Background
Although gallstone disease increases with aging, elderly patients are less likely to undergo cholecystectomy. This is because age itself is a negative predictor after cholecystectomy. The ...ACS-NSQIP risk calculator can therefore help surgeons decide whether to operate or not. However, little is known about the accuracy of this model outside the ACS National Surgical Quality Improvement Program. The aim of the present study is to evaluate the ability of the ACS-NSQIP model to predict the clinical outcomes of patients aged 80 years or older undergoing elective or emergency cholecystectomy.
Study design
The study focused on 263 patients over 80 years of age operated on between 2010 and 2019: 174 were treated as emergencies because of acute cholecystitis (66.2%). Outcomes evaluated are those predicted by the ACS-NSQIP calculator within 30 days of surgery. The ACS-NSQIP model was tested for both discrimination and calibration. Differences among observed and expected outcomes were evaluated.
Results
When considering all patients, the discrimination of mortality was very high, as it was that of severe complications. Considering only the elective cholecystectomies, the discrimination capacity of ACS-NSQIP risk calculator has consistently worsened in each outcome while it remains high considering the emergency cholecystectomies. In the evaluation of the emergency cholecystectomy, the model showed a very high discriminatory ability and, more importantly, it showed an excellent calibration. Comparisons between main outcomes showed small or even negligible differences between observed and expected values.
Conclusion
The results of the present study suggest that clinical decisions on cholecystectomy in a patient aged 80 years or older should be assisted through the ACS-NSQIP model.
Abstract
Background
Immunocompromised patients are at higher risk of surgical site infection and wound complications. However, optimal management in the perioperative period is not well established. ...Present systematic review aims to analyse existing strategies and interventions to prevent and manage surgical site infections and other wound complications in immunocompromised patients.
Methods
A systematic review of the literature was conducted.
Results
Literature review shows that partial skin closure is effective to reduce SSI in this population. There is not sufficient evidence to definitively suggest in favour of prophylactic negative pressure wound therapy. The use of mammalian target of rapamycin (mTOR) and calcineurin inhibitors (CNI) in transplanted patient needing ad emergent or undeferrable abdominal surgical procedure must be carefully and multidisciplinary evaluated. The role of antibiotic prophylaxis in transplanted patients needs to be assessed.
Conclusion
Strict adherence to SSI infection preventing bundles must be implemented worldwide especially in immunocompromised patients. Lastly, it is necessary to elaborate a more widely approved definition of immunocompromised state. Without such shared definition, it will be hard to elaborate the needed methodologically correct studies for this fragile population.
Normothermic and hypothermic oxygenated perfusion for donation after circulatory death in kidney transplantation are becoming popular in Italy, with the purpose of reducing the risk of primary non ...function and delayed graft function due to the prolonged warm ischemia time. Potential complications related to these procedures are currently under investigation and are continuously emerging with the increasing experience. Post-operative infections - in particular graft arteritis - are a rare complication but determine high risk of mortality and of graft loss. The acute onset of the arterial complications makes it very difficult to find an effective treatment, and early diagnosis is crucial for saving both patient and graft. Prevention of such infections in this particular setting are advisable.
We present a patient with an acute arterial rupture after transplantation of a DCD graft treated in-vivo hypothermic oxygenated perfusion. The cause was a severe arteritis of the renal artery caused by Candida krusei and Pseudomonas aeruginosa. We discussed our treatment and we compared it to the other reported series.
Fungal infections in DCD transplant may be treacherous and strategies to prevent them should be advocated.
Acute calculus cholecystitis (ACC) is increasing in frequency within an ageing population, in which biliary tract infection, including cholecystitis and cholangitis, is the second most common cause ...of sepsis, with higher morbidity and mortality rates. Patient's critical conditions, such as septic shock or anaesthesiology contraindication, may be reasons to avoid laparoscopic cholecystectomy-the first-line treatment of ACC-preferring gallbladder drainage. It can aid in patient's stabilization with also the benefit of identifying the causative organism to establish a targeted antibiotic therapy, especially in patients at high risk for antimicrobial resistance such as healthcare-associated infection. Nevertheless, a recent randomized clinical trial showed that laparoscopic cholecystectomy can reduce the rate of major complications compared with percutaneous catheter drainage in critically ill patients too. On the other hand, among the possibilities to control biliary sepsis in non-operative management of ACC, according to recent meta-analysis, endoscopic gallbladder drainage showed better clinical success rate, and it is gaining popularity because of the potential advantage of allowing gallstones clearance to reduce recurrences of ACC. However, complications that may arise, although rare, can worsen an already weak clinical condition, as happened to the high surgical-risk elderly patient taken into account in our case report.
