Rome, Italy
| | | | - Nicola Cillara
- Department of Surgery, Santissima Trinità Hospital, Cagliari, Italy
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7
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Reinke CE, Lim RB. Minimally Invasive Acute Care Surgery. Curr Probl Surg 2021. [DOI: 10.1016/j.cpsurg.2021.101033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
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8
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Reinke CE, Lim RB. Minimally invasive acute care surgery. Curr Probl Surg 2021; 59:101031. [DOI: 10.1016/j.cpsurg.2021.101031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 05/16/2021] [Indexed: 12/07/2022]
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Completely intracorporeal anastomosis in robotic left colonic and rectal surgery: technique and 30-day outcomes. Updates Surg 2021; 73:2137-2143. [PMID: 33993462 DOI: 10.1007/s13304-021-01061-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 04/19/2021] [Indexed: 10/21/2022]
Abstract
As robotic surgery continues to disseminate into the field of colon and rectal surgery, there is a growing interest in the utilization of intracorporeal anastomosis to potentially improve surgical outcomes. The purpoe of this study was to compare feasibility, safety, and short-term outcomes of robotic sigmoid and low anterior resections performed with completely intracorporeal anastomosis (CICA) technique to the traditional extracorporeal assisted anastomosis (ECAA) technique. Consecutive series of patients who underwent elective robotic sigmoid or low anterior resections for benign or malignant disease utilizes either CICA or ECAA between August 2017 and November 2019. Surgical complications were assessed until 30 postoperative days and compared between the two groups. A total of 160 patients were identified; 73 (45.6%) in the CICA group and 87 (54.4%) in the ECAA group. Most of the procedures were performed for malignancy (76%). Estimated blood loss was lower in the CICA group (80.7 mL vs. 110.2 mL; p = 0.048), while operative times were longer (5.9 ± SD hours vs. 4.9 ± SD hours; p = < 0.001). Overall conversion rate was 1.9%, with no conversions in the CICA group. Overall complications occurred in 54 patients (33.8%) with 13 (8.3%) representing major complications. There were no significant differences in 30 day outcomes between the two groups. This study demonstrates the feasibility and safety of robotic sigmoid and low anterior resections with CICA. Outcomes for robotic sigmoid and low anterior resections are encouraging regardless of anastomotic technique (CICA vs ECAA).
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Podda M, Poillucci G, Pacella D, Mortola L, Canfora A, Aresu S, Pisano M, Erdas E, Pisanu A, Cillara N. Appendectomy versus conservative treatment with antibiotics for patients with uncomplicated acute appendicitis: a propensity score-matched analysis of patient-centered outcomes (the ACTUAA prospective multicenter trial). Int J Colorectal Dis 2021; 36:589-598. [PMID: 33454817 DOI: 10.1007/s00384-021-03843-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/08/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE The aim of this prospective multicenter study was to compare antibiotic therapy and appendectomy as treatment for patients with uncomplicated appendicitis confirmed by ultrasound and/or computed tomography. METHODS The study was conducted from January 2017 to January 2018. Data regarding all patients discharged from the participating centers with a diagnosis of uncomplicated appendicitis were collected prospectively. RESULTS Of the 318 patients enrolled in the study, 27.4% underwent antibiotic-first therapy, and 72.6% underwent appendectomy. The matched group was composed of 87 patients in both study arms. Of the 87 patients available of 1-year follow-up in the antibiotic-first group, 64 (73.6%) did not require appendectomy. The complication-free treatment success in the antibiotic-first group was 64.4%. A statistically significant higher complication-free treatment success was found in the appendectomy group: 81.8% in the pre-matching sample and 83.9% in the post-matching sample. Patients in the antibiotic-first group reported lower VAS scores compared to those treated with an appendectomy, both at discharge (2.0 ± 1.7 vs 3.6 ± 2.3) and at 30-day follow-up (0.3 ± 0.6 vs 2.1 ± 1.7). The mean of the days of absence from work was higher in the appendectomy group (β 0.63; 95% CI 0.08-1.18). CONCLUSION Although laparoscopic appendectomy remains the gold standard of treatment for uncomplicated appendicitis, conservative treatment with antibiotics is a safe option in most cases. Approximately 65% of patients treated with antibiotics are symptom-free at 1 year, without increased risk of adverse events should symptoms recur, and better outcomes in terms of less pain and shorter period of absence from work compared to patients undergoing an appendectomy. TRIAL REGISTRATION Clinicaltrials.gov identifier (NCT number): NCT03080103.
