Association between frailty, long-term mortality and functional outcomes for older adults undergoing emergency laparotomy

BACKGROUND

An increasing number of older patients are undergoing emergency laparotomy (EL). Frailty is thought to contribute to adverse outcomes in this group. The best method to assess frailty and impacts on long-term mortality and other important functional outcomes for older EL patients have not been fully explored.

METHODS

A prospective multicenter study of older EL patients was conducted across four hospital sites in New Zealand from August 2017 to September 2022. The Clinical Frailty Scale (CFS) was used to measure frailty-defined as a CFS of ≥5. Primary outcomes were 30-day and one-year mortality. Secondary outcomes were postoperative morbidity, admission for rehabilitation, and increased care level on discharge. A multivariate logistic regression analysis was conducted, adjusting for age, sex, and ethnicity.

RESULTS

A total of 629 participants were included. Frailty prevalence was 14.6%. Frail participants demonstrated higher 30-day and 1-year mortality-20.7% and 39.1%. Following adjustment, frailty was directly associated with a significantly increased risk of short- and long-term mortality (30-day aRR 2.6, 95% CI 1.5, 4.3, p = <0.001, 1-year aRR 2.0, 95% CI 1.5, 2.8, p < 0.001). Frailty was correlated with a 2-fold increased risk of admission for rehabilitation and propensity of being discharged to an increased level of care, complications, and readmission within 30 days.

CONCLUSION

Frailty was associated with increased risk of postoperative mortality up to 1-year and other functional outcomes for older patients undergoing EL. Identification of frailty in older EL patients aids in patient-centered decision-making, which may lead to improvement in outcomes.

Validation of the postoperative Quality of Recovery-15 questionnaire after emergency surgery and association with quality of life at three months

PURPOSE

The Quality of Recovery-15 (QoR-15) tool, validated for measuring postoperative recovery following scheduled surgeries, has not been psychometrically assessed in emergency contexts. Moreover, the QoR-15's associations with long-term outcomes remain underexplored. This study aimed to confirm the validity and reliability of the QoR-15 following emergency surgery and assess its association with three-month postoperative quality of life.

METHODS

We conducted a prospective cohort study (August 2021-April 2022) on adult patients who underwent emergency surgery. The QoR-15 questionnaire was administered before surgery (H0) and at 24 hr (H24) and 48 hr (H48) after surgery. We examined the H24 score's associations with both the three-month quality of life, as assessed by the EQ-5D scale, and the number of days spent at home at 30 (DAH30) and 90 (DAH90) days.

RESULTS

Of the 375 included patients, 352 (94%) completed the QoR-15 at H24 and 338 (90%) were followed up at three months. The population represented the following diverse surgical specialties: orthopedic (51%), gastrointestinal (27%), urologic (13%), and others (9%). The QoR-15 questionnaire confirmed all psychometric qualities (internal consistency, reproducibility, responsiveness, acceptability, construct, and convergent validities) in the emergency context. The average minimum clinical difference was 8.0 at H24. There was an association between QoR-15 at H24 and the three-month quality of life (r = 0.24; 95% confidence interval [CI], 0.14 to 0.34; P < 0.001), DAH30 (r = 0.33; 95% CI, 0.23 to 0.41; P < 0.001), and DAH90 (r = 0.31; 95% CI, 0.22 to 0.40; P < 0.001).

CONCLUSION

The QoR-15 score is valid for measuring early postoperative recovery after emergency surgery. The H24 score significantly correlated with both the three-month quality of life and the number of days at home.

STUDY REGISTRATION

ClinicalTrials.gov (NCT04845763); first submitted 11 April 2021.

Risk Factors of Postoperative Complication and Hospital Mortality after Colorectal Perforation Surgery

Objectives

Colorectal perforation is associated with high morbidity and mortality rates after surgery. We investigated various clinical features of patients who underwent emergency surgery for colorectal perforation and explored the risk factors for postoperative complications and hospital mortality.

Methods

Data from 147 patients who underwent surgery for colorectal perforation were retrospectively reviewed. We investigated various clinical and operative factors, including inflammation-based prognostic scores (IBPSs), and evaluated the risk factors for postoperative complications and hospital mortality due to colorectal perforation.

Results

Among 147 patients, the most frequent postoperative complication was wound infection (32 cases, 21.8%), followed by intra-abdominal abscesses (27 cases, 18.4%) after surgery for colorectal perforation. Time from onset to surgery ≥ 2 days (Hazard ratio [HR] = 2.810, p = 0.0383) and prognostic nutritional index (PNI) < 30 (HR = 3.190, p = 0.0488) were identified as risk factors for intra-abdominal abscess, while neutrophil-lymphocyte ratio (NLR) < 6.15 (HR = 5.020, p = 0.0009) was identified as a risk factor for wound infection. Time from onset to surgery ≥ 2 days (HR = 7.713, p = 0.0492), severe postoperative complications (Clavien-Dindo grade ≥ IIIa) (HR = 10.98, p = 0.0281), and platelet-lymphocyte ratio (PLR) < 144 (HR = 18.84, p = 0.0190) were independent predictive factors for hospital mortality.

Conclusions

Time from onset to surgery and IBPSs such as PNI, NLR, and PLR, may be associated with postoperative complications and hospital mortality due to colorectal perforation.

Mental illness comorbidity significantly impacts surgical outcomes for emergency surgical patients

BACKGROUND

Whilst both mental illness comorbidity and the delivery of emergency surgery are commonplace in Australia, there is little evidence investigating any link between them. As such, this study examines the emergency surgical outcomes for patients with mental illness compared to other surgical patients within the Australian public surgical system.

METHODS

Retrospective cohort study involving adult emergency and elective surgical patients treated at three public hospitals in Sydney, Australia between 2018 and 2019. Patients were identified using ICD-10 diagnosis codes, and grouped by those with decompensated mental illness, chronic depression, or those without mental illness. Outcome measures included those within the emergency department (ED), along with in-hospital mortality and surgical outcomes.

RESULTS

Of 48 338 total patients, 31 890 (66.0%) had elective and 16 448 (34.0%) had emergency surgery. For patients with decompensated mental illness, only 228 (0.7%) had elective whilst 425 (2.6%) had emergency surgery. Their outcomes for this surgery type included being triaged significantly higher (Cat 1 or 2, 34% vs. 15%) and longer ED stays (8.3 vs. 6.6 h). They also had significantly more post-operative complications (26% vs. 8%) and total days in hospital (33.8 vs. 8.5 days). There was no significant difference for in-hospital mortality.

CONCLUSION

Patients with mental illness are significantly more likely to have emergency surgery including presenting to the ED with more acute physical illness and to experience worse surgical outcomes compared to other surgical patients for every measure analyzed except mortality. There is considerable opportunity to further investigate how these differences might be improved.

Emergency Surgical Treatment and Triage: Targeting Optimal Outcomes for Emergency Surgical Patients From Index Encounter Through Definitive Care

BACKGROUND

Patients with emergency surgical conditions (ESCs) experience higher complication rates than those without emergency conditions. Our purpose was to improve time-based key performance indicators (KPIs) of care for ESC patients, including diagnostic workup, empiric stabilization, and referral to definitive care.

METHODS

A rapid response program (ESTAT) was developed to screen for and coordinate optimal, timely care for a spectrum of high-risk ESCs, from the patient's index clinical encounter up to definitive care. The Mann-Whitney test assessed whether any differences in KPIs were statistically significant (P < .05) before compared to after the implementation of ESTAT.

RESULTS

98 patients were identified: 44 in ESTAT group (70% age ≥55, 57% male); 54 in control group (57% age ≥55, 44% male). There were significant decreases from time of index clinical encounter to resuscitation (5 min. vs 34 min., P < .001), to diagnostic imaging (52 min. vs 1 hr. 19 min., P = .004), and to definitive care (2 hr. 17 min. vs 3 hr. 51 min., P = .007) in the ESTAT group compared to the control group, respectively.

DISCUSSION

Improving time-based KPIs for delivery of clinical services is a common goal of medical emergency response systems (MERS) in numerous specialties. Implementation of an ESTAT program provides a screening tool for at-risk patients and reduces time to stabilize, diagnose and triage to definitive surgical intervention. These time benefits may ultimately translate to reduced complication rates for ESC patients. ESTAT may also represent a patient onboarding mechanism for surgical specialty verification programs promoted by quality improvement committees of various professional societies.

A giant ovarian cyst torsion: Case report

INTRODUCTION

Adnexal torsion (AT) is one of a gynecological condition characterized by an acute abdomen. Clinically, a giant ovarian cyst torsion with a diameter of 30 cm is rare. Therefore, an accurate and timely diagnosis and treatment are important.

