Damage control operations in non-trauma patients: defining criteria for the staged rapid source control laparotomy in emergency general surgery

The effect of damage control laparotomy on surgical-site infection risks after emergent intestinal surgery

INTRODUCTION

Damage-control laparotomy has been widely used in general surgery. However, associated surgical-site infection risks have rarely been investigated. Damage-control laparotomy allows for additional opportunities for decontamination. We hypothesized that damage-control laparotomy would be associated with lower surgical-site infection risks compared with laparotomy with only primary fascial closure or with primary fascial and skin closure.

METHODS

Patients admitted for emergent intestinal surgery from 2006 to 2021 were included. Multivariate analyses were performed to identify surgical-site infection-associated risk factors. Although variables like laparotomy type (damage-control laparotomy, primary fascial closure, and primary fascial and skin closure) were provided by National Surgical Quality Improvement Program, other variables such as number of operations were retrospectively collected. P < .05 was considered significant.

RESULTS

Overall, 906 patients were included; 213 underwent damage-control laparotomy, 175 primary fascial closure, and 518 primary fascial and skin closure. Superficial, deep, and organ-space surgical-site infection developed in 66, 6, and 97 patients, respectively. Compared with primary fascial and skin closure, both damage-control laparotomy (odds ratio, 0.30 [95% CI, 0.13-0.73], P = .008) and primary fascial closure (odds ratio, 0.09 [95% CI, 0.02-0.37], P = .001) were associated with lower superficial incisional surgical-site infection but not organ-space surgical-site infection risk (odds ratio, 0.80 [95% CI, 0.29-2.19] P = .667 and odds ratio, 0.674 [95% CI, 0.21-2.14], P = .502, respectively). Body mass index was associated with increased risk of superficial incisional surgical-site infection (odds ratio, 1.06 [95% CI, 1.03-1.09], P < .001) whereas frailty was associated with organ space surgical-site infection (odds ratio, 3.28 [95% CI, 1.29-8.36], P = .013). For patients who underwent damage-control laparotomy, the number of operations did not affect risk of either superficial incisional surgical-site infection or organ space SSI.

CONCLUSION

Herein, compared with primary fascial and skin closure, both damage-control laparotomy and primary fascial closure were associated with lower superficial but not organ space surgical-site infection risks. For patients who underwent damage-control laparotomy, number of operations did not affect surgical-site infection risks.

Magnitude of in-hospital mortality and its associated factors among patients undergone laparotomy at tertiary public hospitals, West Oromia, Ethiopia, 2022

INTRODUCTION

Laparotomy surgery, which involves making an incision in the abdominal cavity to treat serious abdominal disease and save the patient's life, causes significant deaths in both developed and developing countries, including Ethiopia. The number studies examining in-hospital mortality rates among individuals that undergone laparotomy surgery and associated risk factors is limited.

OBJECTIVE

To assess the magnitude of in-hospital mortality and its associated factors among patients undergone laparotomy at tertiary hospitals, West Oromia, Ethiopia, 2022.

METHODS

An institutional based retrospective cross-sectional study was conducted from January 1, 2017, to December 31, 2021. Data were collected using systematic random sampling and based on structured and pretested abstraction sheets from 548 medical records and patient register log. Data were checked for completeness and consistency, coded, imported using Epi-data version 4.6, cleaned and analyzed using SPSS version 25 software. Variables with p < 0.2 in the Bi-variable logistic regression analysis were included in the multivariate logistic regression analysis. The fit of the model was checked by the Hosmer‒Lemeshow test. Using the odds ratio adjusted to 95% CI and a p value of 0.05, statistical significance was declared.

RESULTS

A total of 512 patient charts were reviewed, and the response rate was 93.43%. The overall magnitude of in-hospital mortality was 7.42% [95% CI: 5.4-9.8]. American society of Anesthesiology physiological status greater than III [AOR = 7.64 (95% CI: 3.12-18.66)], systolic blood pressure less than 90 mmHg [AOR = 6.11 (95% CI: 1.98-18.80)], preoperative sepsis [AOR = 3.54 (95% CI: 1.53-8.19)], ICU admission [AOR = 4.75 (95% CI: 1.50-14.96)], and total hospital stay greater than 14 days [(AOR = 6.76 (95% CI: 2.50-18.26)] were significantly associated with mortality after laparotomy surgery.

CONCUSSION

In this study, overall in- hospital mortality was high. Early identification patient's American Society of Anesthesiologists physiological status and provision of early appropriate intervention, and pays special attention to patients admitted with low systolic blood pressure, preoperative sepsis, intensive care unit admission and prolonged hospital stay to improve patient outcomes after laparotomy surgery.

Typhoid Intestinal Perforation Prognostic Score in Poor-Resource Settings

Background

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

Objectives

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

Materials and Methods

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

Results

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

Conclusion

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

Intraoperative Surgical Strategy in Abdominal Emergency Surgery

BACKGROUND

Emergency abdominal surgery is associated with a high rate of postoperative complications and death. Pre- and immediate postoperative bundle-care strategies have improved outcome, but so far, no standardized intraoperative strategies have been proposed. We introduced a quality improvement model of specific intra- and postoperative strategies for the heterogenous group of patients undergoing emergency abdominal surgery. The objective was to evaluate a quality improvement strategy, using an intraoperative, multidisciplinary time-out model in emergency abdominal surgery to apply one of three surgical strategies; definitive-palliative-or damage control surgery.

METHODS

All patients scheduled for any gastrointestinal emergency procedure were stratified dynamically according to standardized criteria for performing definitive-palliative-or damage control surgery. Pre- intra- and postoperative data were collected according to the intraoperative strategy applied. Postoperative complications were displayed according to the Clavien-Dindo-score and the CCI (Comprehensive Complication Index). 30-90-day- and 1-year mortality was presented.

RESULTS

We included 436 consecutive patients undergoing emergency laparotomy or laparoscopy in 2019. Intraoperative strategy was definitive in 326(75%)-palliative in 90(21%) and damage control approach in 20(4%) patients. CCI was 21(0,45), 30(17,54) and 78(54,100) in the definitive-, the palliative-, and the damage control group, respectively. 30-day mortality was; 11.7%, 26.7% and 30%, and the 1-year mortality was 16.9%, 56.7% and 40% in the definitive- the palliative- and the damage control group, respectively.

CONCLUSIONS

We present a multidisciplinary, intraoperative decision-making standard as a potential quality improvement tool of ensuring individualized intra- and postoperative treatment for every emergency surgical patient and for future research-protocols.

[Surgical wound closure in advanced peritonitis]

To date, mortality in widespread peritonitis is still high (15-20%) and increased up to 70-80% in case of septic shock. Surgeons actively discuss wound closure technique in these patients considering intraoperative findings and severity of illness. The authors present scientific data and opinions of national and foreign surgeons regarding the methods of laparotomy closure. There are still no generally accepted criteria for choosing the method of laparotomy closure in secondary widespread peritonitis. Indications and clinical efficacy of each procedure require additional research.