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Affiliation(s)
- Mauro Podda
- Department of Emergency Surgery, Cagliari University Hospital "Duilio Casula", Azienda Ospedaliero-Universitaria di Cagliari, Cagliari, Italy. .,Policlinico Universitario di Monserrato "Duilio Casula", University of Cagliari, SS 554, Km 4,500, 09042, Monserrato, Italy.
| | - Gaetano Poillucci
- Department of General and Specialized Surgery "Paride Stefanini", Policlinico Universitario Umberto I, La Sapienza University, Rome, Italy
| | - Daniela Pacella
- Department of Public Health, University of Naples Federico II, Naples, Italy
| | - Lorenzo Mortola
- Department of Surgery, Azienda Ospedaliero-Universitaria Maggiore della Carità, Novara, Italy
| | - Alfonso Canfora
- Department of Surgery, Villa Betania Hospital, Naples, Italy
| | - Simona Aresu
- Department of Surgery, Nostra Signora della Mercede Hospital, Lanusei, Italy
| | - Marcello Pisano
- Department of Surgery, San Marcellino Hospital, ASSL Cagliari, Muravera, Italy
| | - Enrico Erdas
- Department of General and Endocrine Surgery, Cagliari University Hospital "Duilio Casula", Azienda Ospedaliero-Universitaria di Cagliari, Cagliari, Italy
| | - Adolfo Pisanu
- Department of Emergency Surgery, Cagliari University Hospital "Duilio Casula", Azienda Ospedaliero-Universitaria di Cagliari, Cagliari, Italy
| | - Nicola Cillara
- Department of General Surgery, Santissima Trinità Hospital, ASSL Cagliari, Cagliari, Italy
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11
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Heywood N, Parmar KL, Stott M, Sodde P, Doherty DT, Lim J, Sharma A. The laparoscopy in emergency general surgery (LEGS) study: a questionnaire survey of UK practice. Ann R Coll Surg Engl 2021; 103:120-129. [PMID: 33559556 PMCID: PMC9773896 DOI: 10.1308/rcsann.2020.7005] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
INTRODUCTION Recent consensus guidelines suggest that the laparoscopic approach may be a useful, safe and feasible approach in emergency general surgery. Despite this, the UK National Emergency Laparotomy Audit (NELA) suggests the rate of laparoscopy is low (9% fully laparoscopic) and slow to increase over time. A European survey found uptake to be variable. This UK survey was therefore undertaken to establish current UK practice and to determine factors affecting implementation. MATERIALS AND METHODS A questionnaire survey of currently practising UK consultant general surgeons was carried out by the North West Surgical Research Collaborative, using a secure web-based database maintained by the North West Surgical Trials Centre. RESULTS A total of 151 completed questionnaires were returned from 22 UK centres; 18% of respondents were unaware that laparoscopic cases should be reported to NELA. Appendicectomy (97%) and cholecystectomy (87%) were routinely performed laparoscopically. Laparoscopy was infrequently used in perforation, ischaemia or obstructed hernias. There appears to be equipoise regarding laparoscopic compared with open surgery in small-bowel obstruction among all subspecialty emergency general surgeons, in perforated peptic ulcer among upper gastrointestinal surgeons and in Hinchey III diverticulitis among colorectal surgeons. CONCLUSION Uptake of laparoscopy in UK emergency general surgery is influenced by surgeon preference, subspecialty, patient and operative factors. Further research into outcomes may help to identify areas of greatest potential benefit. The rate of laparoscopy reported by NELA may be an underestimate due to the 18% of surgeons unaware that laparoscopic cases should be reported, which may affect the validity of analyses performed from this dataset.
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Affiliation(s)
- N Heywood
- General Surgery Training Programme, Health Education North West England, Manchester, UK
| | | | - M Stott
- General Surgery Training Programme, Health Education North West England, Manchester, UK
| | - P Sodde
- General Surgery Training Programme, Health Education North West England, Manchester, UK
| | - DT Doherty
- General Surgery Training Programme, Health Education North West England, Manchester, UK
| | - J Lim
- General Surgery Training Programme, Health Education North West England, Manchester, UK
| | - A Sharma
- Manchester University NHS Foundation Trust, Manchester, UK
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12
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Podda M, Khan M, Di Saverio S. Adhesive Small Bowel Obstruction and the six w's: Who, How, Why, When, What, and Where to diagnose and operate? Scand J Surg 2021; 110:159-169. [PMID: 33511902 DOI: 10.1177/1457496920982763] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND AIMS Approximately 75% of patients admitted with small bowel obstruction have intra-abdominal adhesions as their cause (adhesive small bowel obstruction). Up to 70% of adhesive small bowel obstruction cases, in the absence of strangulation and bowel ischemia, can be successfully treated with conservative management. However, emerging evidence shows that surgery performed early during the first episode of adhesive small bowel obstruction is highly effective. The objective of this narrative review is to summarize the current evidence on adhesive small bowel obstruction management strategies. MATERIALS AND METHODS A review of the literature published over the last 20 years was performed to assess Who, hoW, Why, When, What, and Where diagnose and operate on patients with adhesive small bowel obstruction. RESULTS Adequate patient selection through physical examination and computed tomography is the key factor of the entire management strategy, as failure to detect patients with strangulated adhesive small bowel obstruction and bowel ischemia is associated with significant morbidity and mortality. The indication for surgical exploration is usually defined as a failure to pass contrast into the ascending colon within 8-24 h. However, operative management with early adhesiolysis, defined as operative intervention on either the calendar day of admission or the calendar day after admission, has recently shown to be associated with an overall long-term survival benefit compared to conservative management. Regarding the surgical technique, laparoscopy should be used only in selected patients with an anticipated single obstructing band, and there should be a low threshold for conversion to an open procedure in cases of high risk of bowel injuries. CONCLUSION Although most adhesive small bowel obstruction patients without suspicion of bowel strangulation or gangrene are currently managed nonoperatively, the long-term outcomes following this approach need to be analyzed in a more exhaustive way, as surgery performed early during the first episode of adhesive small bowel obstruction has shown to be highly effective, with a lower rate of recurrence.