PATIENT CONCERNS

A 25-year-old unmarried female, presented to the emergency department with intermittent abdominal cramps after a sudden change in position. Considering her symptoms and examination, ultrasound, and magnetic resonance imaging (MRI) results, ovarian cyst torsion was suspected.

DIAGNOSIS

Giant ovarian cyst torsion.

INTERVENTIONS

Surgical intervention with exploratory laparotomy was performed immediately.

OUTCOMES

Intraoperatively, we found a 30-cm left ovarian cyst with a clear root. The left fallopian tube, infundibulopelvic ligament, and ovarian ligament were twisted 900 degrees. Finally, the pathological report revealed mucinous cystadenoma.

CONCLUSION

Giant ovarian cyst torsion with a diameter of 30 cm is rare. Considering her symptoms and examination, ultrasound, and MRI results, ovarian cyst torsion was suspected. The patient was successfully treated using emergency surgery.

COVID-free surgical pathways for treating patients with acute calculous cholecystitis: a retrospective comparative study

Introduction

During the Sars-Cov-2 crisis, some of the resources committed to emergency surgery services were transiently reallocated to the care of patients with severe COVID-19, preserving immediate treatment of mostly non-deferrable conditions. Moreover, the fear of contracting infections or hindering the treatment of critical COVID-19 patients has caused many individuals to defer seeking emergency care. This situation has then possibly modified the standard of care of some common surgical conditions and the relative outcomes. Our aims was to highlight any difference in surgical outcomes in patients treated for acute cholecystitis before and during the COVID-19 outbreak.

Method

This is a retrospective study on a prospectively collected database that included all consecutive patients treated for acute cholecystitis from March 2019 to February 2021 at the Lugano Regional Hospital, a COVID-free hospital for general surgery patients. Patients were divided into pre-and post-COVID-19 outbreak groups. We collected thorough clinical characteristics and intra-and postoperative outcomes.

Results

We included 124 patients, of which 60 and 64 were operated on before and after the COVID-19 outbreak respectively. The two groups resulted similar in terms of patients' clinical characteristics (age, gender, body mass index, ASA score, and comorbidities). Patients in the post-outbreak period were admitted to the hospital 0.7 days later than patients in the pre-outbreak period (3.8 ± 6.0 days vs. 3.1 ± 4.1 days, p = 0.453). Operative time, recovery room time, complications, and reoperations resulted similar between groups. More patients in the post-outbreak period received postoperative antibiotic therapy (63.3% vs. 37.5%, p = 0.004) and for a longer time (6.9 ± 5.1 days vs. 4.5 ± 3.9 days, p = 0.020). No significant histopathological difference was found in operatory specimens.

Discussion

Despite more frequent antibiotic therapy that suggests eventually worse inflammatory local status, our results showed similar outcomes for patients treated for acute cholecystitis before and during the COVID-19 pandemic. The local COVID management, reallocating resources, and keeping COVID-free hospitals was key to offering patients a high standard of treatment.

Hepatic portal venous gas initially manifesting as severe shock: a case series

Hepatic portal venous gas is often referred to as the "sign of death" because it signifies a very poor prognosis if appropriate treatments are not promptly administered. The etiologies of hepatic portal venous gas are diverse and include severe complex abdominal infections, mesenteric ischemia, diving, and complications of endoscopic surgery, and the clinical manifestations are inconsistent among individual patients. Thus, whether emergency surgery should be performed remains controversial. In this report, we present three cases of hepatic portal venous gas. The patients initially exhibited symptoms consistent with severe shock of unknown etiology and were treated in the intensive care unit upon admission. We rapidly identified the cause of each individual patient's condition and selected problem-directed intervention measures based on active organ support, antishock support, and anti-infection treatments. Two patients recovered and were discharged without sequelae, whereas one patient died of refractory infection and multiple organ failure. We hope that this report will serve as a valuable reference for decision-making when critical care physicians encounter similar patients.

Emergency Colorectal Surgery in Those with Cirrhosis: A Population-based Study Assessing Practice Patterns, Outcomes and Predictors of Mortality

Background

Those with cirrhosis who require emergency colorectal surgery are at risk for poor outcomes. Although risk predictions models exists, these tools are not specific to colorectal surgery, nor were they developed in a contemporary setting. Thus, the objective of this study was to assess the outcomes in this population and determine whether cirrhosis etiology and/or the Model for End Stage Liver Disease (MELD-Na) is associated with mortality.

Methods

This population-based study included those with cirrhosis undergoing emergent colorectal surgery between 2009 and 2017. All eligible individuals in Ontario were identified using administrative databases. The primary outcome was 90-day mortality.

Results

Nine hundred and twenty-seven individuals (57%) (male) were included. The most common cirrhosis etiology was non-alcoholic fatty liver disease (NAFLD) (50%) and alcohol related (32%). Overall 90-day mortality was 32%. Multivariable survival analysis demonstrated those with alcohol-related disease were at increased risk of 90-day mortality (hazards ratio [HR] 1.53, 95% confidence interval [CI] 1.2-2.0 vs. NAFLD [ref]). Surgery for colorectal cancer was associated with better survival (HR 0.27, 95%CI 0.16-0.47). In the subgroup analysis of those with an available MELD-Na score (n = 348/927, 38%), there was a strong association between increasing MELD-Na and mortality (score 20+ HR 6.6, 95%CI 3.9-10.9; score 10-19 HR 1.8, 95%CI 1.1-3.0; score <10 [ref]).

Conclusion

Individuals with cirrhosis who require emergent colorectal surgery have a high risk of postoperative complications, including mortality. Increasing MELD-Na score is associated with mortality and can be used to risk stratify individuals.

The effects of troponin screening among patients undergoing acute high-risk abdominal surgery: A retrospective cohort study

BACKGROUND

Acute high-risk abdominal (AHA) surgery is associated with a high short-term mortality rate. This might be partly attributed to myocardial injury after non-cardiac surgery (MINS) defined by elevated postoperative troponin levels. The myocardial injury is often asymptomatic; thus, troponin screening seems to be the best diagnostic method. We aimed to assess whether implementing troponin screening with subsequent individualised interventions as standard care is associated with reduced mortality after AHA surgery. We also explored the treatment implications in the screening period.

METHODS

A retrospective cohort of 558 patients undergoing surgery from February 2018 to March 2021 was included. The patients undergoing surgery before March 2019 served as the historical control group, while the screening group consisted of patients undergoing surgery from March 1, 2019. Troponin I was to be measured 6-12 h postoperatively and in the morning of the succeeding 4 days. Patients with myocardial injury were assessed, and treatment was individualised after multiple disciplinary consultations. The primary outcome was the unadjusted 30-day mortality rates. Inverse probability treatment weighting was used to adjust for selection bias.

RESULTS

We included 558 patients: 382 in the screening group and 176 in the historical control group. In the screening group, 15 patients (3.9%) died before the first blood sampling, and in 31 patients (8.1%), troponin screening was omitted, leaving only 336 patients screened. Myocardial injury was diagnosed in 81 patients (24.1%) of the 336 patients. Of these, 59 (72.8%) had a cardiac consultation. No interventions or alterations in relation to myocardial injury were done in 67 patients (82.7%). The 30-day mortality was 13.8% (95% CI 8.7%-18.9%) in the control group and 11.1% (95% CI 8.0%-14.3%) in the screening group. The absolute risk difference was -2.7% (95% CI -8.7%-3.3%; p = .38), which was unchanged after adjustment. The difference remained unchanged after 90 days and 1 year.

CONCLUSION

The implementation of postoperative troponin screening was not associated with reduced mortality after AHA surgery. Research on the prevention and treatment of MINS is warranted before the implementation of standard troponin screening.

Risk prediction models in emergency surgery: Protocol for a scoping review

BACKGROUND

Risk prediction models are used for many purposes in emergency surgery, including critical care triage and benchmarking. Several risk prediction models have been developed, and some are used for purposes other than those for which they were developed. We aim to provide an overview of the existing literature on risk prediction models used in emergency surgery and highlight knowledge gaps.

METHODS

We will conduct a scoping review on risk prediction models used for patients undergoing emergency surgery in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). We will search Medline, EMBASE, and the Cochrane Library and include all study designs. We aim to answer the following questions: (1) What risk prediction models are used in emergency surgery? (2) Which variables are used in these models? (3) Which surgical specialties are the models used for? (4) Have the models been externally validated? (5) Where have the models been externally validated? (6) What purposes were the models developed for? (7) What are the strengths and limitations of the included models? We will summarize the results descriptively. The certainty of evidence will be evaluated using a modified Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

CONCLUSION

The outlined scoping review will summarize the existing literature on risk prediction models used in emergency surgery and highlight knowledge gaps.