Study of damage control strategy for non-traumatic diseases: a single-center observational study

BACKGROUND

Damage control strategy (DCS) has been introduced not only for trauma but also for acute abdomen, but its indications and usefulness have not been clarified. We examined clinical characteristics of patients who underwent DCS and compared clinical characteristics and results with and without DCS in patients with septic shock.

METHODS

We targeted a series of endogenous abdominal diseases in Kansai Medical University Hospital from April 2013 to March 2019. Clinical characteristics of 26 patients who underwent DCS were examined. Then, clinical characteristics and results were compared between the DCS group (n = 26) and non-DCS group (n = 31) in 57 patients with septic shock during the same period.

RESULTS

All 26 patients who underwent DCS had septic shock, low mean arterial pressure (MAP) before the start of surgery, and required high-dose norepinephrine administration intraoperatively. Their discharge mortality rate was 12%. Among the patients with septic shock, the DCS group had a higher SOFA score (P = 0.008) and MAP was lower preoperatively, but it did not increase even with intraoperative administration of large amounts of fluid replacement and vasoconstrictor. There was no significant difference in 28-day mortality and discharge mortality between the two groups.

CONCLUSIONS

DCS may be useful in patients with severe septic shock.

Damage-control surgery in patients with nontraumatic abdominal emergencies: A systematic review and meta-analysis

BACKGROUND

After the successful implementation in trauma, damage-control surgery (DCS) is being increasingly used in patients with nontraumatic emergencies. However, the role of DCS in the nontrauma setting is not well defined. The aim of this study was to investigate the effect of DCS on mortality in patients with nontraumatic abdominal emergencies.

METHODS

Systematic literature search was done using PubMed. Original articles addressing nontrauma DCS were included. Two meta-analyses were performed, comparing (1) mortality in patients undergoing nontrauma DCS versus conventional surgery (CS) and (2) the observed versus expected mortality rate in the DCS group. Expected mortality was derived from Acute Physiology And Chronic Health Evaluation, Simplified Acute Physiology Score, and Portsmouth Physiological and Operative Severity Score for enUmeration of Mortality and Morbidity scores.

RESULTS

A total of five nonrandomized prospective and 16 retrospective studies were included. Nontrauma DCS was performed in 1,238 and nontrauma CS in 936 patients. Frequent indications for surgery in the DCS group were (weighted proportions) hollow viscus perforation (28.5%), mesenteric ischemia (26.5%), anastomotic leak and postoperative peritonitis (19.6%), nontraumatic hemorrhage (18.4%), abdominal compartment syndrome (17.8%), bowel obstruction (15.5%), and pancreatitis (12.9%). In meta-analysis 1, including eight studies, mortality was not significantly different between the nontrauma DCS and CS group (risk difference, 0.09; 95% confidence interval, -0.06 to 0.24). Meta-analysis 2, including 14 studies, revealed a significantly lower observed than expected mortality rate in patients undergoing nontrauma DCS (risk difference, -0.18; 95% confidence interval, -0.29 to -0.06).

CONCLUSION

This meta-analysis revealed no significantly different mortality in patients undergoing nontrauma DCS versus CS. However, observed mortality was significantly lower than the expected mortality rate in the DCS group, suggesting a benefit of the DCS approach. Based on these two findings, the effect of DCS on mortality in patients with nontraumatic abdominal emergencies remains unclear. Further prospective investigation into this topic is warranted.

LEVEL OF EVIDENCE

Systematic review and meta-analysis, level III.

Effect of Antibiotic Duration in Emergency General Surgery Patients with Intra-Abdominal Infection Managed with Open vs Closed Abdomen

BACKGROUND

Data on duration of antibiotics in patients managed with an open abdomen (OA) due to intra-abdominal infection (IAI) are scarce. We hypothesized that patients with IAI managed with OA rather than closed abdomen (CA) would have higher rates of secondary infections (SIs) independent of the duration of the antibiotic treatment.

METHODS

This was an observational, prospective, multicenter, international study of patients with IAI requiring laparotomy for source control. Demographic and antibiotic duration values were collected. Primary outcomes were SI (surgical site, bloodstream, pneumonia, urinary tract) and mortality. Statistical analysis included ANOVA, chi-square/Fisher's exact test, and logistic regression.

RESULTS

Twenty-one centers contributed 752 patients. The average age was 59.6 years, 43.6% were women, and 43.9% were managed with OA. Overall mortality was 16.1%, with higher rates among OA patients (31.6% vs 4.4%, p < 0.001). OA patients had higher Sequential Organ Failure Assessment (4.7 vs 1.8, p < 0.001), American Society of Anesthesiologists Physical Status (3.6 vs 2.7, p < 0.001), and APACHE II scores (16.1 vs 9.4, p < 0.001). The mean duration of antibiotics was 6.5 days (8.0 OA vs 5.4 CA, p < 0.001). A total of 179 (23.8%) patients developed SI (33.1% OA vs 16.8% CA, p < 0.001). Longer antibiotic duration was associated with increased rates of SI: 1 to 2 days, 15.8%; 3 to 5 days, 20.4%; 6 to 14 days, 26.6%; and more than 14 days, 46.8% (p < 0.001).

CONCLUSIONS

Patients with IAI managed with OA had higher rates of SI and increased mortality compared with CA. A prolonged duration of antibiotics was associated with increased rates of SI. Increased antibiotic duration is not associated with improved outcomes in patients with IAI and OA.

The results of rapid source control laparotomy or open abdomen for acute diverticulitis

INTRODUCTION

Rapid source control laparotomy (RSCL) for the management of non-traumatic intra-abdominal emergencies has increased over the past 25 years when it was advocated for trauma patients. Little data, however, support its widespread use. We hypothesize that the patients with RSCL will have poorer outcomes than those treated with primary fascial closure (PFC).

METHODS

Patients operated for acute diverticulitis from 2014 to 2016 using The American College of Surgeons sponsored National Surgical Quality Improvement Program (NSQIP) data were reviewed. Two groups were identified: PFC, patients with their closed fascia but skin left open (PFC) and RSCL, patients with their left open fascia after the initial operation. The primary outcome of the study was 30-day mortality, with secondary analyses evaluating complications, discharge location and length of stay. Univariate analysis was initially performed followed by propensity score matching.

RESULTS

A total of 460 patients were surgically treated for Hinchey IV diverticulitis of whom 101 (21.9%) had RSCL. The length of stay of the RSCL patients was significantly longer (15 versus 12 days, p, 0.02) than patients in the PFC group. Similarly, the discharge destination for the PFC group was twice as likely to be discharged home as the RSCL group.