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Affiliation(s)
- M Podda
- Department of Emergency Surgery, Policlinico Universitario "Duilio Casula," Azienda Ospedaliero-Universitaria di Cagliari, University of Cagliari, Cagliari, Italy
| | - M Khan
- Department of General and Trauma Surgery, Brighton and Sussex University Hospital NHS Trust, Brighton, UK
| | - S Di Saverio
- Department of General Surgery, University of Insubria, University Hospital of Varese, ASST Sette Laghi, Varese, Italy
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13
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Major P, Stefura T, Wysocki M, Małczak P, Rzepa A, Proczko-Stepaniak M, Szeliga J, Pędziwiatr M. Impact of SARS-CoV-2 pandemic on bariatric care in Poland: results of national survey. BMC Surg 2020; 20:314. [PMID: 33272221 PMCID: PMC7711258 DOI: 10.1186/s12893-020-00990-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 11/29/2020] [Indexed: 12/13/2022] Open
Abstract
Background The SARS-CoV-2 pandemic has reached Poland on March 4th, 2020 and undoubtedly affected all areas of life and medical care, including bariatric care. The study was planned to identify the impact of the SARS-CoV-2 pandemic on bariatric care in Poland. Methods The online survey was designed and distributed to bariatric surgeons. The questionnaire was divided into three parts: demographic characteristics of participants and their bariatric centers, examining the impact of the pandemic on the bariatric care and last part with questions about planned care after the pandemic. Results 49 surgeons participated in the survey. 27 (55%) participants worked in hospitals transformed into COVID-dedicated units. Only 9 (18%) respondents declared uninterrupted bariatric surgery during a pandemic. 91% of surgeons declared continuation of bariatric care with telemedicine techniques. All participants declared a high willingness to resume bariatric surgery after the SARS-CoV-2 pandemic and responded that bariatric procedures should resume immediately when World Health Organisation (WHO) announces the end of a pandemic regardless of oncological treatment. 90% of respondents believe that the pandemic will not affect the safety of bariatric procedures in the future. Conclusions Access to bariatric care during the pandemic is limited and redirected to telemedicine. Surgeons are ready to resume bariatric operations immediately after the pandemic, but its end is difficult to determine. In surgeons’ opinion pandemic will not affect the safety of bariatric surgery in the future. The extended waiting list and financial aspects will be the main issues after the pandemic.
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Affiliation(s)
- Piotr Major
- 2nd Department of General Surgery, Jagiellonian University Medical College, Jakubowskiego 2 st., 30-688, Krakow, Poland
| | - Tomasz Stefura
- 2nd Department of General Surgery, Jagiellonian University Medical College, Jakubowskiego 2 st., 30-688, Krakow, Poland.
| | - Michał Wysocki
- 2nd Department of General Surgery, Jagiellonian University Medical College, Jakubowskiego 2 st., 30-688, Krakow, Poland
| | - Piotr Małczak
- 2nd Department of General Surgery, Jagiellonian University Medical College, Jakubowskiego 2 st., 30-688, Krakow, Poland
| | - Anna Rzepa
- 2nd Department of General Surgery, Jagiellonian University Medical College, Jakubowskiego 2 st., 30-688, Krakow, Poland
| | - Monika Proczko-Stepaniak
- Department of General, Endocrine and Transplant Surgery, Medical University of Gdansk, Gdansk, Poland
| | - Jacek Szeliga
- Department of General, Gastroenterological, and Oncological Surgery, Collegium Medicum Nicolaus Copernicus University, Torun, Poland
| | - Michał Pędziwiatr
- 2nd Department of General Surgery, Jagiellonian University Medical College, Jakubowskiego 2 st., 30-688, Krakow, Poland
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14
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Zatevakhin II, Sazhin AV, Kirienko AI, Nechay TV, Tyagunov AE, Titkova SM, Anurov MV, Fedorov AV, Ivakhov GB, Melnikov-Makarchuk KY, Mareev PV. [Diagnostic and treatment approaches for acute appendicitis in the Russian Federation. Results of the all-Russian survey]. Khirurgiia (Mosk) 2020:5-16. [PMID: 32869609 DOI: 10.17116/hirurgia20200815] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Abstract
OBJECTIVE To improve treatment outcomes in patients with acute appendicitis (AA). MATERIAL AND METHODS An internet survey was performed. Questionnaire consisted of 15 questions concerning diagnosis and treatment of AA: application of prognostic scales, incidence and technical aspects of laparoscopic appendectomy (LA), antibiotic prophylaxis, postoperative management, compliance with international and national clinical guidelines. A total of 690 questionnaires were received and analyzed (3.67% of all surgeons in the Russian Federation). RESULTS Eighteen percent of respondents use at least one prognostic scale. The vast majority of surgeons (92%) use antibiotic prophylaxis. Almost half of respondents place trocars in the triangulation position (44%), one third of surgeons ligate the mesentery of the appendix (35%), most respondents perform mesoappendectomy (60%) with monopolar and bipolar cautery. Forty-five percent of all respondents do not invert the appendix stump. Significant number of respondents use abdominal drainage routinely. Only 3.5% of surgeons use multimodal postoperative analgesia. Less than 22% of patients are operated under low-pressure pneumoperitoneum. Standardization of surgical technique and perioperative approaches including those specified in the guidelines is absent. We also found insufficient awareness of surgeons about international and national clinical guidelines. CONCLUSION This study may be useful for standardizing treatment approaches, choosing the best practice, popularizing and improving of current clinical guidelines.