Improving risk models for patients having emergency bowel cancer surgery using linked electronic health records: a national cohort study

BACKGROUND

Life-saving emergency major resection of colorectal cancer (CRC) is a high-risk procedure. Accurate prediction of postoperative mortality for patients undergoing this procedure is essential for both healthcare performance monitoring and preoperative risk assessment. Risk-adjustment models for CRC patients often include patient and tumour characteristics, widely available in cancer registries and audits. The authors investigated to what extent inclusion of additional physiological and surgical measures, available through linkage or additional data collection, improves accuracy of risk models.

METHODS

Linked, routinely-collected data on patients undergoing emergency CRC surgery in England between December 2016 and November 2019 were used to develop a risk model for 90-day mortality. Backwards selection identified a 'selected model' of physiological and surgical measures in addition to patient and tumour characteristics. Model performance was assessed compared to a 'basic model' including only patient and tumour characteristics. Missing data was multiply imputed.

RESULTS

Eight hundred forty-six of 10 578 (8.0%) patients died within 90 days of surgery. The selected model included seven preoperative physiological and surgical measures (pulse rate, systolic blood pressure, breathlessness, sodium, urea, albumin, and predicted peritoneal soiling), in addition to the 10 patient and tumour characteristics in the basic model (calendar year of surgery, age, sex, ASA grade, TNM T stage, TNM N stage, TNM M stage, cancer site, number of comorbidities, and emergency admission). The selected model had considerably better discrimination compared to the basic model (C-statistic: 0.824 versus 0.783, respectively).

CONCLUSION

Linkage of disease-specific and treatment-specific datasets allowed the inclusion of physiological and surgical measures in a risk model alongside patient and tumour characteristics, which improves the accuracy of the prediction of the mortality risk for CRC patients having emergency surgery. This improvement will allow more accurate performance monitoring of healthcare providers and enhance clinical care planning.

Postoperative Outcomes After Emergency Surgery in COVID-19 Patients: An Ambispective Matched Cohort Study

Purpose There is limited data from the Indian subcontinent regarding the surgical outcomes of coronavirus disease (COVID-19) patients. In this observational study, we aimed to evaluate the postoperative outcomes after emergency surgery in COVID-19 patients compared to concurrent age and gender-matched controls. We also sought to analyze the possible predictors of postoperative mortality in COVID-19 patients. Methods This matched cohort study was conducted in a tertiary care teaching hospital in central India, between 1st July 2021 and 30th June 2022. COVID-19-positive patients undergoing emergency surgery under anesthesia were recruited as cases. Age and gender-matched COVID-19-negative patients undergoing a similar nature of surgery in the same period served as concurrent controls. The cases and controls were compared for the 30-day mortality and perioperative complications. Results The COVID-19-positive surgical cohort had a 12.3 times greater 30-day postoperative overall mortality risk as compared to a matched cohort of patients with a negative COVID-19 test. A positive COVID-19 status was associated with more postoperative complications of acute respiratory distress syndrome (ARDS), sepsis, shock, and persistent hyperglycemia. On analysis of predictors of mortality, the presence of preoperative dyspnea, ARDS, American Society of Anesthesiologists Physical Status (ASA-PS) Class IIIE/IVE, increase in sequential organ failure assessment (SOFA) score, Quick SOFA>1, higher creatinine, bilirubin, and lower albumin were observed to be associated with increased mortality. Conclusions Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in patients undergoing emergency surgery is significantly associated with higher postoperative complications and increased 30-day postoperative mortality.

Exploring the Landscape of General Surgery in the Adolescent Age Group: Challenges and Considerations

INTRODUCTION

The adolescent age group typically ranges from 10 to 19 years. This age group differs from the paediatric and adult populations based on their physiological, psychological, and social behaviour. Patients of this age group usually present with trauma, swellings, burns, hernias, hydroceles, haemorrhoids, fibroadenomas, abscesses, pilonidal diseases, etc. The objective of this study was to identify various causes requiring surgical intervention in adolescent patients and to determine the demography of these patients, reasons for surgery, and surgical outcomes in the patients of the adolescent age group.

MATERIALS AND METHODS

This single-centre, hospital record-based, retrospective, cross-sectional study was conducted on 445 adolescent patients who underwent various general surgical interventions from August 2022 to July 2023 in the Department of General Surgery, Rajendra Institute of Medical Sciences (RIMS), Ranchi.

RESULTS

A total of 445 patients were included in this study; among them, 277 underwent elective surgeries and 168 emergency surgeries. Major surgeries included 315 patients, while 130 were daycare procedures. Males were 294, and 151 were females. Cyst excision was the most performed, followed by fibroadenoma excision. Burn (10.78%) was the most common cause requiring major intervention, followed by intestinal obstruction (6.96%) and perforation (6.51%). Mortality was observed in 6.51% of patients.

CONCLUSION

In this study, the adolescent age group required more elective surgical care as compared to emergency care. Among major surgeries, abdominal laparotomy was most common, and in daycare procedures as well as overall, cyst excision was most performed.

Frequency and risk factors of atrial fibrillation after acute abdominal surgery: A prospective cohort study

BACKGROUND AND AIM

Scarce data exist on the true incidence of postoperative atrial fibrillation (POAF) after acute abdominal surgery and associated outcomes. The current study aimed to identify the frequencies of clinically recognized POAF and associated complications, along with their risk factors.

METHODS

This study was a prospective, single-center cohort study of unselected adult patients referred for acute abdominal surgery during a 3-month period. Through careful review, demographics, comorbidity, and surgical characteristics were prospectively drawn from medical charts. The primary outcome was clinically recognized POAF occurring in-hospital. Logistic regression was used to determine the risk factors of POAF and associated complications. A subgroup was enrolled in a feasibility study of peri- and postoperative continuous cardiac rhythm monitoring.

RESULTS

In total, 450 patients were enrolled. Clinically recognized in-hospital POAF was observed in 22 patients (4.9%). All cases were observed in patients aged ≥60 years, corresponding to 22 of 164 patients (13.4%). Multiple risk factors were observed, such as age, prior atrial fibrillation, heart failure, hypertension, diabetes mellitus, chronic renal disease, and major (vs. minor) surgery. POAF was associated with severe in-hospital complications (POAF group 45.5% vs. non-POAF group 8.6%, p < .001) and in-hospital mortality (POAF group 13.6% vs. non-POAF group 3.0%, p = .043). In total, 295 patients were monitored by continuous cardiac rhythm monitoring for 12,148 h, yielding five patients with asymptomatic AF.

CONCLUSIONS

In conclusion, this prospective study of POAF in patients undergoing acute abdominal surgery showed that one in 20 patients developed clinically recognized in-hospital POAF. Multiple risk factors of POAF were identified. POAF was associated with severe complications up to 30 days after surgery.

Laparoscopic versus Open Emergency Surgery for Right Colon Cancers

BACKGROUND

A laparoscopic approach to right colectomies for emergency right colon cancers is under investigation. This study compares perioperative and oncological long-term outcomes of right colon cancers undergoing laparoscopic or open emergency resections and identifies risk factors for survival.

METHODS

Patients were identified from a prospectively maintained institutional database between 2009 and 2019. Demographics, clinicopathological features, recurrence, and survival were investigated. Cox regression analysis was performed for risk factor analysis.

RESULTS

A total of 202 right colectomies (114 open and 88 laparoscopic) were included. ASA III-IV was higher in the open group. The conversion rate was 14.8%. Laparoscopic surgery was significantly longer (156 vs. 203 min, p < 0.001); pTNM staging did not differ. Laparoscopy was associated with higher lymph node yield, and showed better resection clearance (R0, 78.9 vs. 87.5%, p = 0.049) and shorter postoperative stay (12.5 vs. 8.0 days, p < 0.001). Complication rates and grade were similar. The median length of follow-up was significantly higher in the laparoscopic group (20.5 vs. 33.5 months, p < 0.001). Recurrences were similar (34.2 vs. 36.4%). Open surgery had lower five-year overall survival (OS, 27.1 vs. 51.7%, p = 0.001). Five-year disease-free survival was similar (DFS, 55.8 vs. 56.5%). Surgical approach, pN, pM, retrieved LNs, R stage, and complication severity were risk factors for OS upon multivariate analysis. Pathological N stage and R stage were risk factors for DFS upon multivariate analysis.

CONCLUSIONS

A laparoscopic approach to right colon cancers in an emergency setting is safe in terms of perioperative and long-term oncological outcomes. Randomized control trials are required to further investigate these results.

Incidence of adhesive small bowel obstruction after surgery for colorectal cancer in Sweden 2007-2016

AIM

Population-based data on incidence and risk factors of adhesive small bowel obstruction (SBO) are limited. The aims of this study were to assess the risk of SBO and SBO surgery after bowel resection for colorectal cancer (CRC) and to assess whether this risk is modified by minimally invasive surgery (MIS) and radiotherapy in a retrospective national study.