CONCLUSION

RSCL for acute diverticulitis is a widely used but is associated with prolonged hospitalizations resulting in high rates of discharge to skilled nursing or rehabilitation facilities. Its routine use for diverticulitis should be limited.

Staged laparotomy for acute non-traumatic intra-abdominal emergencies in a tertiary South African unit

INTRODUCTION

Patients undergoing laparotomy for emergency general surgery (EGS) have poor outcomes. Attempts have been made to improve these outcomes by adopting damage control principles known to benefit polytraumatized patients. Studies describing the use of staged laparotomy (SL) in EGS have been modest in size and heterogenous. The aim of this study was to describe our experience with SL at a tertiary hospital in KwaZulu-Natal, South Africa.

METHODS

The Hybrid Electronic Medical Registry (HEMR) at Greys Hospital was interrogated for all consecutive admissions undergoing staged EGS laparotomy. Descriptive and inferential statistics were performed.

RESULTS

From 2012 to 2018, 242 patients (16.5% of all EGS laparotomies) underwent SL for an EGS condition. The median patient age was 38 years old (IQR 27-56 years). Physiological indications were present in 125 patients (51.7%) and non-physiological indications (NPI) in 117 (48.3%). Haemodynamic instability was the most common physiological indication (51; 21.1%) and gross contamination was the most non-physiological indication (91; 37.6%). Adverse event and mortality rates were 84.8% and 26.9%, respectively. Independent predictors of mortality were enteric breach (OR3.9; 95% CI (2.1-7.8)), physiological indication (OR 2.1; 95% CI (1.1-3.7)) and anastomosis (OR 2.0; 1.05-3.73). "Clip and drop" did not contribute to mortality (P = 0.43; OR1.34 (0.64-2.7)). Mortality was higher in the group without repeat laparotomy. Mortality rate was not associated with increasing number of relaparotomies.

CONCLUSION

Patients undergoing EGS laparotomy form a high-risk group. "Clip and drop" approach and number of relaparotomies were not associated with mortality. Indications and components of this approach need to be standardized.

State-of-the-art surgery for sigmoid diverticulitis

Background

In the last two decades, there has been a Copernican revolution in the decision-making for the treatment of Diverticular Disease.

Purpose

This article provides a report on the state-of-the-art of surgery for sigmoid diverticulitis.

Conclusion

Acute diverticulitis is the most common reason for colonic resection after cancer; in the last decade, the indication for surgical resection has become more and more infrequent also in emergency. Currently, emergency surgery is seldom indicated, mostly for severe abdominal infective complications. Nowadays, uncomplicated diverticulitis is the most frequent presentation of diverticular disease and it is usually approached with a conservative medical treatment. Non-Operative Management may be considered also for complicated diverticulitis with abdominal abscess. At present, there is consensus among experts that the hemodynamic response to the initial fluid resuscitation should guide the emergency surgical approach to patients with severe sepsis or septic shock. In hemodynamically stable patients, a laparoscopic approach is the first choice, and surgeons with advanced laparoscopic skills report advantages in terms of lower postoperative complication rates. At the moment, the so-called Hartmann’s procedure is only indicated in severe generalized peritonitis with metabolic derangement or in severely ill patients. Some authors suggested laparoscopic peritoneal lavage as a bridge to surgery or also as a definitive treatment without colonic resection in selected patients. In case of hemodynamic instability not responding to fluid resuscitation, an initial damage control surgery seems to be more attractive than a Hartmann’s procedure, and it is associated with a high rate of primary anastomosis.

Inguinoscrotal hernias containing stomach: risk of emergency presentation

INTRODUCTION

Inguinoscrotal hernias are the commonest form of abdominal wall hernia, but for them to contain stomach is extremely rare. The management of these hernias can be very challenging owing to their acute nature of presentation and distortion of anatomy. Our aim was to systematically review the literature for all reported cases of inguinoscrotal hernias containing stomach. In turn we analysed patient demographics, site of hernia, presentation and treatment. Outcomes were reviewed where available.

METHOD

We conducted a systematic search of the PUBMED, Embase and Medline databases with a combination of keywords: Hernia AND (inguin* OR scrot*) AND (gastric OR gastro*). An author's own case has also been included.

RESULTS

There were 20 case reports included in the review, plus the author's own case. They ranged in publication date from 1942 to 2020. Mean age at presentation was 71 years (range 49 to 87). All cases were male. In total, 62% (n = 13) of cases presented with combined symptoms of abdominal pain and vomiting, 48% (n = 10) presented with gastric outlet obstruction (GOO) and 48% (n = 10) presented with gastric perforation. All successfully treated cases with gastric perforation required a midline laparotomy approach, whereas 56% (n = 5) of patients in the GOO group were successfully treated conservatively. There were three deaths reported in this review, all in the gastric perforation group.

CONCLUSION

Stomach as a content of inguinoscrotal hernias is extremely rare. These hernias predominantly present acutely in the form of GOO or gastric perforation. All patients with gastric perforation will require a midline laparotomy. Patients with GOO can be successfully managed either surgically or in selective cases with conservative management.

Trauma and nontrauma damage-control laparotomy: The difference is delirium (data from the Eastern Association for the Surgery of Trauma SLEEP-TIME multicenter trial)

BACKGROUND

Damage-control laparotomy (DCL) has been used for traumatic and nontraumatic indications. We studied factors associated with delirium and outcome in this population.

METHODS

We reviewed DCL patients at 15 centers for 2 years, including demographics, Charlson Comorbidity Index (CCI), diagnosis, operations, and outcomes. We compared 30-day mortality; renal failure requiring dialysis; number of takebacks; hospital, ventilator, and intensive care unit (ICU) days; and delirium-free and coma-free proportion of the first 30 ICU days (DF/CF-ICU-30) between trauma (T) and nontrauma (NT) patients. We performed linear regression for DF/CF-ICU-30, including age, sex, CCI, achievement of primary fascial closure (PFC), small and large bowel resection, bowel discontinuity, abdominal vascular procedures, and trauma as covariates. We performed one-way analysis of variance for DF/CF-ICU-30 against traumatic brain injury severity as measured by Abbreviated Injury Scale for the head.