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Affiliation(s)
- I I Zatevakhin
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - A V Sazhin
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - A I Kirienko
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - T V Nechay
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - A E Tyagunov
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - S M Titkova
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - M V Anurov
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - A V Fedorov
- Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
| | - G B Ivakhov
- Pirogov Russian National Research Medical University, Moscow, Russia
| | | | - P V Mareev
- Pirogov Russian National Research Medical University, Moscow, Russia
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15
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Costa G, Fransvea P, Podda M, Pisanu A, Carrano FM, Iossa A, Balducci G, Agresta F. The use of emergency laparoscopy for acute abdomen in the elderly: the FRAILESEL Italian Multicenter Prospective Cohort Study. Updates Surg 2020; 72:513-525. [PMID: 32088854 DOI: 10.1007/s13304-020-00726-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Accepted: 02/13/2020] [Indexed: 02/07/2023]
Abstract
As the world population is aging rapidly, emergency abdominal surgery for acute abdomen in the elderly represents a global issue, both in developed and developing countries. Data regarding all the elderly patients who underwent emergency abdominal surgery from January 2017 to December 2017 at 36 Italian surgical departments were analyzed with the aim to appraise the contemporary reality regarding the use of emergency laparoscopy for acute abdomen in the elderly. 1993 patients were enrolled. 1369 (68.7%) patients were operated with an open technique; whereas, 624 (31.3%) underwent a laparoscopic operation. The postoperative morbidity rate was 32.6%, with a statically significant difference between the open and the laparoscopic groups (36.2% versus 22.1%, p < 0.001). The reported mortality rate was 8.8%, with a statistically significant difference between the open and the laparoscopic groups (11.2% versus 2.2%, p < 0.001). Our results demonstrated that patients in the ASA II (58.1%), ASA III (68.7%) and ASA IV (88.5%) groups were operated with the traditional open technique in most of the cases. Only a small percentage of patients underwent laparoscopy for perforated gastro-duodenal ulcer repair (18.9%), adhesiolyses with/without small bowel resection (12.2%), and large bowel resection (10.7%). Conversion to open technique was associated with a higher mortality rate (11.1% versus 2.2%, p < 0.001) and overall morbidity (38.9% versus 22.1%, p = 0.001) compared with patients who did not undergo conversion. High creatinine (p < 0.001) and glycaemia (p = 0.006) levels, low hemoglobin levels (p < 0.001), oral anticoagulation therapy (p = 0.001), acute respiratory failure (p < 0.001), presence of malignancy (p = 0.001), SIRS (p < 0.001) and open surgical approach (p < 0.001) were associated with an increased risk of postoperative morbidity. Regardless of technical progress, elderly patients undergoing emergency surgery are at very high risk for in-hospital complications. A detailed analysis of complications and mortality in the present study showed that almost 9% of elderly patients died after surgery for acute abdomen, and over 32% developed complications.
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Affiliation(s)
- Gianluca Costa
- Emergency Surgery Unit, Sant'Andrea Teaching Hospital, "La Sapienza" University of Rome, Rome, Italy
| | - Pietro Fransvea
- Emergency Surgery Unit, Sant'Andrea Teaching Hospital, "La Sapienza" University of Rome, Rome, Italy
| | - Mauro Podda
- Department of General, Emergency and Minimally Invasive Surgery, Cagliari University Hospital "D. Casula", University of Cagliari, SS 554, Km 4,500, Monserrato, 09042, Cagliari, Italy.
