Objective The aim of this study was to evaluate the impact of angiosome targeted revascularization according to the revascularization method. Design Retrospective observational study. Materials and ...methods This study cohort comprised 744 consecutive patients who underwent infrapopliteal endovascular or surgical revascularization between January 2010 and July 2013. Differences in outcomes after bypass surgery and PTA were adjusted by estimating a propensity score, which was employed for one to one matching as well as adjusted analysis. Results Cox proportional hazards analysis showed that angiosome-targeted revascularization (HR 1.29, 95% CI 1.02–1.65), bypass surgery (HR 1.79, 95% CI 1.41–2.27), C-reactive protein ≤10 mg/dL (HR 1.42, 95% CI 1.11–1.81), and the number of affected angiosomes (HR 0.85, 95% CI 0.74–0.98) were independent predictors of improved wound healing. When adjusted for the number of affected angiosomes and C-reactive protein ≤10 mg/dL, angiosome-targeted bypass surgery was associated with a significantly higher rate of wound healing than non-angiosome-targeted angioplasty (HR 2.27, 95% CI 1.61–3.20). This was confirmed in propensity score adjusted analysis (HR 1.72, 95% CI 1.35–2.16). Among patients who underwent angiosome-targeted revascularization, the propensity score adjusted analysis showed that bypass surgery was associated with a significantly better rate of wound healing (HR 154, 95% CI 1.09–2.16) but similar limb salvage rates when compared with angioplasty (HR 0.79, 95% CI 0.44–1.43). Conclusion Rates of wound healing and limb salvage in patients with critical limb ischemia (CLI) were significantly better after angiosome-targeted revascularization, bypass surgery achieving significantly better wound healing than angioplasty.
Background and Aims:
The laparoscopic approach has been increasingly used to treat adhesive small-bowel obstruction. The aim of this study was to compare the outcomes of a laparoscopic versus an open ...approach for adhesive small-bowel obstruction.
Material and Methods:
Data were retrospectively collected on patients who had surgery for adhesive small-bowel obstruction at a single academic center between January 2010 and December 2012. Patients with a contraindication for the laparoscopic approach were excluded. A propensity score was used to match patients in the laparoscopic and open surgery groups based on their preoperative parameters.
Results:
A total of 25 patients underwent laparoscopic adhesiolysis and 67 patients open adhesiolysis. The open adhesiolysis group had more suspected bowel strangulations and more previous abdominal surgeries than the laparoscopic adhesiolysis group. Severe complication rate (Clavien–Dindo 3 or higher) was 0% in the laparoscopic adhesiolysis group versus 14% in the open adhesiolysis group (p = 0.052). Twenty-five propensity score–matched patients from the open adhesiolysis group were similar to laparoscopic adhesiolysis group patients with regard to their preoperative parameters. Length of hospital stay was shorter in the laparoscopic adhesiolysis group compared to the propensity score–matched open adhesiolysis group (6.0 vs 10.0 days, p = 0.037), but no differences were found in severe complications between the laparoscopic adhesiolysis and propensity score–matched open adhesiolysis groups (0% vs 4%, p = 0.31).
Conclusion:
Patients selected to be operated by the open approach had higher preoperative morbidity than the ones selected for the laparoscopic approach. After matching for this disparity, the laparoscopic approach was associated with a shorter length of hospital stay without differences in complications. The laparoscopic approach may be a preferable approach in selected patients.
Longer duration from symptom onset is associated with increased risk of perforation in appendicitis. In previous studies, in-hospital delay to surgery has had conflicting effects on perforation ...rates. Although preoperative antibiotics have been shown to reduce postoperative infections, there are no data showing that administration of antibiotics while waiting for surgery has any benefits. The aims of this study are to evaluate the role of both in-hospital delay to surgery and antibiotic treatment while waiting for surgery on the rate of appendiceal perforation.
This prospective, open-label, randomized, controlled non-inferiority trial compares the in-hospital delay to surgery of less than 8 hours versus less than 24 hours in adult patients with predicted uncomplicated acute appendicitis. Additionally, participants are randomized either to receive or not to receive antibiotics while waiting for surgery. The primary study endpoint is the rate of perforated appendicitis discovered during appendicectomy. The aim is to randomize 1800 patients, that is estimated to give a power of 90 per cent (χ2) for the non-inferiority margin of 5 percentage points for both layers (urgency and preoperative antibiotic). Secondary endpoints include length of hospital stay, 30-day complications graded using Clavien-Dindo classification, preoperative pain, conversion rate, histopathological diagnosis and Sunshine Appendicitis Grading System classification.