RESULTS

Among 554 DCL patients (25.8% NT), NT patients were older (58.9 ± 15.8 vs. 39.7 ± 17.0 years, p < 0.001), more female (45.5% vs. 22.1%, p < 0.001), and had higher CCI (4.7 ± 3.3 vs. 1.1 ± 2.2, p < 0.001). The number of takebacks (1.7 ± 2.6 vs. 1.5 ± 1.2), time to first takeback (32.0 hours), duration of bowel discontinuity (47.0 hours), and time to PFC were similar (63.2 hours, achieved in 73.5%). Nontrauma and T patients had similar ventilator, ICU, and hospital days and mortality (31.0% NT, 29.8% T). Nontrauma patients had higher rates of renal failure requiring dialysis (36.6% vs. 14.1%, p < 0.001) and postoperative abdominal sepsis (40.1% vs. 17.1%, p < 0.001). Trauma and NT patients had similar number of hours of sedative (89.9 vs. 65.5 hours, p = 0.064) and opioid infusions (106.9 vs. 96.7 hours, p = 0.514), but T had lower DF/CF-ICU-30 (51.1% vs. 73.7%, p = 0.029), indicating more delirium. Linear regression analysis indicated that T was associated with a 32.1% decrease (95% CI, 14.6%-49.5%; p < 0.001) in DF/CF-ICU-30, while achieving PFC was associated with a 25.1% increase (95% CI, 10.2%-40.1%; p = 0.001) in DF/CFICU-30. Increasing Abbreviated Injury Scale for the head was associated with decreased DF/CF-ICU-30 by analysis of variance (p < 0.001).

CONCLUSION

Nontrauma patients had higher incidence of postoperative abdominal sepsis and need for dialysis, while T was independently associated with increased delirium, perhaps because of traumatic brain injury.

LEVEL OF EVIDENCE

Therapeutic study, level IV.

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

Background

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

Case presentation

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

Conclusion

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

Is open abdominal management useful in nontrauma emergency surgery for older adults? A single-center retrospective study

PURPOSE

Open abdominal management (OAM) is being adopted increasingly frequently in nontrauma patients. This study assessed the effectiveness of OAM in nontrauma older adults.

METHODS

We retrospectively reviewed all adults who underwent nontrauma emergency laparotomy requiring postoperative intensive care unit (ICU) management between September 2012 and August 2017 at our hospital. Patients ≥ 80 years old, who underwent OAM, were compared with those < 80 years old. The primary outcome was the 90-day mortality. Secondary outcomes were the 30-day mortality, unplanned relaparotomy, and the ICU length of stay (LOS).

RESULTS

The OAM group comprised 58 patients, including 27 who were ≥ 80 years old. The patients ≥ 80 years old in the OAM group had a significantly higher 90-day mortality rate (33% vs. 10%; p = 0.027) than those < 80 years old. There were no significant differences in the 30-day mortality rate, patients' unplanned relaparotomy rate, or ICU LOS between the patients ≥ 80 years old and those < 80 in the OAM group.

CONCLUSIONS

Older adults who underwent OAM had a significantly higher mortality rate than younger patients. However, the OAM strategy for older nontrauma patients may still be useful and reasonable considering the severe condition of these patients.

Planned Versus On-Demand Relaparotomy Strategy in Initial Surgery for Non-occlusive Mesenteric Ischemia

BACKGROUND

There has been insufficient evidence regarding a treatment strategy for patients with non-occlusive mesenteric ischemia (NOMI) due to the lack of large-scale studies. We aimed to evaluate the clinical benefit of strategic planned relaparotomy in patients with NOMI using detailed perioperative information.

METHODS

We conducted a multicenter retrospective cohort study that included NOMI patients who underwent laparotomy. In-hospital mortality, 28-day mortality, incidence of total adverse events, ventilator-free days, and intensive care unit (ICU)-free days were compared between groups experiencing the planned and on-demand relaparotomy strategies. Analyses were performed using a multivariate mixed effects model and a propensity score matching model after adjusting for pre-operative, intra-operative, and hospital-related confounders.

RESULTS

A total of 181 patients from 17 hospitals were included, of whom 107 (59.1%) were treated using the planned relaparotomy strategy. The multivariate mixed effects regression model indicated no significant differences for in-hospital mortality (61 patients [57.0%] in the planned relaparotomy group vs. 28 patients [37.8%] in the on-demand relaparotomy group; adjusted odds ratio [95% confidence interval] = 1.94 [0.78-4.80]), as well as in 28-day mortality, adverse events, and ICU-free days. Significant reduction in ventilator-free days was observed in the planned relaparotomy group. Propensity score matching analysis of 61 matched pairs with comparable patient severity did not show superiority of the planned relaparotomy strategy.

CONCLUSIONS

The planned relaparotomy strategy, compared with on-demand relaparotomy strategy, did not show clinical benefits after the initial surgery of patients with NOMI. Further studies estimating potential subpopulations who may benefit from this strategy are required.

Total gastrectomy in a case of complicated gastric volvulus: Case report and review of literature

INTRODUCCIóN: Gastric volvulus is characterized by a rotation, in its long or short axis, generating various degrees of obstruction, which can occur acutely or chronically.

CASE

A 45-year-old female. Refers to the performance of laparoscopic Nissen fundoplication 4 years ago. In December 2018, she presented a recurrence of the symptoms associated with reflux, for which a new laparoscopic fundoplication was performed (outside our medical unit) without eventualities or apparent complications. Six months later, he was admitted to our medical unit due to intolerance to the oral route. Thoraco-abdomino-pelvic tomography reports images suggestive of gastric volvulus and mixed hiatal hernia with protrusion of colon, stomach, duodenum, jejunum and mesenteric vessels, with data suggestive of complication or ischemia of these structures. An emergency operating room was requested to perform an exploratory laparotomy. Gastric volvulus, ischemia and gastric necrosis were observed in the cavity, for which a total gastrectomy and restitution of the intestinal transit were carried out by means of an esophagus-jejunum end-to-side Roux-en-Y anastomosis.

DISCUSSION

There is no scientific evidence or algorithms described for the management of this condition, according to the management described in the literature, decision-making by our team surgical procedure matches current recommendations.

CONCLUSION

In accordance with what is described in the literature, we consider it important to carry out a retrospective study that describes the bases for standardizing the management of this complication, and assessing models for conducting prospective multicenter studies that allow the creation of an algorithm and clinical guideline.

Hierarchical regression of ASA prediction model in predicting mortality prior to performing emergency laparotomy a systematic review

BACKGROUND

In light of increasing litigations around performing emergency surgery, various predictive tools are used for prediction of mortality prior to surgery. There are many predictive tools reported in literature, with ASA being one of the most widely accepted tools. Therefore, we attempted to perform a systematic review and meta-analysis to conclude ASA's ability in predicting mortality for emergency surgeries.

METHODS

A wide literature search was conducted across MEDLINE and other databases using PubMed and Ovid with the following keywords; "Emergency laparotomy", "Surgical outcomes", "Mortality" and "Morbidity." A total of 3989 articles were retrieved and only 11 articles met the inclusion criteria for this meta-analysis. Data was pooled and then analysed using the STATA 16.1 software. We conducted hierarchal regression between the following variables; mortality, gender, low ASA (ASA 1-2) and high ASA (ASA 3-5).