METHODS

CRCBaSe, a nationwide register linkage originating from the Swedish Colorectal Cancer Register, was used to identify Stage I-III CRC patients who underwent resection in 2007-2016, with follow-up throughout 2017. Matched CRC-free comparators (1:6) were included as a reference of SBO and SBO surgery incidence. The association between MIS and preoperative radiotherapy and the incidence rate of SBO was evaluated in adjusted multivariable Cox regression models.

RESULTS

Among 33 632 CRC patients and 198 649 comparators, the 5-year cumulative incidence of SBO and SBO surgery was 7.6% and 2.2% among patients and 0.6% and 0.2% among comparators, with death as a competing risk. In all patients, MIS was associated with a reduced incidence of SBO (hazard ratio [HR] 0.7, 95% CI 0.6-0.8) and SBO surgery (HR 0.5, 95% CI 0.3-0.7). In rectal cancer patients, radiotherapy was associated with an increased incidence of SBO (HR 1.6, 95% CI 1.4-1.8) and SBO surgery (HR 1.7, 95% CI 1.3-2.3).

DISCUSSION

Colorectal cancer surgery is associated with a marked increase in risk of SBO, compared with the general population. The incidence is further increased if open surgery or radiotherapy is performed.

Appendiceal duplication: a case report of horseshoe-shaped appendix and implications for patient safety

Appendiceal anomalies, particularly double appendices, are rare and mainly detected during non-appendiceal surgery in adults. Misrecognizing them can have serious consequences, both clinically and legally. It is critical that surgeons pay attention to the anatomical variations of the vermiform appendix, and always consider the possibility of duplicated appendix when diagnosing a right iliac fossa pain. Misdiagnosis can lead to life-threatening medical complications for the patient, with medico-legal implications.

Clinical Course and Management of Patients with Emergency Surgery Treated with Direct Oral Anticoagulants or Vitamin K Antagonists-Results of the German Prospective RADOA-Registry

(1) Background: The clinical management of anticoagulated patients treated with direct oral anticoagulants (DOAC) or Vitamin K antagonists (VKA) needing emergency surgery is challenging. (2) Methods: The prospective German RADOA registry investigated treatment strategies in DOAC- or VKA-treated patients needing emergency surgery within 24 h after admission. Effectiveness was analysed by clinical endpoints including major bleeding. Primary observation endpoint was in hospital mortality until 30 days after admission. (3) Results: A total of 78 patients were included (DOAC: 44; VKA: 34). Median age was 76 years. Overall, 43% of the DOAC patients and 79% of the VKA patients were treated with prothrombin complex concentrates (PCC) (p = 0.002). Out of the DOAC patients, 30% received no hemostatic treatment compared to 3% (1/34) of the VKA patients (p = 0.002), and 7% of the DOAC patients and 21% of the VKA patients developed major or clinically relevant non-major bleeding at the surgical site (p = 0.093). In-hospital mortality was 13% with no significant difference between the two treatment groups (DOAC: 11%, VKA: 15%; p > 0.20). (4) Conclusions: The 30-day in-hospital mortality rate was comparable between both patient groups. VKA patients required significantly more hemostatic agents than DOAC patients in the peri- and postoperative surgery period.

The role of geriatric nutritional risk index as a predictor for postoperative outcomes in gastrointestinal emergencies

BACKGROUND

The geriatric nutritional risk index (GNRI) is a simple nutritional and inflammatory marker for older adults. The aim of the present study was to investigate the usefulness of the GNRI in older adults who underwent emergency gastrointestinal surgery.

METHODS

This study included 206 older adults who had undergone emergency gastrointestinal surgery. We retrospectively investigated the relationship between the GNRI and postoperative complications. Univariate and multivariate analyses were performed to evaluate risk factors for postoperative complications. We then evaluated the association between GNRI and clinical variables among older adults undergoing emergency gastrointestinal surgery.

RESULTS

Postoperatively, all complications occurred in 89 (43%) older adults, infectious in 53 (26%), and non-infectious in 36 (17%). In the multivariate analysis, age (p = 0.016), GNRI (p = 0.012), operative severity (p = 0.003), and operation time (p = 0.003) were independent risk factors for all postoperative complications. While the GNRI (p = 0.049) was an independent risk factor for infectious complications, age (p = 0.035) and bleeding volume (p = 0.035) were independent risk factors for postoperative non-infectious complications. In the low GNRI group, age (p = 0.029), serum C-reactive protein levels (p < 0.001), and proportion of sarcopenia (p < 0.001) were significantly higher, and the length of hospital stay (p < 0.001) was significantly longer than that in the high GNRI group. In Spearman's rank correlation coefficient, the skeletal mass index and the GNRI had a positive correlation (r = 0.415 and p < 0.001).

CONCLUSION

The GNRI may be a predictor of postoperative infectious complications in older adults after emergency gastrointestinal surgery, suggesting the usefulness of the GNRI as a nutritional marker and sarcopenia-related parameter.

TRIAL REGISTRATION NUMBER

No. 22-16.

Effectiveness of Tranexamic Acid in Trauma Patients: A Systematic Review

Tranexamic acid (TXA), a fibrinolytic agent, effectively inhibits plasminogen activation, thereby reducing fibrinolysis and hemorrhage. This study focused on its application in trauma patients undergoing emergency surgery, a critical area due to trauma's significant role in mortality. Our investigation involved a meticulous screening of randomized controlled trials from databases including Scopus, PubMed, Web of Science, and Cochrane. The findings indicate that TXA intervention is promising in enhancing outcomes for trauma patients. However, the drug's effectiveness may vary based on the specific nature of the medical condition. In summary, robust evidence suggests that TXA can diminish blood loss, lower transfusion rates, reduce complications, and improve hemoglobin and hematocrit levels in surgical patients. Consequently, TXA should be considered a crucial medication, readily available to mitigate morbidity and mortality in surgical settings. Future research should explore factors influencing TXA's effectiveness in traumatic brain injury cases and across a broad spectrum of surgical scenarios in diverse patient populations. This would further guide clinicians in refining and optimizing the use of TXA.

Torsion of Meckel's diverticulum-a case report and literature review

Meckel's diverticulum (MD) is the most common congenital anomaly of the gastrointestinal tract. Torsion is a rare complication of MD with only 48 cases described in the English literature to date. We describe a case of a 22-year-old male who presented to the emergency department with lower abdominal pain. Pre-operative computed tomography scan suggested a torted MD. This was confirmed on diagnostic laparoscopy and managed with segmental resection of the MD and a concurrent appendicectomy. Histopathology confirmed torsion of MD and a normal appendix. The patient recovered well without any complications. Torsion occurs invariably with giant MD defined as a length of >5 cm. Surgical options for MD include diverticulectomy, wedge resection and segmental resection via laparoscopic or open approach. The rate of pre-operative diagnosis remains low but with advances in imaging and awareness of this condition, this is likely to increase with time.

Rectal stercoral perforation: an uncommon anatomical localization of a rare surgical emergency

A stercoral rectal perforation is an uncommon cause of acute abdominal pain with only limited cases documented in medical literature. Timely and accurate imaging is essential when this condition is suspected, and immediate surgical intervention is imperative upon confirming the diagnosis of bowel perforation. Usually, the definitive diagnosis of a stercoral rectal perforation is established intraoperatively and a Hartmann procedure with (temporary) end colostomy is performed. In this case report, we present our first-hand experience in managing a stercoral rectal perforation, highlighting the importance of early diagnosis and rapid surgical intervention to achieve favorable outcomes.

[Emergency surgical care in the Volgograd region between 2017 and 2021]

OBJECTIVE

To analyze the indicators of emergency surgical care in the Volgograd region between 2017 and 2021.

MATERIAL AND METHODS

We summarized and analyzed primary statistical data presented in annual analytical collections of the chief surgeon of the Ministry of Healthcare of Russia «Surgical care In Russian Federation» (Revishvili A.Sh. et al.) and the Rosstat collections «Regions of Russia. Socio-economic indicators».

RESULTS

According to analytic system outworked in the Vishnevsky National Research Medical Center of Surgery, surgical service in the Volgograd region dropped from the 64th to the 82nd place among other entities between 2017 and 2021. Insufficient innovative development of surgical service is evidenced by small number of surgeons, common part-time work, no dynamics in introduction of laparoscopic surgeries and high in-hospital mortality in some acute abdominal disease. Work of regional surgical service was compared with socio-economic development of region and monitoring indicators in the «Health» national project.

CONCLUSION

Improving the efficacy of surgical service in the Volgograd region requires joint efforts of the entire regional healthcare system.

