Implementing an outpatient surgical management in moderated-high risk patients with groin hernia repair

PURPOSE

There is a growing trend to expand Ambulatory Surgery (AS) criteria in abdominal wall surgery. No Admission (NOADS) circuit. The present study aimed to assess the impact of classification criteria on postoperative results and hospital stays in a NOADS versus a conventional admission circuit to throw some light on surgical circuit inclusion.

METHODS

A retrospective analysis of a prospective;y maintained database was performed comparing groin hernia's interventions in a NOADS vs Admission circuit in our center in 2018-2021. A multiple regression predictive model followed by a retrospective retest were dessigned to assess the impact of each criterion on hospital stay. In total, 743 patients were included, 399 in the Admission circuit (ADC) and 344 in NOADS circuit (NOADS).

RESULTS

There were no statistical differences in complication or readmission rates (p = 0.343 and p = 0.563), nevertheless, a shorter hospital stay was observed in NOADS (p = 0.000). A hierarchical multiple regression predictive model proposed two opposite scenarios. The best scenario, not likely to need admission, was a female patient operated via the laparoscopic approach of a unilateral primary hernia (Estimated Postoperative Stay: 0.049 days). The worst scenario, likely to need admission, was a male patient operated via the open approach of a bilateral and recurrent hernia (Estimated Postoperative Stay: 1.505 Days).

CONCLUSION

Groin hernia patients could safely benefit from a No Admission (NOADS) circuit. Our model could be useful for surgical circuit decision-making, especially for best/worst scenarios.

Outcomes of a multidisciplinary Diabetic Foot Day Unit

OBJECTIVE

To analyse the main characteristics of patients and the health outcomes obtained and to evaluate the impact of peripheral artery disease (PAD) in patients treated in our multidisciplinary Diabetic Foot Unit.

RESEARCH DESIGN AND METHODS

Observational prospective study. 273 patients from two different populations (with and without PAD - classified according to the presence of distal pulses) treated over a 14-month period in the multidisciplinary Diabetic Foot Unit were included. The data on patient characteristics and outcomes were analysed for the purpose of comparison. For the inference study, a comparison of medians with the non-parametric test for independent samples for the quantitative variables and a χ² test for the comparison of proportions in qualitative variables were performed.

RESULTS

Patients with PAD ulcers were older (60 (54-67) vs. 64 (75-81), p=0.000) and had a higher macrovascular burden (8.1% vs. 29% for ischaemic heart disease history, p=0.000; 6.7% vs. 18.1% for cerebrovascular disease history, p=0.004). Their Texas Score was higher (p=0.000) and their major amputation rate was higher (1.4% vs. 12.3%, p=0.001). They had less background of previous ulcers (52.6% vs. 26.8%, p=0.000), their episode duration was shorter (4 (0-10) vs. 0 (0-3) weeks, p=0.000), and their proportional need for antibiotic therapy was lower (64.4% vs. 51.4%, p=0.03).

CONCLUSIONS

The differences found between ulcers with and without vascular involvement support the need for a different approach and for the inclusion of vascular surgeons on the team. The multidisciplinary care model for diabetic foot patients could be effective and improve health outcomes.

Ventral hernia repair in high-risk patients and contaminated fields using a single mesh: proportional meta-analysis

PURPOSE

The use of mesh is a common practice in ventral hernia repair (VHR). Lack of consensus on which prosthetic material works better in different settings remains. This meta-analysis aims to summarize the available evidence on hernia recurrence and complications after repair with synthetic, biologic, or biosynthetic/bioabsorbable meshes in hernias grade 2-3 of the Ventral Hernia Working Group modified classification.

METHODS

A literature search was conducted in January 2021 using Web of Science (WoS), Scopus, and MEDLINE (via PubMed) databases. Randomized Controlled Trials (RCTs) and observational studies with adult patients undergoing VHR with either synthetic, biologic, or biosynthetic/bioabsorbable mesh were included. Outcomes were hernia recurrence, Surgical Site Occurrence (SSO), Surgical Site Infection (SSI), 30 days re-intervention, and infected mesh removal. Random-effects meta-analyses of pooled proportions were performed. Quality of the studies was assessed, and heterogeneity was explored through sensitivity analyses.

RESULTS

25 articles were eligible for inclusion. Mean age ranged from 47 to 64 years and participants' follow-up ranged from 1 to 36 months. Biosynthetic/bioabsorbable mesh reported a 9% (95% CI 2-19%) rate of hernia recurrence, lower than synthetic and biologic meshes. Biosynthetic/bioabsorbable mesh repair also showed a lower incidence of SSI, with a 14% (95% CI 6-24%) rate, and there was no evidence of infected mesh removal. Rates of seroma were similar for the different materials.