Introduction
Non-operative management (NOM) of uncomplicated acute appendicitis is a well-established alternative to upfront surgery. The administration of intravenous broad-spectrum antibiotics is ...usually performed in hospital, and only one study described outpatient NOM. The aim of this multicentre retrospective non-inferiority study was to evaluate both safety and non-inferiority of outpatient compared to inpatient NOM in uncomplicated acute appendicitis.
Methods
The study included 668 consecutive patients with uncomplicated acute appendicitis. Patients were treated according to the surgeon’s preference: 364 upfront appendectomy, 157 inpatient NOM (inNOM), and 147 outpatient NOM (outNOM). The primary endpoint was the 30-day appendectomy rate, with a non-inferiority limit of 5%. Secondary endpoints were negative appendectomy rate, 30-day unplanned emergency department (ED) visits, and length of stay.
Results
30-day appendectomies were 16 (10.9%) in the outNOM group and 23 (14.6%) in the inNOM group (
p
= 0.327). OutNOM was non-inferior to inNOM with a risk difference of—3.80% 97.5% CI (− 12.57; 4.97). No difference was found between inNOM and outNOM groups for the number of complicated appendicitis (3 vs. 5) and negative appendectomy (1 vs. 0). Twenty-six (17.7%) outNOM patients required an unplanned ED visit after a median of 1 (1–4) days. In the outNOM group, the mean cumulative in-hospital stay was 0.89 (1.94) days compared with 3.94 (2.17) days in the inNOM group (
p
< 0.001).
Conclusions
Outpatient NOM was non-inferior to inpatient NOM with regard to the 30-day appendectomy rate, while a shorter hospital stay was found in the outNOM group. Further, studies are required to confirm these findings.
Background
Existing guidelines for predicting common bile duct stones (CBDS) are not specific for acute calculous cholecystitis (ACC). This paper is a posthoc analysis of the S.P.Ri.M.A.C.C study ...aiming to prospectively validate on a large independent cohort of patients the Israeli Score (IS) in predicting CBDS in patients with ACC.
Methods
The S.P.Ri.M.A.C.C. study is an observational multicenter prospective study endorsed by the World Society of Emergency Surgery (WSES). Between September 1st, 2021, and September 1st, 2022, 1201 participants were included. The Chi-Square test was used to compare categorical data. A Cochran-Armitage test was run to determine whether a linear trend existed between the IS and the presence of CBDS. To assess the accuracy of the prediction model, the receiver operating characteristic (ROC) curve was generated, and the area under the ROC curve (AUC) was calculated. Logistic regression was run to obtain Odds Ratio (OR). A two-tailed
p
< 0.05 was considered statistically significant.
Results
The rate of CBDS was 1.8% in patients with an IS of 0, 4.2% in patients with an IS of 1, 24.5% in patients with 2 and 56.3% in patients with 3 (
p
< 0.001). The Cochran-Armitage test of trend showed a statistically significant linear trend,
p
< 0.001. Patients with an IS of 3 had 64.4 times (95% CI 24.8–166.9) higher odds of having associated CBDS than patients with an IS of 0. The AUC of the ROC curve of IS for the prediction of CBDS was 0.809 (95% CI 0.752–0.865,
p
< 0.001). By applying the highest cut-off point (3), the specificity reached 99%, while using the lowest cut-off value (0), the sensitivity reached 100%.
Conclusion
The IS is a reliable tool to predict CBDS associated with ACC. The algorithm derived from the IS could optimize the management of patients with ACC.