Emergency Resection of a Bleeding Ruptured Malignant Phyllodes Tumor of the Breast

Ruptured phyllodes tumors, though extremely rare, can necessitate emergency surgery in certain cases, particularly those with active bleeding. A 51-year-old woman presented to our hospital with a newly identified mass in her right breast that developed over the past two months. The tumor had ruptured through the paramammary nipple. While initially diagnosed with a phyllodes tumor and scheduled for elective surgery, she experienced active bleeding from the ruptured tumor, leading to a drop in hemoglobin levels. An emergency right simple mastectomy was performed to control the bleeding. Postoperatively, no complications or recurrences were observed. Phyllodes tumors, which are characterized by rapid growth, may present with active bleeding following rupture and may require emergency surgery.

Development of predictive score for postoperative dysphagia after emergency abdominal surgery in patients of advanced age

Aim

Postoperative dysphagia after emergency abdominal surgery (EAS) in patients of advanced age has become problematic, and appropriate dysphagia management is needed. This study was performed to identify predictive factors of dysphagia after EAS and to explore the usefulness of swallowing screening tools (SSTs).

Methods

This retrospective study included 267 patients of advanced age who underwent EAS from 2012 to 2022. They were assigned to a dysphagia group and non-dysphagia group using the Food Intake Level Scale (FILS) (dysphagia was defined as a FILS level of <7 on postoperative day 10). From 2018, original SSTs including a modified water swallowing test were performed by nurses.

Results

The incidence of postoperative dysphagia was 22.8% (61/267). Patients were significantly older in the dysphagia than non-dysphagia group. The proportions of patients who had poor nutrition, cerebrovascular disorder, Parkinson's disease, dementia, nursing-care service, high intramuscular adipose tissue content (IMAC), and postoperative ventilator management were much higher in the dysphagia than non-dysphagia group. Using logistic regression analysis, high IMAC, postoperative ventilator management, cerebrovascular disorder, and dementia were correlated with postoperative dysphagia and were assigned 10, 4, 3, and 3 points, respectively, according to each odds ratio. The optimal cut-off value was 7 according to a receiver operating characteristics curve. Using 1:1 propensity score matching for high-risk patients, the incidence of postoperative dysphagia was reduced by SSTs.

Conclusions

The new prediction score obtained from this study can identify older patients at high risk for dysphagia after EAS, and SSTs may improve these patients' short-term outcomes.

Sigmoid Diverticulitis in a Tight Spot: An Atypical Presentation Within a Ventral Hernia

Ventral hernia and acute diverticulitis may present with similar symptoms posing difficulty in clinical diagnosis. Rarely, complicated sigmoid diverticulitis is found within an irreducible ventral hernia sac in the emergency setting. Intraoperative decision on the appropriate surgical option depends on the surgeon's experience and the patient's clinical state. We present a case of a middle-aged female who came in with infraumbilical hernia containing necrotic sigmoid diverticulitis. Her surgical history was cesarean section and total abdominal hysterectomy with a re-look laparotomy. She had an emergency exploration of the hernia through a midline incision, excision of the necrotic diverticulum, and the formation of loop colostomy at the site of the hernia. Post-operative recovery was uneventful and she has been scheduled for an elective sigmoid colectomy and reversal of the stoma. This study highlights that complicated sigmoid diverticulitis can rarely present as an irreducible ventral hernia and that less is often more in safely getting patients out of trouble in an emergency.

A call for clarity: a scoping review of predictors of poor outcome after emergency abdominal surgery for inflammatory bowel disease

AIM

The medical management of inflammatory bowel disease (IBD) is rapidly progressing; however, many patients with the disease still require surgery. Often this is done as an emergency. Initiatives such as the National Emergency Laparotomy Audit have shown how evidence-based emergency surgery improves outcomes for the patient. The aim of this scoping review is to describe the current evidence base on risk stratification in emergency abdominal surgery for IBD.

METHODS

A literature search, abstract and full paper screening resulted in 17 articles representing 63 472 patients from seven countries.

RESULTS

It is likely that age, the American Society of Anesthesiologists grade, comorbidity and organ dysfunction play a similar role in risk stratification in IBD patients as in other emergency abdominal surgery cohorts. However, the reporting of what is considered an IBD emergency is variable. Six studies include clear definitions of emergency in our study. The range of what is considered an emergency is within 12 h of admission to any time within an unplanned admission.

CONCLUSION

To have data driven, evidence-based emergency surgical practice in IBD we need consistency of reporting, including the definitions of emergency and urgency. Core descriptor sets in IBD would be valuable.

Feasibility of laparoscopic resection for perforated diverticulitis: a retrospective observational study of 77 consecutive patients

BACKGROUND

Perforated colonic diverticulitis with purulent or fecal contamination (PCD) is a surgical emergency with high morbidity and mortality. Traditionally, open surgery as a Hartmann procedure (HP) has been performed. Feasibility of the laparoscopic approach (LA) either with primary anastomosis (PA) or as an HP has been shown, but evidence and implementation into daily routine remain low. We analysed all patients with PCD and emergency surgery at our institution to compare post-operative outcomes between LA and open surgery. Our results should add more evidence about the potential benefit of LA in treating PCD.

METHODS

This retrospective analysis conducted at a tertiary care centre in Germany included all patients with PCD undergoing emergency surgery between June 2007 and February 2019. Mortality and postoperative morbidity according to Clavien-Dindo-Classification are the primary endpoints. Secondary endpoints were stoma-free survival and length of hospital stay.

RESULTS

Seventy-seven patients were identified (41 female/36 male; median age 67.9 years). Sixty patients underwent a LA (conversion in 9 of 60, 15%). PA has been performed in 25 of 77 patients (22 LA, 3 with open surgery). Severe complications and death (Clavien-Dindo-Classification grade IIIb-V) were lower in patients with LA (17/60, 28%) compared to open surgery (9/17, 53%; p = 0.082) as well as the length of hospital stay (LOS; LA 9 days vs. open surgery 17 days; p = 0.016).

CONCLUSION

The LA is feasible in the majority of patients with PCD and may be warranted as a routine in emergency surgery. Although limited by a selection bias of this retrospective study, the LA seems to reduce morbidity and LOS.

Repair of diaphragmatic hernias: Retrospective analysis of 70 cases

BACKGROUND

Congenital and traumatic diaphragmatic hernias (DH) can lead to respiratory and gastrointestinal complications that can be the cause of serious morbidity and mortality. In this study, we aimed to share our experience with the surgical repair of complicated or non-complicated DH.

METHODS

Patients who were operated on under emergency or elective conditions with the diagnosis of DH between 2009 and 2023 were analyzed retrospectively. Demographic characteristics, histories, symptoms, etiology of DH, computed tomography find-ings, surgical techniques, and postoperative outcomes of the patients were recorded.

RESULTS

The mean age of the cases was 51.5±18.5, and 29 were female and 41 were male. Hernia etiology was found to be con-genital (40%), traumatic (32.8%), spontaneous (14.3%), and iatrogenic (12.8%), respectively. The mean diameter of the defects was 7.3±2.76 cm (range: 3-15 cm), and 84% of the defects were on the left side. Sixty percent of the cases were treated by laparoscopic surgery and 11.4% by laparotomy. The conversion rate from laparoscopic to open was 24.3%. Dual mesh was used in 48% of the pa-tients, and primary suturing was applied in 34%. The postoperative mortality rate was 7.1%.

CONCLUSION

DH is an important cause of morbidity and mortality due to abdominal organ strangulation and pulmonary and cardiac complications. When a DH is diagnosed, laparoscopic or open surgery is the treatment that should be preferred.

Understanding the Geographic Distribution of Diverticulitis Hospitalizations in Washington State

BACKGROUND

The incidence of diverticulitis in the United States is increasing, and hospitalization remains a surrogate for disease severity. State-level characterization of diverticulitis hospitalization is necessary to better understand the distribution of disease burden and target interventions.

METHODS

A retrospective cohort of diverticulitis hospitalizations from 2008 through 2019 was created using Washington State's Comprehensive Hospital Abstract Reporting System. Hospitalizations were stratified by acuity, presence of complicated diverticulitis, and surgical intervention using ICD diagnosis and procedure codes. Patterns of regionalization were characterized by hospital case burden and distance travelled by patients.

RESULTS

During the study period, 56,508 diverticulitis hospitalizations occurred across 100 hospitals. Most hospitalizations were emergent (77.2%). Of these, 17.5% were for complicated diverticulitis, and 6.6% required surgery. No single hospital received more than 5% (n = 235) of average annual hospitalizations. Surgeons operated in 26.5% of total hospitalizations (13.9% of emergent hospitalizations, and 69.2% of elective hospitalizations). Operations for complicated disease made up 40% of emergent surgery and 28.7% of elective surgery. Most patients traveled fewer than 20 miles for hospitalization, regardless of acuity (84% for emergent hospitalization and 77.5% for elective hospitalization).