RESULTS

1. High ASA was associated with a higher rate of mortality in males with 'p' value of 0.0001 at alpha value of 0.025. 2. The female gender itself showed a significantly high mortality rate, irrespective of low ASA or high ASA with 'p' value of 0.04 at alpha value of 0.05. 3. ITU admissions with a high ASA had a greater number of deaths compared to low ASA. 'p' value of 0.0054 at alpha value of 0.01.

CONCLUSION

Higher ASA showed a direct association with mortality and the male gender. The female gender was associated with a higher risk of mortality regardless of the ASA grades.

Damage control surgery for the treatment of perforated acute colonic diverticulitis: A systematic review

BACKGROUND

Acute colonic diverticulitis (ACD) complications arise in approximately 8% to 35% patients and the most common ones are represented by phlegmon or abscess, followed by perforation, peritonitis, obstruction, and fistula. In accordance with current guidelines, patients affected by generalized peritonitis should undergo emergency surgery. However, decisions on whether and when to operate ACD patients remain a substantially debated topic while algorithm for the best treatment has not yet been determined. Damage control surgery (DCS) represents a well-established method in treating critically ill patients with traumatic abdomen injuries. At present, such surgical approach is also finding application in non-traumatic emergencies such as perforated ACD. Thanks to a thorough systematic review of the literature, we aimed at achieving deeper knowledge of both indications and short- and long-term outcomes related to DCS in perforated ACD.

METHODS

We performed a systematic literature review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA) guidelines. Pubmed/MEDLINE, Embase, Scopus, Cochrane Library, and Web of Science databases were used to search all related literature.

RESULTS

The 8 included articles covered an approximately 13 years study period (2006-2018), with a total 359 patient population. At presentation, most patients showed III and IV American Society of Anesthesiologists (ASA) score (81.6%) while having Hinchey III perforated ACD (69.9%). Most patients received a limited resection plus vacuum-assisted closure at first-look while about half entire population underwent primary resection anastomosis (PRA) at a second-look. Overall morbidity rate, 30-day mortality rate and overall mortality rate at follow-up were between 23% and 74%, 0% and 20%, 7% and 33%, respectively. Patients had a 100% definitive abdominal wall closure rate and a definitive stoma rate at follow-up ranging between 0% and 33%.

CONCLUSION

DCS application to ACD patients seems to offer good outcomes with a lower percentage of patients with definitive ostomy, if compared to Hartmann's procedure. However, correct definition of DCS eligible patients is paramount in avoiding overtreatment. In accordance to 2016 WSES (World Society of Emergency Surgery) Guidelines, DCS remains an effective surgical strategy in critically ill patients affected by sepsis/septic shock and hemodynamical unstability.

Retrospective Validation of an Algorithmic Treatment Pathway for Necrotizing Pancreatitis

The role of surgical intervention for necrotizing pancreatitis has evolved; however, no widely accepted algorithm has been established to guide timing and optimal modality in the minimally invasive era. This study aimed to retrospectively validate an established institutional timing- and physiologic-based algorithm constructed from evidence-based guidelines in a high-volume hepatopancreatobiliary center. Patients with necrotizing pancreatitis requiring early (≤six weeks from symptom onset) or delayed (>six weeks) surgical intervention were reviewed over a four-year period (n = 100). Early intervention was provided through laparoscopic drain-guided retroperitoneal debridement (n = 15) after failed percutaneous drainage unless they required an emergent laparotomy (due to abdominal compartment syndrome, bowel necrosis/perforation, or hemorrhage) after which conservative, sequential open necrosectomy was performed (n = 47). Robot-assisted (n = 16) versus laparoscopic (n = 22) transgastric cystgastrostomy for the delayed management of walled-off pancreatic necrosis was compared, including patient factors, operative characteristics, and 90-day clinical outcomes. Major complications after early debridement were similarly high (open 25% and drain-guided 27%), yet 90-day mortality was low (open 8.5% and drain-guided 7.1%). Patient and operative characteristics and 90-day outcomes were statistically similar for robotic versus laparoscopic transgastric cystogastrostomy. Our evidence-based algorithm provides a stepwise approach for the management of necrotizing pancreatitis, emphasizing minimally invasive early and late interventions when feasible with low morbidity and mortality. Robot-assisted transgastric cystogastrostomy is an acceptable alternative to a laparoscopic approach for the delayed treatment of walled-off pancreatic necrosis.

Are the Benefits of Rapid Source Control Laparotomy Realized after Acute Colonic Perforation?

Background: The indications for damage-control laparotomy (DCL) in patients with intra-abdominal injuries have evolved from its use in trauma patients with hypothermia, coagulopathy, and acidosis to use in general surgical patients with acute intestinal perforations. Whereas some patients may be acidotic, most are not hypothermic or afflicted with coagulopathies. Recent study suggests the benefits to patients of rapid source-control laparotomy (RSCL) are not realized in patients with acute abdominal emergencies. Methods: Three years of data (2014-2016) from The American College of Surgeons National Surgical Quality Improvement Program (ACSNSQIP) were assessed. The patient populations were separated into RSCL patients who had their fascia left open after the initial source control operation and those who had primary fascial closure (PFC). The principal outcome of interest in this study was death within thirty days. A secondary analysis was performed evaluating complications and length of stay. Results: Of the 1,381 patients who qualified for the study, 396 (28.7%) were managed with RSCL and the remaining 985 patients had PFC. After a univariable analysis, propensity score matching was performed. The median hospital length of stay was 20 days (95% confidence interval [CI] 18-22) versus 14 (95% CI 13-16; p < 0.001) in RSCL and PFC, respectively. A larger number of patients having RSCL went to a rehabilitation facility than those having PFC (18.7%; versus 11.2%; p = 0.014). The 30-day mortality rate in patients in the RSCL group was significantly higher than in the PFC group ((32.6% versus 16.9%; p < 0.001). Conclusion: These data provide strong evidence that RSCL may not be beneficial for routine use in perforated colon surgery.

Rethinking our definition of operative success: predicting early mortality after emergency general surgery colon resection

Background

The postoperative outcomes of emergency general surgery patients can be fraught with uncertainty. Although surgical risk calculators exist to predict 30-day mortality, they are often of limited utility in preparing patients and families for immediate perioperative complications. Examination of trends in mortality after emergent colectomy may help inform complex perioperative decision-making. We hypothesized that risk factors could be identified to predict early mortality (before postoperative day 5) to inform operative decisions.

Methods

This analysis was a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program database (2012-2014). Patients were stratified into three groups: early death (postoperative day 0-4), late death (postoperative day 5-30), and those who survived. Multivariable logistic regression was used to explore characteristics associated with early death. Kaplan-Meier models and Cox regression were used to further characterize their impact.