CONCLUSIONS

This meta-analysis did not show meaningful differences among materials. However, the best proportions towards lower recurrence and complication rates after grade 2-3 VHR were after using biosynthetic/slowly absorbable mesh reinforcement. These results should be taken with caution, as head-to-head comparative studies between biosynthetic and synthetic/biologic meshes are lacking. Although, biosynthetic/bioabsorbable materials could be considered an alternative to synthetic and biologic mesh reinforcement in these settings.

Factors associated with recruitment success in the phase 2a study of aztreonam-avibactam development programme: a descriptive qualitative analysis among sites in Spain

OBJECTIVE

Successful clinical trials are subject to recruitment. Recently, the REJUVENATE trial, a prospective phase 2a open-label, single-arm interventional clinical trial conducted within the Innovative Medicines Initiative-supported Combatting Bacterial Resistance in Europe-Carbapenem Resistance project, was published, with 85% of the recruitment performed in Spain. We analysed the recruitment success in this trial by establishing a model of recruitment practice.

METHODS

A descriptive qualitative study was performed from May 2016 to October 2017 at 10 participating Spanish centres. Data were extracted from: (1) feasibility questionnaires to assess the centre's potential for patient enrolment; (2) delegation of responsibility records; (3) pre-screening records including an anonymised list of potentially eligible and (4) screening and enrolment records. A descriptive analysis of the features was performed by the participating centre. Pearson's and Spearman's correlation coefficients were calculated to determine factors of recruitment success.

RESULTS

The highest recruitment rate was observed in Hospitals 3 and 6 (58.8 and 47.0 patients per month, respectively). All the study teams were multidisciplinary with a median of 15 members (range: 7-22). Only Hospitals 3, 5 and 6 had dedicated nursing staff appointed exclusively to this study. Moreover, in those three hospitals and in Hospital 9, the study coordinator performed exclusive functions as a research planner, and did not assume these functions for the other hospitals. The univariate analysis showed a significant association between recruitment success and months of recruitment (p=0.024), number of staff (p<0.001), higher number of pharmacists (p=0.005), infectious disease specialists (p<0.001), the presence of microbiologist in the research team (p=0.018) and specifically dedicated nursing staff (p=0.036).

CONCLUSIONS

The existence of broad multidisciplinary teams with staff dedicated exclusively to the study as well as the implementation of a well-designed local patient assessment strategy were the essential optimisation factors for recruitment success in Spain.

TRIAL REGISTRATION NUMBER

NCT02655419; EudraCT 2015-002726-39; analysis of pre-screened patients.

Simplified risk-prediction for benchmarking and quality improvement in emergency general surgery. Prospective, multicenter, observational cohort study

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.

Pharmacokinetics and safety of aztreonam/avibactam for the treatment of complicated intra-abdominal infections in hospitalized adults: results from the REJUVENATE study

Objectives

To investigate pharmacokinetics (PK) and safety (primary objectives) and efficacy (secondary objective) of the investigational monobactam/β-lactamase inhibitor combination aztreonam/avibactam in patients with complicated intra-abdominal infection (cIAI).

Methods

This Phase 2a open-label, multicentre study (NCT02655419; EudraCT 2015-002726-39) enrolled adults with cIAI into sequential cohorts for 5–14 days treatment. Cohort 1 patients received an aztreonam/avibactam loading dose of 500/137 mg (30 min infusion), followed by maintenance doses of 1500/410 mg (3 h infusions) q6h; Cohort 2 received 500/167 mg (30 min infusion), followed by 1500/500 mg (3 h infusions) q6h. Cohort 3 was an extension of exposure at the higher dose regimen. Doses were adjusted for creatinine clearance of 31–50 mL/min (Cohorts 2 + 3). All patients received IV metronidazole 500 mg q8h. PK, safety and efficacy were assessed.

Results

Thirty-four patients (Cohort 1, n = 16; Cohorts 2 + 3, n = 18) comprised the modified ITT (MITT) population. Mean exposures of aztreonam and avibactam in Cohorts 2 + 3 were consistent with those predicted to achieve joint PK/pharmacodynamic target attainment in >90% patients. Adverse events (AEs) were similar between cohorts. The most common AEs were hepatic enzyme increases [n = 9 (26.5%)] and diarrhoea [n = 5 (14.7%)]. Clinical cure rates at the test-of-cure visit overall were 20/34 (58.8%) (MITT) and 14/23 (60.9%) (microbiological-MITT population).