| | - Adolfo Pisanu
- Department of General, Emergency and Minimally Invasive Surgery, Cagliari University Hospital "D. Casula", University of Cagliari, SS 554, Km 4,500, Monserrato, 09042, Cagliari, Italy
| | - Francesco Maria Carrano
- Department of General, Emergency and Transplant Surgery, Ospedale di Circolo e "Fondazione Macchi", ASST Sette Laghi, University of Insubria, Varese, Italy
| | - Angelo Iossa
- Department of Medicine and Surgical Sciences and Biotechnologies, "La Sapienza" University of Rome, Polo Pontino, Latina, Italy
| | - Genoveffa Balducci
- Emergency Surgery Unit, Sant'Andrea Teaching Hospital, "La Sapienza" University of Rome, Rome, Italy
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16
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Manco G, Caramaschi S, Rolando G, Malagoli M, Zanelli G, Reggiani Bonetti L, Rossi A. Primary laparoscopic approach to repair perforated peptic ulcer. A retrospective cohort study. MINERVA CHIR 2020; 75:436-441. [PMID: 32456394 DOI: 10.23736/s0026-4733.20.08287-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Perforated peptic ulcer is a serious complication of peptic ulcer disease and carries high risk for morbidity and mortality. Although the incidence of peptic ulcer disease has decreased in recent decades, the percentage of patients with perforated peptic ulcer requiring emergency surgery remains constant. The use of laparoscopic management as a first choice for the treatment of the perforation is growing but is not routine in many centers. METHODS Clinical and surgical data on 42 patients underwent surgical treatment for perforated peptic ulcer from January 2012 to December 2016 were collected. Laparoscopic repair of the perforation with a three-port technique was made in all cases. The Boey scoring system was used to predict the prognosis. RESULTS All patients underwent suture-closure of the ulcer, and omental patch through laparoscopy without conversion to open surgery. Duodenal leakages occurred in 3 patients (7.1%), then treated with a conservative approach and resolved on the 10th postoperative day. Two patients (4.7%) had deep space infections in the first week after surgery, therefore subdiaphragmatic and pelvic abscess were drained by ultrasound guidance. Four patients (9.5%) died up to 30-day post-surgery due to progression of multisystem organ failure in absence of leakages or infections. All these patients were American Society of Anesthesiologists Classification >III and Boey Score 3. CONCLUSIONS Our data show that a primary laparoscopic approach in patients with peptic ulcer perforation is associated with postoperative advantages and acceptable rates of morbidity and mortality, essentially related to high Boey Score. Therefore, we suggest that the surgical repair of PPU could be always started laparoscopically.
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Affiliation(s)
- Gianrocco Manco
- Department of Surgery, University of Modena and Reggio Emilia, University Hospital of Modena, Modena, Italy
| | - Stefania Caramaschi
- Department of Medical and Surgical Sciences for Children and Adults, University of Modena and Reggio Emilia, University Hospital of Modena, Modena, Italy -
| | - Giovanni Rolando
- Department of Surgery, University of Modena and Reggio Emilia, University Hospital of Modena, Modena, Italy
| | - Marzio Malagoli
- Department of Surgery, University of Modena and Reggio Emilia, University Hospital of Modena, Modena, Italy
| | - Giuliana Zanelli
- Department of Medical and Surgical Sciences for Children and Adults, University of Modena and Reggio Emilia, University Hospital of Modena, Modena, Italy
| | - Luca Reggiani Bonetti
- Department of Medical and Surgical Sciences for Children and Adults, University of Modena and Reggio Emilia, University Hospital of Modena, Modena, Italy
| | - Aldo Rossi
- Department of Surgery, University of Modena and Reggio Emilia, University Hospital of Modena, Modena, Italy
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17
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Lasek A, Wysocki M, Mavrikis J, Myśliwiec P, Bobowicz M, Dowgiałło-Wnukiewicz N, Kenig J, Stefura T, Walędziak M, Pędziwiatr M. Comparison of stump closure techniques during laparoscopic appendectomies for complicated appendicitis - results from Pol-LA (Polish laparoscopic appendectomy) multicenter large cohort study. Acta Chir Belg 2020; 120:116-123. [PMID: 30747049 DOI: 10.1080/00015458.2019.1573527] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background: In general, the three main options for stump closure in laparoscopic appendectomy are clips, endoscopic staplers and endoloops. However, there is no gold standard, especially regarding complicated acute appendicitis which is generally associated with worse outcomes.Objectives: We aimed to assess the outcomes of different stump closure techniques during laparoscopic appendectomies for complicated appendicitisMethods: Our multicenter observational study of 18 surgical units assessed the outcomes of 1269 laparoscopic appendectomies for complicated appendicitis that used the three main stump closure techniques: clips, staplers and endoloops. Groups were compared in terms of peri- and postoperative outcomes.Results: Staplers were superior in terms of overall morbidity (9.79 vs. 3.29% vs. 7.41%, p = .017) and length of stay (4 vs. 3 vs. 4 days, p < .001) respectively for clips, staplers and endoloops. However, no differences in major complication rates, postoperative intraabdominal abscess formation, reintervention rates and readmission rates were found.Conclusion: Although our results show some clinical benefits of staplers for appendix stump closure, they are based on a non-randomized group of patients and are therefore prone to selection bias. Further well-designed trials taking into consideration not only the clinical benefits, but also, the economic aspects of the surgical treatment of complicated acute appendicitis are needed to confirm our results.