DISCUSSION

Hospitalizations for diverticulitis are primarily emergent, nonoperative, and broadly distributed across Washington State. Hospitalization and surgery occur close to patients' homes, regardless of acuity. This decentralization needs to be considered if improvement initiatives and research in diverticulitis are to have meaningful, population-level impact.

Prognostic factors of poor postoperative outcomes in gastrectomies

Background

Gastric cancer is one of the most common cancers worldwide and is the third most common cause of cancer related death. Improving postoperative results by understanding risk factors which impact outcomes is important. The current study aimed to compare immediate perioperative outcomes following gastrectomy.

Methods

302 patients following gastric resections over a 10-year period (January 2009-January 2020) were identified in a database and retrospectively analysed. Epidemiological as well as perioperative data was analysed, and a univariate and multivariate analysis performed to identify risk factors for in-hospital mortality.

Results

In general, gastrectomies were mainly performed electively (total vs. subtotal 95% vs. 85%, p = 0.004). Patients having subtotal gastrectomy needed significantly more PRBC transfusions compared to total gastrectomy (p = 0.039). Most emergency surgeries were performed for benign diseases, such as ulcer perforations or bleeding and gastric ischaemia. Only emergency surgery was significantly associated with poorer overall survival (HR 2.68, 95% CI 1.32-5.05, p = 0.003).

Conclusion

In-hospital mortality was comparable between total and subtotal gastrectomies. Only emergency interventions increased postoperative fatality risk.

Identifying Trauma Patients in Need for Emergency Surgery in the Prehospital Setting: The Prehospital Prediction of In-Hospital Emergency Treatment (PROPHET) Study

Prehospital field triage often fails to accurately identify the need for emergent surgical or non-surgical procedures, resulting in inefficient resource utilization and increased costs. This study aimed to analyze prehospital factors associated with the need for emergent procedures (such as surgery or interventional angiography) within 6 h of hospital admission. Additionally, our goal was to develop a prehospital triage tool capable of estimating the likelihood of requiring an emergent procedure following hospital admission. We conducted a retrospective observational study, analyzing both prehospital and in-hospital data obtained from the Lombardy Trauma Registry. We conducted a multivariable logistic regression analysis to identify independent predictors of emergency procedures within the first 6 h from admission. Subsequently, we developed and internally validated a triage score composed of factors associated with the probability of requiring an emergency procedure. The study included a total of 3985 patients, among whom 295 (7.4%) required an emergent procedure within 6 h. Age, penetrating injury, downfall, cardiac arrest, poor neurological status, endotracheal intubation, systolic pressure, diastolic pressure, shock index, respiratory rate and tachycardia were identified as predictors of requiring an emergency procedure. A triage score generated from these predictors showed a good predictive power (AUC of the ROC curve: 0.81) to identify patients requiring an emergent surgical or non-surgical procedure within 6 h from hospital admission. The proposed triage score might contribute to predicting the need for immediate resource availability in trauma patients.

Emergency/Elective Surgery and Emergency Percutaneous Interventions in Liver Hydatid Cysts and Their Results

BACKGROUND

Hydatid cyst may remain asymptomatic for several years or may become complicated. The aim of this study is to evaluate the patients who were operated on for liver hydatid cyst in our clinic and the results of preoperative or postoperative complications.

METHODS

The data of 836 patients who underwent surgery (n = 750) or Puncture, Aspiration, Injection, and Re-aspiration (n = 86) for hydatid cyst disease in our clinic between January 2006 and January 2021 were evaluated retrospectively.

RESULTS

Surgical operation was performed in 750 of the patients and Puncture, Aspiration, Injection, and Re-aspiration procedure was performed in 89 of the patients. In the surgery and Puncture, Aspiration, Injection, and Re-aspiration group, respiratory distress, anaphylaxis, allergic rash, and urticaria were observed in 11 patients (8 in Puncture, Aspiration, Injection, and Re-aspiration group and 3 in open surgery group). All patients recovered with emergency medical interventions. Recurrence was observed after the percutaneous procedure in 11 cases and after surgery in 36 cases. There was no statistically significant difference between the surgical and Puncture, Aspiration, Injection, and Re-aspiration groups in terms of recurrence and cyst infection (P = .253 and P = .547, respectively). The incidence of the development of intrabiliary rupture, allergic reaction, and intraperitoneal rupture was found 135 (16.14%), 12 (1.43%), and 2 (0.23%) in our study, respectively.

CONCLUSIONS

Intraperitoneal or intrabiliary rupture is a rare but fatal complication of hydatid cyst. The presence of fever, jaundice, abdominal pain, urticaria, and anaphylactic reactions in endemic areas should take the suspicion of hydatid cyst rupture. The timing of surgery is an important factor affecting morbidity and mortality. Detailed exploration of the abdomen in emergency surgery for rupture hydatid cyst is essential for recurrence.

Evaluation of a modified emergency surgical acuity score in predicting operative and non-operative mortality and morbidity in an acute surgical unit

BACKGROUND

Emergency general surgery (EGS) patients have an increased risk of mortality and morbidity compared to other surgical patients. Limited risk assessment tools exist for use in both operative and non-operative EGS patients. We assessed the accuracy of a modified Emergency Surgical Acuity Score (mESAS) in EGS patients at our institution.

METHODS

A retrospective cohort study from an acute surgical unit at a tertiary referral hospital was performed. Primary endpoints assessed included death before discharge, length of stay (LOS) >5 days and unplanned readmission within 28 days. Operative and non-operative patients were analysed separately. Validation was performed using the area under the receiver operating characteristic (AUROC), Brier score and Hosmer-Lemeshow test.

RESULTS

A total of 1763 admissions between March 2018 and June 2021 were included for analysis. The mESAS was an accurate predictor of both death before discharge (AUROC 0.979, Brier score 0.007, Hosmer-Lemeshow P = 0.981) and LOS >5 days (0.787, 0.104, and 0.253, respectively). The mESAS was less accurate in predicting readmission within 28 days (0.639, 0.040, and 0.887, respectively). The mESAS retained its predictive ability for death before discharge and LOS >5 days in the split cohort analysis.

CONCLUSION

This study is the first to validate a modified ESAS in a non-operatively managed EGS population internationally and the first to validate the mESAS in Australia. The mESAS accurately predicts death before discharge and prolonged LOS for all EGS patients, providing a highly useful tool for surgeons and EGS units worldwide.

An 8-year retrospective review of emergency laparotomy outcomes in a Queensland rural hospital

OBJECTIVE

Emergency laparotomy (EL) is a major operation performed in critically unwell patients. The National Emergency Laparotomy Audit (NELA), undertaken in the UK since 2013 has shown progressive improvement in clinical outcomes, specifically reduced mortality, and length of stay (LOS) through the implementation of perioperative key performance indicators (KPIs) (ANZ J Surg. 2021;91:2575, Br J Surg. 2015;102:57, Br J Surg. 2017;104:463, JAMA Surg. 2019;154:e190145). The objective is to generate a rural hospital EL audit (MELA) to evaluate local outcomes and clinical standards of practice with regional, national, and international benchmarks.

METHODS

A review of medical records between January 2014 and December 2021 of patients who undergo an EL. Data collected include patient demographics, clinical information, compliance to KPIs and the primary outcomes of 30-day mortality and LOS.

DESIGN

This is a descriptive quantitative study. The inclusion and exclusion criteria were similar to those defined in NELA and ANZELA-QI.

SETTING AND PARTICIPANTS

The general surgeons at the rural hospital provide emergency surgery services for the North-West Queensland community.

MAIN OUTCOME MEASURES

To review local clinical outcomes of 30-day mortality, LOS, and adherence to perioperative KPIs.

RESULTS

Overall, 84 patients met inclusion criteria. The median age (IQR) was 61 (48.8-70.3) years. The 30-day mortality was 3.6% and mean LOS was 12.8 (±13.4) days which was secondary to the low-risk patients within the data set. Compliance to KPIs (≥80%) was achieved in five of eight standards assessed.

CONCLUSION

Local outcomes appear to be comparable to national and international benchmarks and a similar rural setting. The audited cohort outperformed the national standard in adherence to perioperative KPIs.

Anesthesia and perioperative pain relief in the frail elderly patient

Demand for anesthesia and analgesia for the frail elderly is continuously increasing as the likelihood of encountering very elderly, very vulnerable, and very compromised patients has, ever so subtly, increased over the last three decades. The anesthesiologist has, increasingly, been obliged to offer professional services to frail patients. Fortunately, there has been a dramatic improvement in medications, methods of drug delivery, critical monitoring, and anesthesia techniques. Specific methodologies peculiar to the frail are now taught and practiced across all anesthesia subspecialties. However, administering anesthesia for the frail elderly is vastly different to giving an anesthetic to the older patient. Frail patients are increasingly cared for in specialized units-geriatric intensive therapy units, post-acute care services, palliative, hospices, and supportive care and aged care facilities. Several medications (e.g., morphine-sparing analgesics) more suited to the frail have become universally available in most centers worldwide so that best-practice, evidence-based anesthesia combinations of drugs and techniques are now increasingly employed. Every anesthetic and pain management techniques in the frail elderly patient are going to be discussed in this review.