Results

A total of 18 803 patients were analyzed. Overall 30-day mortality was 12.5% (3316); of these, 37.1% (899) were early deaths. The preoperative factors most predictive of early death were septic shock (OR 3.62, p<0.001), ventilator dependence (OR 2.81, p<0.001), and ascites (OR 1.63, p<0.001). Postoperative complications associated with early death included pulmonary embolism (OR 5.78, p<0.001), presence of new-onset or ongoing postoperative septic shock (OR 4.45, p<0.001) and new-onset renal failure (OR 1.89, p<0.001). Patients with both preoperative and postoperative shock had an overall mortality rate of 47% with over half of all deaths occurring in the early period.

Conclusions

Nearly 40% of patients who die after emergent colon resection do so before postoperative day 5. Early mortality is heavily influenced by the presence of both preoperative and new or persistent postoperative septic shock. These results demonstrate important temporal trends of mortality, which may inform perioperative patient and family discussions and complex management decisions.

Level of evidence

Level III. Study type: Prognostic.

A strategy for improving the prognosis of non-occlusive mesenteric ischemia (NOMI): a single-center observational study

Aim

The purpose of this study was to determine the prognostic factors of non‐occlusive mesenteric ischemia (NOMI) and to examine treatment strategies that could improve its prognosis.

Methods

We retrospectively identified 30 patients who underwent emergency laparotomy for NOMI in Kansai Medical University Hospital (Hirakata, Japan) from April 2013 to December 2017. We examined prognostic factors related to discharge outcome and also examined the prognostic impact of open abdominal management and second look operation strategy (OSS) by dividing the patients into the non‐OSS group and the OSS group.

Results

The primary end‐point was a prognostic factor for outcome at discharge of the 30 patients. The outcome at discharge was compared between the survival group and the death group. Multivariate analysis was undertaken on two items from the univariate analysis that showed a significant difference (computed tomography findings of intestinal pneumatosis and acute disseminated intravascular coagulation [DIC] score). As a result, there was a significant difference in the factors of intestinal pneumatosis (odds ratio = 0.054; 95% confidence interval, 0.005–0.607; P = 0.018) and DIC score (odds ratio = 1.892; 95% confidence interval, 1.077–3.323; P = 0.027). The secondary end‐point was the treatment outcome before and after the application of OSS. Operation time was significantly shorter and the amount of bleeding was also significantly less in the OSS group.

Conclusion

Computed tomography findings of intestinal pneumatosis and the acute disseminated intravascular coagulation score were found to be prognostic factors for survival in patients with NOMI. Aggressive laparotomy to determine the definitive diagnosis is needed and OSS could be useful to improve patient prognosis for survival from NOMI.

A differentiated approach to repeat small-bowel anastomoses in patients with postoperative peritonitis: a prospective cohort study

BACKGROUND

Postoperative peritonitis still remains the cause of a high mortality rate in emergency abdominal surgery. Here we aimed to evaluate the efficacy of different surgical strategies for small-bowel perforations that resulted in postoperative peritonitis.

METHODS

Surgical management results for 140 patients with postoperative peritonitis due to small-bowel perforations, necrosis and anastomotic leakage were comparatively analyzed. Using the APACHE-II and MPI scoring systems, different surgeon attitudes were examined in three patient groups (primary anastomosis, delayed anastomosis, and enterostomy).

RESULTS

The surgical approach in patient group I (n = 47, APACHE-II 11.7 ± 1.2, MPI 14.7 ± 1.3) involved the closure of small-bowel perforations or small-bowel resection to place primary anastomosis. The mortality rate was 17%. Patient group II (n = 48, APACHE-II 16.8 ± 0.7, MPI 19.3 ± 0.3) underwent delayed small-bowel anastomosis during planned relaparotomies. The mortality rate was 18.8%. Because patients in patient group III (n = 45, APACHE-II 22.3 ± 1.3, MPI 24.6 ± 1.2) were in very critical condition, anastomoses were not placed after bowel resection, and the surgical procedure was completed with enterostomy. The highest mortality rate of 37.8% was documented in this patient group.

CONCLUSION

The differentiated surgical approach undertaken herein using delayed small-bowel anastomosis in more serious patients with postoperative peritonitis was able to mitigate the risk of recurrent anastomotic leaks and was not accompanied by a considerable rise in mortality. The mortality for primary repair and delayed primary closure was basically the same (17.0% and 18.8%, p = 0.03); however, delayed anastomosis in the patients with postoperative peritonitis at higher APACHE-II and MPI scores for severity of illness showed 15.1% less complications in the form of anastomotic leaks (p = 0.04).

Damage Control Surgery for Non-traumatic Abdominal Emergencies

BACKGROUND

Damage control surgery (DCS) was a major paradigm change in the management of critically ill trauma patients and has gradually expanded in the general surgery arena, but data in this setting are still scarce. The study aim was to evaluate outcomes of DCS in patients with general surgery emergencies.

METHODS

Between 2005 and 2015, 164 patients (104 men, age 66) underwent DCS for non-traumatic abdominal emergencies. The decision to perform DCS was triggered by the presence of at least one trauma DCS criterion: hypotension (<70 mmHg), hypothermia (<35 °C), acidosis (pH < 7.25), coagulopathy (INR ≥ 1.7) and massive (>5 RBC) transfusion. Statistical tests were performed to identify risk factors for operative mortality. Observed outcomes were compared to those predicted by commonly employed scores (APACHE II, POSSUM, P-POSSUM, SAPS II).

RESULTS

DCS was performed for acute mesenteric ischemia (n = 68), peritonitis (n = 44), pancreatitis (n = 28), bleeding (n = 14) and other (n = 10). Abdominal compartment syndrome was associated in 52 patients (32%). Seventy-four (45%) patients died and 150 patients (91%) experienced complications. On multivariate analysis, age (p = 0.018) and INR ≥ 1.7 (p = 0.001) were independent predictors of mortality. Mortality was 24% (13/55), 48% (22/46) and 62% (39/63) in patients with one, two and ≥3 DCS criteria, respectively. Comparison of observed and score-predicted mortality suggested DCS use resulted in significant survival benefit of the whole cohort and of patients with pancreatitis and postoperative peritonitis.

CONCLUSIONS

DCS can be lifesaving in critically ill patients with general surgery emergencies. Patients with peritonitis and acute pancreatitis are those who benefit most of the DCS approach.

2017 WSES guidelines on colon and rectal cancer emergencies: obstruction and perforation

ᅟ

Obstruction and perforation due to colorectal cancer represent challenging matters in terms of diagnosis, life-saving strategies, obstruction resolution and oncologic challenge. The aims of the current paper are to update the previous WSES guidelines for the management of large bowel perforation and obstructive left colon carcinoma (OLCC) and to develop new guidelines on obstructive right colon carcinoma (ORCC).