The concept and the role of emergency general surgery (EGS) has progressively evolved over the last decades, and dedicated pathways are required for EGS, similarly to what has already been ...established for trauma. EGS patients, together with trauma patients, represent 20% of inpatient population in the USA, and 25% of inpatient costs. These patients have a high rate of health care utilization, higher mortality rates and longer hospital stay. International guidelines and current evidences show that organizational models improve the outcome of the patients in the EGS setting. The cornerstones of a structured and effective EGS organizational model are surgical expertise, quick decision making, organizational performance and clinical competence. There is a strong need for dedicated and “subspecialist” emergency surgeons. At the same time, emergency surgeons should be inserted in an effective system with the ability to be continuously enhanced and improved. The organization of such a dedicated system will improve the level of competence in the management of surgical emergency, guaranteeing to a vast amount of population an emergency surgical service with high skills, knowledge and a guidelines-guided treatment.
Abstract
Background
In 2017, the World Society of Emergency Surgery published its guidelines for the management of adult and pediatric patients with splenic trauma. Several issues regarding the ...follow-up of patients with splenic injuries treated with NOM remained unsolved.
Methods
Using a modified Delphi method, we sought to explore ongoing areas of controversy in the NOM of splenic trauma and reach a consensus among a group of 48 international experts from five continents (Africa, Europe, Asia, Oceania, America) concerning optimal follow-up strategies in patients with splenic injuries treated with NOM.
Results
Consensus was reached on eleven clinical research questions and 28 recommendations with an agreement rate ≥ 80%. Mobilization after 24 h in low-grade splenic trauma patients (WSES Class I, AAST Grades I–II) was suggested, while in patients with high-grade splenic injuries (WSES Classes II–III, AAST Grades III–V), if no other contraindications to early mobilization exist, safe mobilization of the patient when three successive hemoglobins 8 h apart after the first are within 10% of each other was considered safe according to the panel. The panel suggests adult patients to be admitted to hospital for 1 day (for low-grade splenic injuries—WSES Class I, AAST Grades I–II) to 3 days (for high-grade splenic injuries—WSES Classes II–III, AAST Grades III–V), with those with high-grade injuries requiring admission to a monitored setting. In the absence of specific complications, the panel suggests DVT and VTE prophylaxis with LMWH to be started within 48–72 h from hospital admission. The panel suggests splenic artery embolization (SAE) as the first-line intervention in patients with hemodynamic stability and arterial blush on CT scan, irrespective of injury grade. Regarding patients with WSES Class II blunt splenic injuries (AAST Grade III) without contrast extravasation, a low threshold for SAE has been suggested in the presence of risk factors for NOM failure. The panel also suggested angiography and eventual SAE in all hemodynamically stable adult patients with WSES Class III injuries (AAST Grades IV–V), even in the absence of CT blush, especially when concomitant surgery that requires change of position is needed. Follow-up imaging with contrast-enhanced ultrasound/CT scan in 48–72 h post-admission of trauma in splenic injuries WSES Class II (AAST Grade III) or higher treated with NOM was considered the best strategy for timely detection of vascular complications.
Conclusion
This consensus document could help guide future prospective studies aiming at validating the suggested strategies through the implementation of prospective trauma databases and the subsequent production of internationally endorsed guidelines on the issue.
Intra-abdominal infections (cIAIs) constitute an important cause of morbidity and mortality. Numerous risk factors may influence prognosis of cIAIs. This study aims to evaluate which parameters and ...scores may better predict prognostic outcomes in cIAIs. This is a single-center prospective observational study. Data from sixty-five patients were collected during a four-month period. Univariate and multivariate analysis for physiological parameters and ROC curves for SIRS, qSOFA and WISS scores were calculated in relation to mortality, intensive care unit (ICU) admission and surgical complications. Blood oxygen saturation level (SpO2), heart and respiratory rate, systolic blood pressure (SBP), level of consciousness, INR, C-reactive protein (CRP), white blood cells, source control and health care-acquired infections affect prognosis in cIAIs according to univariate analysis. On multivariate analysis level of consciousness, SpO2, CRP, diffuse peritonitis, INR and SBP significantly influenced prognosis in cIAIs. AUROC for WISS score were 0.89 for mortality, 0.86 for major complications, 0.76 for ICU admission. In our study many risk factors adversely affect prognostic outcomes in cIAIs; PIPAS study probably may provide even better results on that. Moreover, WISS score reached remarkable performance in predicting mortality and major surgical complications in abdominal sepsis; qSOFA did not achieve satisfactory results in none of analyzed outcomes.
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