Impact of Postoperative Imaging Following Emergency Surgery for Penetrating Ballistic Thoracic Trauma

INTRODUCTION

Patients undergoing emergent surgical procedures after penetrating trauma can benefit from postoperative imaging studies to identify potential missed injuries or indications to additional surgery. Aim of this study is to describe postoperative imaging findings in patients who underwent emergent operation for thoracic gunshot wounds (GSWs) and the subsequent need for further surgery, diagnostic evaluations or consults.

METHODS

Patients who survived to receive imaging evaluation after emergency surgery for penetrating chest trauma in a level I trauma center between 2017 and 2021 were included. Results of postoperative diagnostic evaluation were screened to determine their impact on the subsequent management.

RESULTS

Overall, 125 patients admitted with a thoracic GSW underwent an emergent surgical procedure and 29 survived to receive postoperative imaging and were included. Postoperative CT-scan was performed in 26 (89.6%) patients, echocardiography in 8 (27.5%). Other tests included esophagoscopy (1) and bronchoscopy (1). Impact on management of abnormal imaging included a new indication to surgery or additional procedures in 7 cases and need for additional imaging or consults in other 8 cases. Bone fractures and lung injuries were more often diagnosed on postoperative CT-scan. In 3 patients, abnormal echocardiographic findings led to a second cardiac operation.

CONCLUSION

Following emergency surgery for penetrating trauma, completion of injury assessment with CT-scan can lead to identification of missed or additional injuries, while other imaging is indicated according to operative findings. In this study, 24.1% had additional surgical pathology identified by postoperative imaging while others had findings requiring additional studies or specialist consult evaluations.

Characteristics and management of patients undergoing emergency surgery for diabetic foot attack

BACKGROUND

Diabetic foot attack (DFA) is considered one of the worst manifestations of diabetic foot. It is necessary to act quickly to prevent amputation and save the patient's life. The aim of this study is to reveal the characteristic features of DFAs and be a guide to healthcare professionals to manage and refer these patients.

METHODS

Sixty-five patients with DFAs were analyzed retrospectively. Demographics were collected. All patients' ınfectious dis-eases Society of America/International Working Group on the Diabetic Foot (IDSA/IWDGF) stages, site ıschemia neuropathy, bacterial ınfection and depth (SINBAD) and laboratory risk ındicator for necrotizing fasciitis (LRINEC) scores were calculated. According to these measurements, patients were categorized and statistical results were obtained.

RESULTS

We found that patients who underwent emergency surgery due to DFA applied to an average of two hospitals before applying to our facility and the median acceptance time since the beginning of the first complaint was 9 days. All patients were IDSA/IWDGF stages three and four. Most of the patients had SINBAD scores between four and six. 60% of the patients were at high risk for necrotizing fasciitis according to the LRINEC score. 58.2% of patients had periferic arterial stenosis and the amputation rate was 69.2%. 21.3% of the patients were followed in the intensive care unit, and our patients' mortality rate was 4.2%.

CONCLUSION

DFA is an emergency surgical condition that requires high clinical suspicion. If not diagnosed and treated with emergency surgery, it has a high mortality and amputation rate. High white blood cell count in patients, local and systemic signs of inflammation, presence of subcutaneous emphysema in the lower extremities on a direct X-ray radiography, and high blood sugar should be considered as warning signs for DFA. Emergency surgical intervention should be performed on these patients, and if the patient is not in a suitable center for emergency surgery, they should be rapidly referred to a center with experienced clinicians.

Meckel's Diverticulum Causing Ileal Volvulus and Peritonitis after a Recent Appendectomy: A Case Report and Literature Review-We Should Likely Resect an Incidental MD

Meckel's diverticulum (MD) is the most common congenital anomaly of the gastrointestinal tract with a 1-3% prevalence in the general population. The surgical management of symptomatic MD is well described in the literature, but there is still no consensus on the indication for prophylactic resection of incidental asymptomatic MD. To address this issue, we extensively reviewed the current literature and report our experience with laparoscopic management of an unusual case of MD causing ileal volvulus and acute peritonitis two weeks after a laparoscopic appendectomy for acute gangrenous appendicitis performed in another hospital. A 50-year-old man presented to the emergency department with acute and severe abdominal pain, vomiting, and constipation. He had undergone a laparoscopic appendectomy for acute appendicitis two weeks before in another hospital. The patient was apyretic, distressed, and seeking an antalgic position. The abdomen was mildly distended and tender, and the Blumberg sign was mildly positive in the central quadrants. The clinical picture deteriorated with fever, peritonismus, and leukocytosis. A CT scan showed an ileo-ileal adhesion near the ileocolic junction and dilatation of the upstream loops with the air-fluid levels. Through an urgent laparoscopy, a necrotic mass, the MD, was wedge-resected, and the surrounding ileal volvulus derotated. The postoperative course was uneventful. There is no definitive consensus on the appropriate management of incidental asymptomatic MD, although several studies have attempted to identify guiding criteria. Features of the MD, the patient's risk factors, clinical presentation, and surgical approach need to be considered to establish definitive guidelines for the management of incidental asymptomatic MD. In the absence of definitive guidelines, personal expertise and judgement are the main resources for the surgeon approaching an incidental asymptomatic MD.

The Impact of the COVID-19 Pandemic on Surgical Services in Brazil's Healthcare System: A Retrospective Cross-Sectional Study

Background The coronavirus disease 2019 (COVID-19) pandemic provoked disruptions in healthcare delivery, leading to the cancellation and postponement of various health services, including surgery. Numerous countries closed their borders and established laws mandating the use of face masks and social distancing and enforced lockdowns, and various activities were constrained. Brazil, the largest and most populous country in Latin America, also experienced a rapid and sustained surge in infections and deaths. Brazil was the most severely impacted nation in Latin America. The impact of the pandemic on surgical services in Brazil has not been adequately studied since most studies only cover the early phases of the pandemic. Thus, this study aimed to assess the impact of the COVID-19 pandemic on surgical services throughout the entire period. Methods A retrospective cross-sectional design was used to examine surgical cases from 2019 to 2022 and compared the following indicators: (1) number of hospital admissions, (2) length of hospital stay (LOS) (in days), and (3) volume of urgent and elective procedures. Data was divided into four time periods, pre-pandemic (March-December 2019), pandemic (March-December 2020), recovery (March-December 2021), and post-pandemic (March-December 2022), and was analyzed for the number of admissions and LOS based on surgical procedures performed by stratifying according to region, sex, age, and type of surgery (urgent versus elective). Results The number of admissions for surgical procedures ranged between 859,646 and 4,015,624 for 2019, 686,616 and 3,419,234 for 2020, 787,791 and 3,829,019 for 2021, and 760,512 and 3,857,817 for 2022 for the category of region; 4,260,900 and 5,991,775 for 2019, 3,594,117 and 4,984,710 for 2020, 4,182,640 and 5,590,808 for 2021, and 4,077,651 and 5,561,928 for 2022 for the category of sex; and 2,170,288 and 3,186,117 for 2019, 1,516,830 and 2,825,189 for 2020, 1,748,202 and 3,030,272 for 2021, and 1,900,023 and 2,859,179 for 2022 for the category of age. The variable age showed a comparable trend, albeit with an expressive decline for surgeries in the age range of 0-19 years. The LOS (in days) for surgical procedures ranged between 110,157 and 910,846 for 2019, 58,562 and 897,734 for 2020, 67,926 and 904,137 for 2021, and 100,467 and 823,545 for 2022. Thoracic surgery indicated no statistically significant difference in the number of admissions and LOS. Elective surgeries had a decline in the number of admissions and LOS, a 13% and 9.3% decline between 2019 and 2020, respectively. Urgent surgeries experienced a slight decrease in admissions and LOS, with a decline of 2.4% and 2.8% between 2019 and 2020, respectively. Conclusions Population characteristics, such as age, sex, and region, showed decreased hospital admissions during the pandemic, followed by a recovery toward pre-pandemic levels afterward. The number of surgical admissions and the length of hospital stays decreased during the pandemic but gradually returned to pre-pandemic levels in the recovery and post-pandemic phases. Notably, thoracic surgery remained statistically consistent across all periods, indicating its emergency nature compared to other surgeries. Thus, we conclude that the pandemic had minimal impact on thoracic surgery cases, contributing to a stable trend.