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Affiliation(s)
- Anna Lasek
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland
| | - Michał Wysocki
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland
- Center for Research, Training and Innovation in Surgery (CERTAIN Surgery), Kraków, Poland
| | - Judene Mavrikis
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland
| | - Piotr Myśliwiec
- 1st Department of General and Endocrinological Surgery, Medical University of Bialystok, Bialystok, Poland
| | - Maciej Bobowicz
- Department of Surgical Oncology, Medical University of Gdansk, Gdansk, Poland
| | - Natalia Dowgiałło-Wnukiewicz
- Department of General, University of Warmia and Mazury in Olsztyn, Minimally Invasive and Elderly Surgery, Olsztyn, Poland
| | - Jakub Kenig
- Department of General, Oncologic and Geriatric Surgery, Jagiellonian University Medical College, Krakow, Poland
| | - Tomasz Stefura
- Students’ Scientific Society of 2nd Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland
| | - Maciej Walędziak
- Department of General, Oncological, Metabolic and Thoracic Surgery, Military Institute of Medicine, Warsaw, Poland
| | - Michał Pędziwiatr
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland
- Center for Research, Training and Innovation in Surgery (CERTAIN Surgery), Kraków, Poland
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18
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Laparoscopy and resection with primary anastomosis for perforated diverticulitis: challenging old dogmas. Updates Surg 2020; 72:21-28. [DOI: 10.1007/s13304-020-00708-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 01/16/2020] [Indexed: 01/25/2023]
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Use of minimally invasive surgery in emergency general surgery procedures. Surg Endosc 2019; 34:2258-2265. [PMID: 31388806 DOI: 10.1007/s00464-019-07016-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 07/19/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Minimally invasive surgery (MIS) has demonstrated superior outcomes in many elective procedures. However, its use in emergency general surgery (EGS) procedures is not well characterized. The purpose of this study was to examine the trends in utilization and outcomes of MIS techniques in EGS over the past decade. METHODS The 2007-2016 ACS-NSQIP database was utilized to identify patients undergoing emergency surgery for four common EGS diagnoses: appendicitis, cholecystitis/cholangitis, peptic ulcer disease, and small bowel obstruction. Trends over time were described. Preoperative risk factors, operative characteristics, outcomes, morbidity, and trends were compared between MIS and open approaches using univariate and multivariate analysis. RESULTS During the 10-year study period, 190,264 patients were identified. The appendicitis group was the largest (166,559 patients) followed by gallbladder disease (9994), bowel obstruction (6256), and peptic ulcer disease (366). Utilization of MIS increased over time in all groups (p < 0.001). There was a concurrent decrease in mean days of hospitalization in each group: appendectomy (2.4 to 2.0), cholecystectomy (5.7 to 3.2), peptic ulcer disease (20.3 to 11.7), and bowel obstruction (12.9 to 10.5); p < 0.001 for all. On multivariate analysis, use of MIS techniques was associated with decreased odds of 30-day mortality, surgical site infection, and length of hospital stay in all groups (p < 0.001). CONCLUSIONS Use of MIS techniques in these four EGS diagnoses has increased in frequency over the past 10 years. When adjusted for preoperative risk factors, use of MIS was associated with decreased odds of wound infection, death, and length of stay. Further studies are needed to determine if increased access to MIS techniques among EGS patients may improve outcomes.
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Liu L, Lv N, Hou C. Effects of a multifaceted individualized pneumoperitoneum strategy in elderly patients undergoing laparoscopic colorectal surgery: A retrospective study. Medicine (Baltimore) 2019; 98:e15112. [PMID: 30946379 PMCID: PMC6456156 DOI: 10.1097/md.0000000000015112] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Laparoscopic colorectal surgery may adversely affect respiration, circulation, and acid-base balance in elderly patients, owing to the relatively long duration of CO2 absorption. We conducted this retrospective study to determine the safety and efficacy of warmed, humidified CO2 pneumoperitoneum in elderly patients undergoing laparoscopic colorectal surgery. METHODS We enrolled 245 patients between January 2016 and August 2018.The experimental group (warming and humidification group [WH]) received warmed (37°C), humidified (98%) insufflation of CO2, and the control group (cold, dry CO2/control group [CD]) received standard CO2 (19°C, 0%). All other aspects of patient care were standardized. Intraoperative hemodynamic data, arterial blood pH, and lactic acid levels were recorded. We also recorded intra-abdominal pressure, incidence of shivering 1 hour after surgery, satisfaction scores of patients and surgeons 24 hours after surgery, times to first flatus/defecation, first bowel movement, and tolerance of semiliquid food, discharge time, and incidence of vomiting, diarrhea, and surgical site infections. RESULTS Compared with the WH group, heart rate and mean arterial pressure were significantly higher from T3 to T8 (P < .05), lactic acid levels were significantly higher from T4 to T9 (P < .05), and recovery time in the post-anesthesia care unit (PACU) was significantly longer in the CD group (P < .05). Patient and surgeon satisfaction scores were significantly higher in the WH group than the CD group (P < .05). In addition, the times to first flatus/defecation and bowel movement were significantly longer in the CD group (P < .05). No significant differences were noted between the groups in the time to tolerance of semiliquid food and time of discharge (P > .05). The incidence of vomiting, diarrhea, and shivering was significantly lower in the WH group (P < .05). The number of patients with a shivering grade of 0 was significantly higher in the WH group, whereas the number with a shivering grade of 3 was significantly higher in the CD group (P < .05). CONCLUSION Warmed, humidified insufflation of CO2 in elderly patients undergoing laparoscopic colorectal surgery could stabilize hemodynamics, and reduce lactic acid levels, recovery time in the PACU, and the incidence of acute gastrointestinal injury-related symptoms.