There are no previous randomized controlled studies for either in-hospital delay or preoperative antibiotic treatment. The trial will yield new level 1 evidence.EU Clinical Trials Register, EudraCT Number: 2019-002348-26; registration number: NCT04378868 (http://www.clinicaltrials.gov).
Background and aims:
Today, a significant proportion of solid abdominal organ injuries, whether caused by penetrating or blunt trauma, are managed nonoperatively. However, the controversy over ...operative versus nonoperative management started more than a hundred years ago. The aim of this review is to highlight some of the key past observations and summarize the current knowledge and guidelines in the management of solid abdominal organ injuries.
Materials and Methods:
A non-systematic search through historical articles and references on the management practices of abdominal injuries was conducted utilizing early printed volumes of major surgical and medical journals from the late 19th century onwards.
Results:
Until the late 19th century, the standard treatment of penetrating abdominal injuries was nonoperative. The first article advocating formal laparotomy for abdominal gunshot wounds was published in 1881 by Sims. After World War I, the policy of mandatory laparotomy became standard practice for penetrating abdominal trauma. During the latter half of the 20th century, the concept of selective nonoperative management, initially for anterior abdominal stab wounds and later also gunshot wounds, was adopted by major trauma centers in South Africa, the United States, and little later in Europe. In blunt solid abdominal organ injuries, the evolution from surgery to nonoperative management in hemodynamically stable patients aided by the development of modern imaging techniques was rapid from 1980s onwards.
Conclusion:
With the help of modern imaging techniques and adjunctive radiological and endoscopic interventions, a major shift from mandatory to selective surgical approach to solid abdominal organ injuries has occurred during the last 30–50 years.
Background and Aims:
Perioperative myocardial infarction is an underdiagnosed complication causing morbidity, mortality, and considerable costs. However, evidence of preventive and therapeutic ...options is scarce. We investigated the incidence and outcome of perioperative myocardial infarction in non-cardiac surgery patients in order to define a target population for future interventional trials.
Material and Methods:
We conducted a prospective single-center study on non-cardiac surgery patients aged 50 years or older. High-sensitivity troponin T and electrocardiograph were obtained five times perioperatively. Perioperative myocardial infarction diagnosis required a significant troponin T release and an ischemic sign or symptom. Perioperative risk calculator was used for risk assessment.
Results:
Of 385 patients with systematic ischemia screening, 27 patients (7.0%) had perioperative myocardial infarction. The incidence was highest in vascular surgery—19 of 172 patients (11.0%). The 90-day mortality was 29.6% in patients with perioperative myocardial infarction and 5.6% in non–perioperative myocardial infarction patients (p < 0.001). Perioperative risk calculator predicted perioperative myocardial infarction with an area under curve of 0.73 (95% confidence interval: 0.64–0.81).
Conclusion:
Perioperative myocardial infarction is a common complication associated with a 90-day mortality of 30%. The ability of the perioperative risk calculator to predict perioperative myocardial infarction was fair supporting its routine use.
New solutions for complex bleeding in trauma Coimbra, R.; Leppaniemi, A.
European journal of trauma and emergency surgery (Munich : 2007),
12/2014, Letnik:
40, Številka:
6
Journal Article
Appendicectomy is a common emergency operation. The aim of this analysis was to study the effect of preoperative delay on disease progression, and whether a novel scoring system (Atema score) could ...be useful in predicting complicated appendicitis.
Patients with uncomplicated acute appendicitis on CT and who underwent appendicectomy in 2014-2015 were analysed for patient characteristics, preoperative delay and outcomes.
Of 837 patients with uncomplicated appendicitis on CT, 187 (22.3 per cent) were found to have complicated appendicitis at surgery. The median time estimate for perforation was 25.4 h after CT, with an hourly rate of perforation of 2 per cent. Patients with an Atema score of 6 or less and those with no appendicolith on CT and a C-reactive protein level below 51 mg/l were the slowest to develop perforation, reaching a perforation rate of 5 per cent in 7.1 and 7.6 h respectively.
A substantial proportion of patients with uncomplicated acute appendicitis on CT have complicated appendicitis at surgery. However, in patients with no risk factors, surgery can be postponed safely for up to 7 h.
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