Methods

The literature was extensively queried for focused publication until December 2017. Precise analysis and grading of the literature has been performed by a working group formed by a pool of experts: the statements and literature review were presented, discussed and voted at the Consensus Conference of the 4th Congress of the World Society of Emergency Surgery (WSES) held in Campinas in May 2017.

Results

CT scan is the best imaging technique to evaluate large bowel obstruction and perforation. For OLCC, self-expandable metallic stent (SEMS), when available, offers interesting advantages as compared to emergency surgery; however, the positioning of SEMS for surgically treatable causes carries some long-term oncologic disadvantages, which are still under analysis. In the context of emergency surgery, resection and primary anastomosis (RPA) is preferable to Hartmann’s procedure, whenever the characteristics of the patient and the surgeon are permissive. Right-sided loop colostomy is preferable in rectal cancer, when preoperative therapies are predicted.

With regards to the treatment of ORCC, right colectomy represents the procedure of choice; alternatives, such as internal bypass and loop ileostomy, are of limited value.

Clinical scenarios in the case of perforation might be dramatic, especially in case of free faecal peritonitis. The importance of an appropriate balance between life-saving surgical procedures and respect of oncologic caveats must be stressed. In selected cases, a damage control approach may be required.

Medical treatments including appropriate fluid resuscitation, early antibiotic treatment and management of co-existing medical conditions according to international guidelines must be delivered to all patients at presentation.

Conclusions

The current guidelines offer an extensive overview of available evidence and a qualitative consensus regarding management of large bowel obstruction and perforation due to colorectal cancer.

Volvulus

Intestinal volvulus, regardless of location, is a rare disease process, but one that requires high suspicion and timely diagnosis given the increased incidence of intestinal necrosis and potential mortality. Most patients with intestinal volvulus require some form of surgical intervention. However, over the last few decades, the work-up and management of intestinal volvulus has changed given constant advancements in technology and patient care. Most importantly, however, is recognizing the need for emergent versus more elective surgery because this influences the morbidity and mortality for the individual patient.

Abdominal sepsis

PURPOSE OF REVIEW

To summarize the recent evidence on the treatment of abdominal sepsis with a specific emphasis on the surgical treatment.

RECENT FINDINGS

A multitude of surgical approaches towards abdominal sepsis are practised. Recent evidence shows that immediate closure of the abdomen has a better outcome. A short course of antibiotics has a similar effect as a long course of antibiotics in patients with intra-abdominal infection without severe sepsis.

SUMMARY

Management of abdominal sepsis requires a multidisciplinary approach. Closing the abdomen permanently after source control and only reopening it in case of deterioration of the patient without other (percutaneous) options is the preferred strategy. There is no convincing evidence that damage control surgery is beneficial in patients with abdominal sepsis. If primary closure of the abdomen is impossible because of excessive visceral edema, delayed closure using negative pressure therapy with continuous mesh-mediated fascial traction shows the best results.

Second-look laparostomy for perforated gangrenous gastric volvulus to prevent total gastrectomy

A 42-year-old Caucasian woman presented to the emergency department with severe upper abdominal pain and vomiting. Clinically, she was septic, and abdominal examination suggested peritonitis. Following immediate resuscitation, the patient was stabilised and underwent urgent contrast-enhanced CT of the abdomen and pelvis. This revealed a mesenteroaxial gastric volvulus with traction on the mesentery and a small volume of free fluid. She underwent laparotomy revealing gangrenous gastric fundus perforation complicated by persistent intraoperative hypotension. This mandated a damage-control approach for the patient's safety entailing a limited-sleeve gastrectomy and laparostomy formation. Stabilisation in the intensive care unit allowed for a safer return to the operating room. On second look 24 hours later, previously ischaemic non-viable-looking portions of the stomach had recovered their blood supply. The patient was discharged 31 days postoperatively after recovering from the operations, postoperative wound infections and pleural effusions.

Emergency treatment of complicated colorectal cancer

Aim

To find evidence to suggest the best approach in patients admitted as an emergency for complicated colorectal cancer.

Methods

The medical records of 131 patients admitted as an emergency with an obstructing, perforated, or bleeding colorectal cancer to Noble’s Hospital, Isle of Man, and the Umberto I University Hospital, Rome, were retrospectively evaluated. Patients were divided in 3 groups on the basis of the emergency treatment they received, namely 1) immediate resection, 2) damage control procedure and elective or semielective resection, and 3) no radical treatment. Demographic variables, clinical data, and treatment data were considered, and formed the basis for the comparison of groups. Primary endpoints were 90-day mortality and morbidity. Secondary endpoints were length of stay, number of lymph nodes analyzed, rate of radical R0 resections, and the number of patients who had chemoradiotherapy.

Results

Forty-two patients did not have any radical treatment because the cancer was too advanced or they were too ill to tolerate an operation, 78 patients had immediate resection and 11 had damage control followed by elective resection. There was no statistically significant difference between immediate resections and 2-stage treatment in 90-day mortality and morbidity (mortality: 15.4% vs 0%; morbidity: 26.9% vs 27.3%), number of nodes retrieved (16.6±9.4 vs 14.9±5.7), and rate of R0 resections (84.6% vs 90.9%), but mortality was slightly higher in patients who underwent immediate resection. The patients who underwent staged treatment had a higher possibility of receiving a laparoscopic resection (11.5% vs 36.4%).

Conclusion

The present study failed to demonstrate a clear superiority of one treatment with respect to the other, even if there is an interesting trend favoring staged resection.

2017 WSES guidelines for the management of iatrogenic colonoscopy perforation

Iatrogenic colonoscopy perforation (ICP) is a severe complication that can occur during both diagnostic and therapeutic procedures. Although 45–60% of ICPs are diagnosed by the endoscopist while performing the colonoscopy, many ICPs are not immediately recognized but are instead suspected on the basis of clinical signs and symptoms that occur after the endoscopic procedure. There are three main therapeutic options for ICPs: endoscopic repair, conservative therapy, and surgery. The therapeutic approach must vary based on the setting of the diagnosis (intra- or post-colonoscopy), the type of ICP, the characteristics and general status of the patient, the operator’s level of experience, and surgical device availability.

Although ICPs have been the focus of numerous publications, no guidelines have been created to standardize the management of ICPs. The aim of this article is to present the World Society of Emergency Surgery (WSES) guidelines for the management of ICP, which are intended to be used as a tool to promote global standards of care in case of ICP. These guidelines are not meant to substitute providers’ clinical judgment for individual patients, and they may need to be modified based on the medical team’s level of experience and the availability of local resources.

Rapid Source-Control Laparotomy: Is There a Mortality Benefit in Septic Shock?