Conclusions

Observed AEs were consistent with the known safety profile of aztreonam monotherapy, with no new safety concerns identified. These data support selection of the aztreonam/avibactam 500/167 mg (30 min infusion) loading dose and 1500/500 mg (3 h infusions) maintenance dose q6h regimen, in patients with creatinine clearance >50 mL/min, for the Phase 3 development programme.

Are Spanish surgeons prepared to treat trauma patients? Multicentre descriptive observational study

PURPOSE

Specific training in the management of trauma patients is beneficial for surgeons. Training through specific courses in this area has a direct impact on the care of these patients. The aim of this work is to understand the participation and specific training in the care of trauma patients by Spanish surgeons.

METHODS

A national survey was conducted and administered to all members of the Spanish Association of Surgeons. The survey assessed their degree of participation in emergency surgery, and therefore the probability of attending trauma patients, their assessment of the initial care of trauma patients in their centre, and their specific training in this field.

RESULTS

The survey was completed by 510 surgeons from 47 Spanish provinces, with Catalonia and Andalusia being the most represented regions. In total, 456 (89.41%) of those surveyed work in the emergency department on a routine basis. Only 171 (33.53%) refer to having a registry of trauma patients in their hospital. While 79.02% of surgeons reported that general surgeons are not involved in care of severe trauma from the outset, only 66.47% have completed the ATLS course, 40.78% the DSTC course and 18.82% the MUSEC course. Despite this, 85.69% believe that the ATLS course should be compulsory during residency and 43.33% believe that severe trauma care in their hospital is poor or very poor.

CONCLUSION

Only 40% have received specific training in definitive surgical management of severe trauma. Despite this, a large percentage of surgeons work in the emergency department on a routine basis and potentially face the challenge of managing these patients.

Association of Negative Pressure Wound Therapy and Dermatotraction for Management of Necrotizing Soft Tissue Infections: A Case Series

INTRODUCTION

Soft tissue infections (STIs), which include infections of the skin, subcutaneous tissue, fascia, and muscle, encompass a wide variety of heterogeneous pathologies. Treatment of STIs is based on surgical debridement of the affected area. One such treatment, negative pressure wound therapy (NPWT), has improved the management of STIs.

OBJECTIVE

The purpose of this study is to assess the safety and utility of NPWT in conjunction with dermatotraction in the early stage management of necrotizing STIs.

MATERIALS AND METHODS

The authors report a retrospective series of 3 cases in which NPWT and dermatotraction (NPWT-D) were used in an attempt to manage necrotizing STI. The NPWT-D device combination was employed to approximate the edges of the wounds. The NPWT device was changed every 2 or 3 days, and dermatotraction tension was adjusted concurrently.

RESULTS

The NPWT-D device changes ranged from 3 to 4 times for 2 of the 3 patients, as 1 patient passed away secondary to STIs and therefore did not receive complete treatment. The total treatment ranged from 8 to 10 days in the remaining 2 patients. In both cases, complete wound closure was achieved while avoiding skin grafts. After 5 days of therapy in the incomplete treatment case, the wound area was reduced by about half.

CONCLUSIONS

Based on the experiences herein, NPWT-D may be a safe and useful alternative surgical treatment for the management of necrotizing STIs. In the present cases, NPWT-D improved and shortened the wound healing process, and it achieved a tertiary wound closure, thereby avoiding the need for skin grafts.

Use of polyvinylidene fluoride (PVDF) meshes for ventral hernia repair in emergency surgery

PURPOSE

The implantation of non-absorbable meshes is the gold standard technique for ventral hernia (VH) repairs. However, emergency surgeries are often related to contaminated/infected fields, where the implantation of prosthetic materials may not be recommendable. Our aim was to evaluate the results of polyvinylidene fluoride (PVDF) meshes used for contaminated and/or complicated VH repairs in the acute setting.

METHODS

We conducted a retrospective analysis of patients with VH who underwent emergency surgery involving PVDF meshes, in a tertiary hospital (from November 2013 to September 2019). We analyzed postoperative complications and 1-year recurrence rates. We evaluated the relationships between contamination grade, mesh placement, infectious complications, and recurrences.

RESULTS

We gathered data on 123 patients; their mean age was 62.3 years, their mean BMI was 31.1 kg/m², and their mean CeDAR index was 51.6. 96.4% of patients had a grade 2-3 ventral hernia according to the Rosen index. The mean defect width was 8 cm (IQR 2-18). 93 cases (75.6%) were described as contaminated or dirty surgeries. A PVDF mesh was placed using an IPOM technique in 56.3% of cases, and via interposition location in 39.9%. The one-month recurrence rate was 5.7% and recurrence after one year was 19.1%. The overall mortality rate was 27.6%. Risk of recurrence was related to patients with a Rosen score over 2 (p < 0.001), as well as with postoperative SSI (p = 0.045). Higher recurrence rates were not related to PVDF mesh placement.