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Mirabella A, Fiorentini T, Tutino R, Falco N, Fontana T, De Marco P, Gulotta E, Gulotta L, Licari L, Salamone G, Melfa I, Scerrino G, Lupo M, Speciale A, Cocorullo G. Laparoscopy is an available alternative to open surgery in the treatment of perforated peptic ulcers: a retrospective multicenter study. BMC Surg 2018; 18:78. [PMID: 30253756 PMCID: PMC6156951 DOI: 10.1186/s12893-018-0413-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 09/17/2018] [Indexed: 02/07/2023] Open
Abstract
Background Perforated peptic ulcers (PPU) remain one of the most frequent causes of death. Their incidence are largely unchanged accounting for 2–4% of peptic ulcers and remain the second most frequent abdominal cause of perforation and of indication for gastric emergency surgery. The minimally invasive approach has been proposed to treat PPU however some concerns on the offered advantages remain. Methods Data on 184 consecutive patients undergoing surgery for PPU were collected. Likewise, perioperative data including shock at admission and interval between admission and surgery to evaluate the Boey’s score. It was recorded the laparoscopic or open treatments, the type of surgical procedure, the length of the operation, the intensive care needed, and the length of hospital stay. Post-operative morbidity and mortality relation with patient’s age, surgical technique and Boey’s score were evaluated. Results The relationship between laparoscopic or open treatment and the Boey’s score was statistically significant (p = 0.000) being the open technique used for the low-mid group in 41.1% and high score group in 100% and laparoscopy in 58.6% and 0%, respectively. Postoperative complications occurred in 9.7% of patients which were related to the patients’ Boey’s score, 4.7% in the low-mid score group and 21.4% in the high risk score group (p = 0.000). In contrast morbidity was not related to the chosen technique being 12.8% in open technique and 5.3% in laparoscopic one (p = 0.092, p > 0.05). 30-day post-operative mortality was 3.8% and occurred in the 0.8% of low-mid Boey’s score group and in the 10.7% of the high Boey’s score group (p = 0.001). In respect to the surgical technique it occurred in 6.4% of open procedures and in any case in the Lap one (p = 0.043). Finally, there was a statistically significant difference in morbidity and mortality between patients < 70 and > 70 years old (p = 0.000; p = 0.002). Conclusions Laparoscopy tends to be an alternative method to open surgery in the treatment of perforated peptic ulcer. Morbidity and mortality were essentially related to Boey’s score. In our series laparoscopy was not used in high risk Boey’s score patients and it will be interesting to evaluate its usefulness in high risk patients in large randomized controlled trials.
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Affiliation(s)
- Antonino Mirabella
- O.U. of Emergency and General Surgery of "Villa Sofia" Hospital, Palermo, Italy
| | - Tiziana Fiorentini
- O.U. of Emergency and General Surgery of "Cervello" Hospital, Palermo, Italy
| | - Roberta Tutino
- Department of Surgical, Oncological and Stomatological Disciplines, University of Palermo, Palermo, Italy.
| | - Nicolò Falco
- Department of Surgical, Oncological and Stomatological Disciplines, University of Palermo, Palermo, Italy
| | - Tommaso Fontana
- Department of Surgical, Oncological and Stomatological Disciplines, University of Palermo, Palermo, Italy
| | - Paolino De Marco
- Department of Surgical, Oncological and Stomatological Disciplines, University of Palermo, Palermo, Italy
| | - Eliana Gulotta
- Department of Surgical, Oncological and Stomatological Disciplines, University of Palermo, Palermo, Italy
| | - Leonardo Gulotta
- Department of Surgical, Oncological and Stomatological Disciplines, University of Palermo, Palermo, Italy
| | - Leo Licari
- Department of Surgical, Oncological and Stomatological Disciplines, University of Palermo, Palermo, Italy
| | - Giuseppe Salamone
- Department of Surgical, Oncological and Stomatological Disciplines, University of Palermo, Palermo, Italy
| | - Irene Melfa
- Department of Surgical, Oncological and Stomatological Disciplines, University of Palermo, Palermo, Italy
| | - Gregorio Scerrino
- Department of Surgical, Oncological and Stomatological Disciplines, University of Palermo, Palermo, Italy
| | - Massimo Lupo
- O.U. of Emergency and General Surgery of "Villa Sofia" Hospital, Palermo, Italy
| | - Armando Speciale
- O.U. of Emergency and General Surgery of "Cervello" Hospital, Palermo, Italy
| | - Gianfranco Cocorullo
- Department of Surgical, Oncological and Stomatological Disciplines, University of Palermo, Palermo, Italy
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Risk factors for intraabdominal abscess formation after laparoscopic appendectomy - results from the Pol-LA (Polish Laparoscopic Appendectomy) multicenter large cohort study. Wideochir Inne Tech Maloinwazyjne 2018; 14:70-78. [PMID: 30766631 PMCID: PMC6372867 DOI: 10.5114/wiitm.2018.77272] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 07/04/2018] [Indexed: 01/29/2023] Open
Abstract
Introduction According to meta-analyses laparoscopic appendectomy is associated with many benefits. However, in comparison to open surgery an increased rate of intraabdominal abscesses (IAA) has been reported. Identification of predictive factors for this complication may help to identify patients with higher risk of IAA. Aim To identify potential risk factors for intraabdominal abscess after laparoscopic appendectomy (LA). Material and methods Eighteen surgical units in Poland and Germany submitted data of patients undergoing LA to the online web-based database created by the Polish Videosurgery Society of the Association of Polish Surgeons. It comprised 31 elements related to the pre-, intra- and postoperative period. Surgical outcomes were compared among the groups according to occurrence of IAA. Univariate and multivariate logistic regression models were used to identify potential risk factors for IAA. Results 4618 patients were included in the analysis. IAA were found in 51 (1.10%) cases. Although several risk factors were found in univariate analysis, in the multivariate model, only the presence of complicated appendicitis was statistically significant (OR = 2.98, 95% CI: 1.11–8.04). Moreover, IAA has a significant influence on postoperative reintervention rate (OR = 126.95, 95% CI: 67.98–237.06), prolonged length of stay > 8 days (OR = 41.32, 95% CI: 22.86–74.72) and readmission rate (OR = 33.89, 95% CI: 18.60–34.73). Conclusions Intraabdominal abscesses occurs relatively rarely after LA. It is strongly associated with complicated appendicitis. Occurrence of this complication has a great influence on the postoperative period and due to the nature of its treatment is associated with the need for reintervention, prolonged length of stay and by extension possible readmission.