Palliative Treatment of Bowel Obstruction With Colostomy Under Local Anesthesia in Frail Patients: A Single-Site Experience

INTRODUCTION

Attendance of patients to the emergency department due to acute large bowel obstruction is a common phenomenon. Most of these patients are elderly, critically ill, and with high comorbidity. The literature suggests that more than 50% of these cases are due to colon cancer. Since this condition is considered to be an emergency, immediate intervention and response is imperative.

PURPOSE

The aim of the present study is to present our surgical technique of colostomy formation under local anesthesia in selected critically ill patients, with increased perioperative risk and acute large bowel obstruction.

MATERIALS AND METHODS

This is a retrospective study of 24 patients, with obstipation, who underwent emergency colostomy under local anesthesia, during the period from 2014 to 2021.

RESULTS

The mean age of the patients was 77 years. The vast majority of patients had an American Society of Anesthesiologists (ASA) score of ≥3 and a Charlson score of ≥7. The most common colostomy was transverse colostomy (21/24 patients). The patients' hospitalization ranged from four to 42 days. Only one patient died. All colostomies functioned properly in the immediate postoperative period. Only one patient required postoperative admission to the ICU.

CONCLUSIONS

Colostomy under local anesthesia in critically ill, elderly patients is an alternative option for the treatment of ileus.

Machine learning-based prediction of postoperative mortality in emergency colorectal surgery: A retrospective, multicenter cohort study using Tokushukai medical database

Background

Although prognostic factors associated with mortality in patients with emergency colorectal surgery have been identified, an accurate mortality risk assessment is still necessary to determine the range of therapeutic resources in accordance with the severity of patients. We established machine-learning models to predict in-hospital mortality for patients who had emergency colorectal surgery using clinical data at admission and attempted to identify prognostic factors associated with in-hospital mortality.

Methods

This retrospective cohort study included adult patients undergoing emergency colorectal surgery in 42 hospitals between 2012 and 2020. We employed logistic regression and three supervised machine-learning models: random forests, gradient-boosting decision trees (GBDT), and multilayer perceptron (MLP). The area under the receiver operating characteristics curve (AUROC) was calculated for each model. The Shapley additive explanations (SHAP) values are also calculated to identify the significant variables in GBDT.

Results

There were 8792 patients who underwent emergency colorectal surgery. As a result, the AUROC values of 0.742, 0.782, 0.814, and 0.768 were obtained for logistic regression, random forests, GBDT, and MLP. According to SHAP values, age, colorectal cancer, use of laparoscopy, and some laboratory variables, including serum lactate dehydrogenase serum albumin, and blood urea nitrogen, were significantly associated with in-hospital mortality.

Conclusion

We successfully generated a machine-learning prediction model, including GBDT, with the best prediction performance and exploited the potential for use in evaluating in-hospital mortality risk for patients who undergo emergency colorectal surgery.

How does a local instrumental variable method perform across settings with instruments of differing strengths? A simulation study and an evaluation of emergency surgery

Local instrumental variable (LIV) approaches use continuous/multi-valued instrumental variables (IV) to generate consistent estimates of average treatment effects (ATEs) and Conditional Average Treatment Effects (CATEs). There is little evidence on how LIV approaches perform according to the strength of the IV or with different sample sizes. Our simulation study examined the performance of an LIV method, and a two-stage least squares (2SLS) approach across different sample sizes and IV strengths. We considered four 'heterogeneity' scenarios: homogeneity, overt heterogeneity (over measured covariates), essential heterogeneity (unmeasured), and overt and essential heterogeneity combined. In all scenarios, LIV reported estimates with low bias even with the smallest sample size, provided that the instrument was strong. Compared to 2SLS, LIV provided estimates for ATE and CATE with lower levels of bias and Root Mean Squared Error. With smaller sample sizes, both approaches required stronger IVs to ensure low bias. We considered both methods in evaluating emergency surgery (ES) for three acute gastrointestinal conditions. Whereas 2SLS found no differences in the effectiveness of ES according to subgroup, LIV reported that frailer patients had worse outcomes following ES. In settings with continuous IVs of moderate strength, LIV approaches are better suited than 2SLS to estimate policy-relevant treatment effect parameters.

A Case of Atraumatic Acute Carpal Tunnel Syndrome Requiring Emergency Surgery

Acute carpal tunnel syndrome (ACTS) is an urgent condition in which symptoms progress rapidly on an hourly basis, and emergency surgery may be required to treat it. ACTS often occurs after a traumatic event such as a fracture of the distal radius, and rarely occurs non-traumatically. We present a case of a 60-year-old male with ACTS secondary to acute synovitis due to rheumatoid arthritis. The patient complained of strong numbness from the thumb to the ring finger and pain in the palm, and he was unable to actively flex or extend his fingers. In addition, severe tenderness was observed in the palm; on the contralateral side, no obvious tenderness of the forearm and wrist joint was observed. Due to the intolerable pain and numbness, ACTS was suspected. Internal pressure from the forearm to the palm was measured, and it was found that the internal pressure of the carpal tunnel was elevated at 150 mmHg. Based on these findings, non-traumatic ACTS was diagnosed, and emergency surgery was performed. The transverse carpal ligament was exposed, an incision was made from the distal end, and the proximal part was fully incised to the forearm fascia so that the carpal tunnel was completely released. The synovial membranes around the median nerve were peeled off, confirming that the nerve had been loosened sufficiently. After the operation, finger pain and numbness improved dramatically from the day after surgery. Proper diagnosis and prompt treatment with surgical median nerve decompression are crucial for good functional recovery in these patients.

Diffuse Peritonitis Caused by Splenic Abscess After Laparoscopic Sleeve Gastrectomy: A Case Report

A splenic abscess (SA) following sleeve gastrectomy (SG) is a rare manifestation of a gastric leak (GL). The clinical findings include fever, abdominal pain, leukocytosis, and an elevated C-reactive protein. A computed tomography scan is diagnostic and can show signs of GL, or diffuse peritonitis. Treatment can either be non-operative (including large-spectrum antibiotics and percutaneous drainage) or surgical (including splenectomy). We present the case of a 41-year-old female patient with SA, with septic shock and diffuse peritonitis, successfully treated with a splenectomy three months post-SG.

Idiopathic Sclerosing Encapsulating Peritonitis Associated With Persistent Descending Mesocolon: A Surgical Puzzle

During our practice as clinical surgeons, we have encountered situations in which exploratory abdominal laparotomies have yielded unexpected outcomes, despite conducting thorough and rigorous preoperative studies. A rare condition called sclerosing encapsulating peritonitis (SEP), in which a fibrocollagenous membrane encircles the intestine and other abdominal organs, surprised us in a case of an acute abdomen. Persistent descending mesocolon is another unusual condition in which the descending colon is transferred downward and to the right abdominal region because its mesocolon is unable to merge with the posterior abdominal wall. Those two different conditions are extremely rare and were never been described in a single case. We present a case of an 80-year-old male who presented in the emergency department with an acute abdomen and puzzled us.

Surgical Techniques and Stoma-related Complications Associated With Emergency Stoma Creation

BACKGROUND/AIM

Determination of risk factors for stoma-related complications associated with emergency stoma creation may impact on reducing complications and improving the quality of life of ostomy patients; however, there are only few reports on stoma-related complications associated with emergency stoma creation. Our study aimed to identify risk factors associated with stoma-related complications after emergency surgery, and evaluate surgical techniques for good stoma creation in the emergency setting.

PATIENTS AND METHODS

A retrospective analysis of patient and surgical characteristics was performed in 104 consecutive patients who underwent ileostomy or colostomy as emergency surgery between January 2020 and December 2022 at the Gunma University Hospital.

RESULTS

Preoperative stoma site marking was performed in 70 (67.3%) patients. Colostomies and ileostomies were performed in 78 (75.0%) and 26 (25.0%) patients, respectively. The skin bridge technique was used in 13 (12.5%) patients. Stoma-related complications were diagnosed in 62 (59.6 %) patients, with peristomal skin disorders (47.1%) as the most common complication, followed by mucocutaneous separation (31.7%), and stoma retraction (19.2%). In the multivariate analysis, body mass index (BMI) [odds ratio (OR)=5.570, 95% confidence interval (CI)=1.233-25.167, p=0.026], skin bridge technique (OR=0.144, 95% CI=0.031-0.670, p=0.014), and stoma height (OR=0.134, 95% CI=0.038-0.469, p=0.002) were independent risk factors for stoma-related complications after emergency stoma creation.

CONCLUSION

In emergency stoma creation, higher BMI and lower stoma height are associated with stoma-related complications. Using the skin bridge technique could reduce the risk of stoma-related complications after emergency stoma creation.