CONCLUSION

The use of PVDF meshes for emergency VH repairs in contaminated surgeries seems safe and useful, with reasonable recurrence rates, and acceptable infectious complication rates, similar to those published in the literature.

[Emergency Surgery and Trauma Care During COVID-19 Pandemic. Recommendations of the Spanish Association of Surgeons]

La infección por el nuevo coronavirus SARS-CoV-2 (enfermedad por coronavirus 2019 [COVID-19]) ha determinado la necesidad de la reorganización de muchos centros hospitalarios en el mundo. España, como uno de los epicentros de la enfermedad, ha debido asumir cambios en la práctica totalidad de su territorio. Sin embargo, y desde el inicio de la pandemia, en todos los centros que atienden urgencias quirúrgicas ha sido necesario el mantenimiento de su cobertura, aunque igualmente ha sido inevitable introducir directrices especiales de ajuste al nuevo escenario que permitan el mantenimiento de la excelencia en la calidad asistencial. Este documento desarrolla una serie de indicaciones generales para la cirugía de urgencias y la atención al politraumatizado desarrolladas desde la literatura disponible y consensuadas por un subgrupo de profesionales desde el grupo general Cirugía-AEC-COVID-19. Estas medidas van encaminadas a contemplar un riguroso control de la exposición en pacientes y profesionales, a tener en cuenta las implicaciones de la pandemia sobre diferentes escenarios perioperatorios relacionados con la urgencia y a una adaptación ajustada a la situación del centro en relación con la atención a pacientes infectados.

Acute appendicitis during pregnancy: differences in clinical presentation, management, and outcome

OBJECTIVES

To analyze the clinical presentation, management, and outcome of acute appendicitis (AA) in pregnant and nonpregnant women of childbearing age.

MATERIAL AND METHODS

Descriptive study of 2 cohorts of women (pregnant -P- and nonpregnant -NP-). The women, who were matched according to risk factors, were included when they underwent an emergency appendectomy based on clinical suspicion of AA. We recorded age, medical history, clinical presentation, management, and outcome. Pregnant women were classified according to gestational age of the fetus (trimester).

RESULTS

. We included 153 women (51 P, 102 NP). The mean (SD) age was 28.8 (6.5) years (P women, 29.7 [5.8] years; NP, 28.3 [6.8]; P=.242). The mean Alvarado score was 7.1 (1.6) (P, 6.7 [1.7]; NP, 7.3 [1.5]; P=.016). The rate of complicated AA was higher in P (19.6%) than NP (2.9%) women (P<.001). Pregnancy was also associated with higher rates of surgical wound infection (P, 14.0%; NP, 3.0%; P=.016) and a longer mean hospital stay (P, 5.1 [4.8] days; NP, 1.7 [1.0]; P<.001). In the third trimester of P, poorer outcomes were recorded in relation to these risks (P=.031; P=.003, and P<.001, respectively).

CONCLUSION

The atypical clinical presentation of AA during pregnancy makes diagnosis difficult and may lead to a higher incidence of complicated AA and surgical wound infection as well as longer hospital stays, particularly when AA presents in the third trimester.

The Acute Care Surgery model in the world, and the need for and implementation of trauma and emergency surgery units in Spain

The Acute Care Surgery model groups trauma and emergency surgery with surgical critical care. Conceived and extended during the last 2 decades throughout North America, the magnitude and clinical idiosyncrasy of emergency general surgery have determined that this model has been expanded to other parts of the world. In our country, this has led to the introduction and implementation of the so-called trauma and emergency surgery units, with common objectives as those previously published for the original model: to decrease the rates of emergency surgery at night, to allow surgeons linked to elective surgery to develop their activity in their own disciplines during the daily schedule, and to become the perfect link and reference for the continuity of care. This review summarizes how the original model was born and how it expanded throughout the world, providing evidence in terms of results and a description of the current situation in our country.

Laparoscopic aproach in post-traumatic chylous ascites

Chylous ascites is a rare condition little reported in literature, with even more exceptional traumatic origin. Its production mechanism is not known exactly but has been attributed to hyperflexion or hyperextension of the spine leading to a rupture of lymph ducts. We present a case of post-traumatic chyloperitoneum in a young patient after abdominal blunt trauma. Conservative treatment should be the first therapeutic option, especially if the origin is traumatic, reserving more aggressive possibilities for cases that do not respond after 15 days, if debt is greater than 1.5 litres/day in adult patients or in those with metabolic complications. A laparoscopic approach is indicated to confirm the diagnosis and to rule out other associated injuries that may require other surgical procedures.