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Poillucci G, Mortola L, Podda M, Di Saverio S, Casula L, Gerardi C, Cillara N, Presenti L. Laparoscopic appendectomy vs antibiotic therapy for acute appendicitis: a propensity score-matched analysis from a multicenter cohort study. Updates Surg 2017; 69:531-540. [PMID: 29101666 DOI: 10.1007/s13304-017-0499-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 10/25/2017] [Indexed: 12/13/2022]
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A prospective non-randomized controlled, multicenter trial comparing Appendectomy and Conservative Treatment for Patients with Uncomplicated Acute Appendicitis (the ACTUAA study). Int J Colorectal Dis 2017; 32:1649-1660. [PMID: 28812175 DOI: 10.1007/s00384-017-2878-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/28/2017] [Indexed: 02/04/2023]
Abstract
PURPOSE Acute appendicitis (AA) is among the most common causes of lower abdominal pain and admissions to the emergency department. Over the past 20 years, there has been a renewed interest in the conservative management of uncomplicated AA, and several studies demonstrated that an antibiotic-first strategy is a viable treatment option for uncomplicated AA. The aim of this prospective non-randomized controlled, multicenter trial is to compare antibiotic therapy and emergency appendectomy as treatment for patients with uncomplicated AA confirmed by US and/or CT or MRI scan. METHODS All adult patients in the age range 18 to 65 years with suspected AA, consecutively admitted to the Surgical Department of the 13 participating Italian Hospitals, will be invited to take part in the study. A multicenter prospective collected registry developed by surgeons, radiologists, and pathologists with expertise in the diagnosis and treatment of uncomplicated acute appendicitis represents the best research method to assess the long-term role of antibiotics in the management of the disease. Comparison will be made between surgical and antibiotic-first approaches to uncomplicated AA through the analysis of the primary outcome measure of complication-free treatment success rate based on 1-year follow-up. Quality of life, length of hospital stay, pain evaluation, and time to return to normal activity will be evaluated as secondary outcome measures. TRIAL REGISTRATION Clinicaltrials.gov ID: NCT03080103.
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Salamone G, Raspanti C, Licari L, Falco N, Rotolo G, Augello G, Melfa G, Gulotta G. Non-Occlusive Mesenteric Ischemia (NOMI) in Parkinson's disease: case report. G Chir 2017; 38:71-76. [PMID: 28691670 PMCID: PMC5509387 DOI: 10.11138/gchir/2017.38.2.071] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Non-occlusive mesenteric ischemia (NOMI) is a severe pathological condition characterized by signs and symptoms of bowel obstruction, intestinal necrosis resulting from acute and/or chronic inadequate blood perfusion, in the absence of an organic vascular obstruction detectable by imaging techniques. A 64 years old man case with a history of Parkinson's disease in high-functioning levodopa treatment is presented. Clinical and radiological signs of intestinal obstruction were observed. He underwent surgical operation with total colectomy and terminal ileostomy for generalized secondary peritonitis due to perforation of sigmoid colon. Ischemic pancolitis was first suspected. In third post-operative day a contrastenhanced CT scan was performed in the evidence of fever and sub-occlusive symptoms. It was found absence of reliable evidence of vascular changes; superior mesenteric artery and vein patency is maintained A NOMI was then diagnosed. NOMI represents about 0.04% of mesenteric artery diseases. It is correlated with a poor prognosis with a mortality estimated of 70-90%. Parkinson's disease, considering neurodegenerative alterations that characterize it, can be considered as a predisposing factor. The combined treatment with high doses of levodopa and vasodilators, such as PGE (Prostaglandin E), can contribute to an improvement in prognosis.
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