BACKGROUND

In the 1990s, damage control laparotomy (DCL) became a proved approach to treat intra-abdominal injuries caused by trauma. In the ensuing two decades, this approach has been applied to non-traumatic abdominal processes as well. Although the benefits of DCL are clear, the benefit of rapid source-control laparotomy (RSCL) for non-traumatic abdominal diseases is much less clear. However, two recent cohort analyses identified significant increases in the mortality rate with RCSL compared with primary fascial closure (PFC). The purpose of this study was to assess the efficacy of RSCL in patients with septic shock.

METHODS

The 2015 National Surgical Quality Improvement Project (NSQIP) database was queried for 11 International Statistical Classifications of Diseases (ICD)-10 codes associated with septic shock. Collected data included age, gender, body mass index (BMI), wound class, American Society of Anesthesiologists (ASA) class, operative time, number of risk factors, and presence or absence of post-operative pneumonia. The risk factors were diabetes mellitus, alcohol or tobacco abuse, blood dyscrasias, disseminated cancer, and cardiac, gastrointestinal, pulmonary, hepatobiliary, or renal dysfunction. The primary outcomes were rate of re-operation, prevalence of post-operative pneumonia, hospital length of stay (LOS), and death by 30 days.

RESULTS

The RSCL and PFC cohorts were each comprised of 56 patients matched for propensity scores for ICD-10 code. There were no significant differences in wound or ASA class, BMI, gender, or number of risk factors between the two cohorts. The operative time for RSCL was significantly shorter than for PFC (median 84 vs. 128 min, respectively; p = 0.002). There was no significant difference in re-operation rate, prevalence of post-operative pneumonia, LOS, or mortality rate between the two cohorts.

CONCLUSIONS

Although this analysis showed no clear advantage to RSCL in the management of septic shock, it may be a means to salvage certain patients. The best way to assess the relative value of RSCL is a prospective trial.

Nontraumatic Emergency Laparotomy: Surgical Principles Similar to Trauma Need to Be Adopted?

OBJECTIVES

In 2011, the Royal College of Surgeons published Emergency Surgery: Standards for Unscheduled Care in response to variable clinical outcomes for emergency surgery. The purpose of this study was to examine whether different treatment modalities would alter survival.

METHODS

All patients who underwent emergency laparotomy between April 2011 and December 2012 at Warwick Hospital (Warwick, UK) were included retrospectively. Information relating to their demographics; preoperative score; primary pathology; timing of surgery; intraoperative details; and postoperative outcome, including 30-day mortality, were collated for statistical analysis.

RESULTS

In total, 91 patients underwent 97 operations. The median age was 64 years (range 50-90, male:female 1:2). Sixty-five percent of cases were obstruction and perforation, and 66% of all operations were performed during office hours. The unadjusted 30-day mortality was 15.4%. Compared with nonsurvivors, survivors had a significantly higher Portsmouth-Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity score (P < 0.001), prolonged duration of hypotension and use of inotropes (P = 0.013), higher volume of colloid use (P = 0.04), and lower core body temperature (P < 0.05). Grades of surgeons did not influence mortality.

CONCLUSIONS

The 30-day mortality rate is comparable to the national standard. Further studies are warranted to determine whether trauma management modalities may be adopted to target high-risk patients who exhibit the lethal triad of hypotension, coagulopathy, and hypothermia.

Open abdomen critical care management principles: resuscitation, fluid balance, nutrition, and ventilator management

The term "open abdomen" refers to a surgically created defect in the abdominal wall that exposes abdominal viscera. Leaving an abdominal cavity temporarily open has been well described for several indications, including damage control surgery and abdominal compartment syndrome. Although beneficial in certain patients, the act of keeping an abdominal cavity open has physiologic repercussions that must be recognized and managed during postoperative care. This review article describes these issues and provides guidelines for the critical care physician managing a patient with an open abdomen.

Rapid Source-Control Laparotomy: Is There a Mortality Benefit?

BACKGROUND

The purpose of this study was to determine the influence rapid source-control laparotomy (RSCL) has on the mortality rate in non-trauma patients with intra-abdominal infection. The hypothesis was that RSCL reduces deaths and hospital lengths of stay (LOS) in patients compared with definitive repair and primary fascial closure (PFC).

METHODS

The International Classification of Diseases-10 codes for sepsis, gastric and duodenal ulcer perforation or hemorrhage, incisional or ventral hernia with obstruction, intestinal volvulus, ileus with obstruction, diverticulitis with perforation or abscess, vascular disorder of intestine, non-traumatic intestinal perforation, peritoneal abscess, and unspecified peritonitis were used to query the 2015 National Surgical Quality Improvement Project (NSQIP) database for all patients treated with either RSCL or PFC. The two groups of patients were compared on the basis of LOS and deaths. Collected data included age, gender, body mass index (BMI), site classification, American Society of Anesthesiologists (ASA) class, operative time, number of risk factors, and pre-operative septic state.

RESULTS

After adjusting for the aforementioned variables, propensity score-matched cohorts (n = 210 in each cohort) were used to evaluate the influence of incision closure type on LOS and mortality rate. The odds of death (31.4% vs. 21.4%) with RSCL was 1.78 (95% confidence interval 1.08-2.95; p = 0.02) times that of PFC. Closure type was not significantly associated with an increased LOS (median 14 vs. 11 days; p = 0.35).

CONCLUSIONS

This retrospective cohort analysis demonstrated that RSCL is associated with higher odds of death in general surgical patients with intra-abdominal infection. There is a need for further studies to delineate what, if any, physiologic parameters indicate a need for RSCL.

Chitosan Oligosaccharide Reduces Propofol Requirements and Propofol-Related Side Effects

Propofol is one of the main sedatives but its negative side effects limit its clinical application. Chitosan oligosaccharide (COS), a kind of natural product with anti-pain and anti-inflammatory activities, may be a potential adjuvant to propofol use. A total of 94 patients receiving surgeries were evenly and randomly assigned to two groups: 10 mg/kg COS oral administration and/or placebo oral administration before being injected with propofol. The target-controlled infusion of propofol was adjusted to maintain the values of the bispectral index at 50. All patients’ pain was evaluated on a four-point scale and side effects were investigated. To explore the molecular mechanism for the functions of COS in propofol use, a mouse pain model was established. The activities of Nav1.7 were analyzed in dorsal root ganglia (DRG) cells. The results showed that the patients receiving COS pretreatment were likely to require less propofol than the patients pretreated with placebo for maintaining an anesthetic situation (p < 0.05). The degrees of injection pain were lower in a COS-pretreated group than in a propofol-pretreated group. The side effects were also more reduced in a COS-treated group than in a placebo-pretreated group. COS reduced the activity of Nav1.7 and its inhibitory function was lost when Nav1.7 was silenced (p > 0.05). COS improved propofol performance by affecting Nav1.7 activity. Thus, COS is a potential adjuvant to propofol use in surgical anesthesia.