[Colonic gallstone ileus: A rare cause of intestinal obstruction]

BACKGROUND

A gallstone colonic ileus is a very rare condition.

CLINICAL CASE

The case is reported of an 87 year-old patient who came to the Emergency Department due to an intestinal obstruction of several days onset, which was caused by a gallstone affected sigmoid colon.

CONCLUSION

Colonic gallstone ileus is a rare disease that usually occurs in older patients due to the passage of large gallstone directly from the gallbladder to colon, through a cholecystocolonic fistula. It has a high morbidity and mortality.

[Role of care surgery in the treatment of pseudomembranous colitis]

BACKGROUND

Pseudomembranous colitis, caused by Clostridium difficile, has seen an increased incidence in recent years, driven mainly by the indiscriminate use of antibiotics. Although initial treatment is medical, the role of emergency surgery has gained ground due to high mortality and the emergence of increasingly virulent strains. In our country the prevalence is still low so that sometimes our experience in handling is limited.

AIM

To analyze our surgical experience in treatment of this disease and to remember the role of surgery as well as some technical aspects of it.

CLINICAL CASES

We present 2 cases of patients who have suffered a fulminant pseudomembranous colitis unresponsive to initial medical treatment and requiring urgent surgical intervention with a good response to it.

CONCLUSIONS

It is important to keep in mind the surgical option in treatment of pseudomembranous colitis, especially when it presents as fulminant colitis, there are associated complications or failure to respond to medical treatment.

The use of TachoSil as sealant in an experimental model of colonic perforation

BACKGROUND

The suture dehiscence has traditionally represented a major surgical problem that has not fully resolved. Surgeons should perform sutures in nonoptimal conditions using different methods of sealing and/or reinforcement of suture. The aim is to assess the effectiveness of TachoSil in an experimental model of colon perforations in a simulated precarious situation.

METHODS

Forty Wistar rats of both genders (14-24 weeks old) were equally divided in 2 groups; study group was submitted to extended starvation and segmental ischemia. The surgical complications analyzed were animal death, colonic leaks, or intra-abdominal infection, either as local abscesses or diffuse peritonitis. The burst pressure was measured in millimeters of mercury. The histological analysis was performed according to Ehrlich and Hunt numerical scale modified by Phillips.

RESULTS

Only 1 animal belonging to the study group died as a consequence of the colonic ischemia. The eventual colonic leak or diffuse peritonitis was reported. Three local abscesses were observed in the study group and one in the control group, and numerous microscopic abscesses in histological analysis (12 vs. 11) were detected. The average burst pressure in the study group was 209.47 ± 50.274 versus 203 ± 51.514 mm Hg in the control group. No differences were observed in any of the variables analyzed in the histological activity.

CONCLUSION

TachoSil has proven useful as a sealant of colonic perforations in our experimental study. We therefore conclude that its use in situations of insecurity may be adequate, even in optimal conditions in which reinforcement of previous suture is not strictly required.

Breast cancer in males

BACKGROUND

Male breast cancer has a very low incidence (<1%). It has traditionally been considered to have a poorer prognosis than breast cancer in females due to delayed diagnosis as a cause of decreased survival. Our goal is to analyze our series and to identify factors influencing survival.

METHODS

We conducted a retrospective study from 1997-2008 (n = 32). Inclusion criteria were male gender and histological confirmation of breast cancer. We analyzed epidemiological data (age and personal and family history), tumors (size, grade of differentiation, histological type, location, TNM stage, receptors), therapeutic regimen (surgical technique, adjuvant therapy) and survival (relapse, followup, death).

RESULTS

Male breast cancer represents 0.9% of all breast cancers treated in our center. The average age of our patients was 66.84 years. Only 9.3% demonstrated gynecomastia as a presenting complaint. Histologically, 90% were infiltrating ductal type; 59.25% were diagnosed in early stages (I-II) compared to 40.74% in stages III-IV. Aggressive surgical techniques are still performed, compared to conservative techniques (74.19% vs. 19.36%). With a median follow-up of 52.82 months, the mortality rate was 16%. Existence of distant metastasis has been the only statistically significant factor in survival.

CONCLUSIONS

The percentage of cases of male breast cancer is very low compared to breast cancer in females. Limited studies in the literature make gender-specific findings difficult. A low percentage of conservative surgical procedures are performed, even though this has increased considerably in recent years. The existence of distant metastasis was the main determinant of survival.