Although most patients with acute pancreatitis have the mild form of the disease, about 20-30% develops a severe form, often associated with single or multiple organ dysfunction requiring intensive ...care. Identifying the severe form early is one of the major challenges in managing severe acute pancreatitis. Infection of the pancreatic and peripancreatic necrosis occurs in about 20-40% of patients with severe acute pancreatitis, and is associated with worsening organ dysfunctions. While most patients with sterile necrosis can be managed nonoperatively, patients with infected necrosis usually require an intervention that can be percutaneous, endoscopic, or open surgical. These guidelines present evidence-based international consensus statements on the management of severe acute pancreatitis from collaboration of a panel of experts meeting during the World Congress of Emergency Surgery in June 27-30, 2018 in Bertinoro, Italy. The main topics of these guidelines fall under the following topics: Diagnosis, Antibiotic treatment, Management in the Intensive Care Unit, Surgical and operative management, and Open abdomen.
A common feature of external duodenal fistulae is the devastating effect of the duodenal content rich in bile and pancreatic juice on nearby tissues with therapy-resistant local and systemic ...complications. This study analyzes the results of different management options with emphasis on successful fistula closure rates.
A retrospective single academic center study of adult patients treated for complex duodenal fistulas over a 17-year period with descriptive and univariate analyses was performed.
Fifty patients were identified. First line treatment was surgical in 38 (76%) cases and consisted of resuture or resection with anastomosis combined with duodenal decompression and periduodenal drainage in 36 cases, rectus muscle patch, and surgical decompression with T-tube in one each. Fistula closure rate was 29/38 (76%). In 12 cases, the initial management was nonoperative with or without percutaneous drainage. The fistula was closed without surgery in 5/6 patients (1 patient died with persistent fistula). Among the remaining 6 patients eventually operated, fistula closure was achieved in 4 cases. There was no difference in successful fistula closure rates among initially operatively versus nonoperatively managed patients (29/38 vs. 9/12, p = 1.000). However, when considering eventually failed nonoperative management in 7/12 patients, there was a significant difference in the fistula closure rate (29/38 vs. 5/12, p = 0.036). The overall in-hospital mortality rate was 20/50 (40%).
Surgical closure combined with duodenal decompression in complex duodenal leaks offers the best chance of successful outcome. In selected cases, nonoperative management can be tried, accepting that some patients may require surgery later.
The prognostic role of what a surgeon observes in the abdomen of patients with complicated intra-abdominal infection (cIAI) is largely unknown. The aim of this prospective study was to systemically ...analyze components of the intra-abdominal view (IAV) and their association to severe complicated intra-abdominal sepsis (SCIAS) or mortality.
The study cohort consisted of adult patients with cIAI. The operating surgeon filled a paper form describing the intra-abdominal view. Demographics, operative details, and preoperative physiological status were collected. Descriptive, univariate, and multivariate statistical analyses were performed, and a new score was developed based on regression coefficients. The primary outcome was a composite outcome of SCIAS or 30-day mortality, in which SCIAS was defined as organ dysfunctions requiring intensive care unit admission.
A total of 283 patients were analyzed. The primary outcome was encountered in 71 (25%) patients. In the IAV, independent risk factors for the primary outcome were fecal or bile as exudate (odds ratio (OR) 1.98, 95% confidence interval 1.05-3.73), diffuse peritonitis (OR 2.15, 1.02-4.55), diffuse substantial redness of the peritoneum (OR 5.73, 2.12-15.44), and a non-appendiceal source of cIAI (OR 11.20, 4.11-30.54). Based on these factors, an IAV score was developed and its performance analyzed. The area under the receiver operating characteristic for the IAV score was 0.81. The IAV score also correlated significantly with several outcomes and organ dysfunctions.
The extent of peritonitis, diffuse substantial redness of the peritoneum, type of exudate, and source of infection associate independently with SCIAS or mortality. A high IAV score associates with mortality and organ dysfunctions, yet it needs further external validation. Combining components of IAV into comprehensive scoring systems for cIAI patients may provide additional value compared to the current scoring systems.
The study protocol was retrospectively registered on April 4, 2016, right after the first enrolled patient at Clinicaltrials.gov database (NCT02726932).
Ventral incisional hernias are common indications for elective repair and frequently complicated by recurrence. Surgical meshes, which may be synthetic, bio-synthetic, or biological, decrease ...recurrence and, resultingly, their use has become standard. While most patients are greatly benefited, mesh represents a permanently implanted foreign body. Mesh may be implanted within the intra-peritoneal, preperitoneal, retrorectus, inlay, or onlay anatomic positions. Meshes may be associated with complications that may be early or late and range from minor to severe. Long-term complications with intra-peritoneal synthetic mesh (IPSM) in apposition to the viscera are particularly at risk for adhesions and potential enteric fistula formation. The overall rate of such complications is difficult to appreciate due to poor long-term follow-up data, although it behooves surgeons to understand these risks as they are the ones who implant these devices. All surgeons need to be aware that meshes are commercial devices that are delivered into their operating room without scientific evidence of efficacy or even safety due to the unique regulatory practices that distinguish medical devices from medications. Thus, surgeons must continue to advocate for more stringent oversight and improved scientific evaluation to serve our patients properly and protect the patient-surgeon relationship as the only rationale long-term strategy to avoid ongoing complications.
This publication presents the most recent findings on nutrition and protective nutrients in biology and medicine. The book provides a valuable reference for both layman and health professionals in ...this complex field. Information is provided on nutritional medicine and cell protective mechanisms of nutritional factors; vitamins, minerals, trace elements and essential fatty acids as a method of treating and preventing disorders; and nutritional medicine
The exact incidence and outcomes of acute occlusive arterial mesenteric ischaemia (AMI) are unclear as most studies include only patients diagnosed correctly while alive. The aim of this study was to ...assess the incidence, mortality, and diagnostics of AMI by also including patients diagnosed post-mortem.
This retrospective study comprised patients diagnosed with AMI either alive or post-mortem between 2006 and 2015 within a healthcare district serving 1.6 million inhabitants. Key exclusion criteria were venous or non-obstructive ischaemia.
A total of 470 patients were included in the study of which 137 (29%) were diagnosed post-mortem. The most common misdiagnoses on those not diagnosed alive were unspecified infection (n = 19, 17%), gastrointestinal bleeding (n = 13, 11%), and ileus (n = 13, 11%). Of those diagnosed alive (n = 333), 187 (56%) underwent active surgical or endovascular treatment. During the 2006 – 2015 period, the overall incidence of AMI was 3.05 (95% CI 2.78 – 3.34)/100 000 person years and 26.66 (95% CI 24.07 – 29.45) for those aged 70 years or more. The mean autopsy rate during the study period was 29% for the overall population (32% during 2006 – 2010 and 25% during 2011 – 2015) and 18% for those aged 70 years or more. Overall, the 90-day mortality was 83% in all patients. The ninety day mortality decreased, being 87% during the first period (2006 – 2010) and 79% during the second period (2011 – 2015) (p = .029), while at the same time the proportion of patients diagnosed alive rose from 71% to 80% (p = .030) and the number of endovascular revascularisations rose from 1% to 5% (p = .022).
A significant proportion of patients with AMI are not diagnosed alive, which is reflected in the mortality rates. Post-mortem examinations and autopsy rate data continue to be key factors in epidemiological studies on AMI.
Open abdomen (OA) treatment in patients with peritonitis is increasing worldwide. Various temporary abdominal closure devices are being used. This study included patients with complicated diffuse ...secondary peritonitis, OA, and vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM). The aim of this study was to describe mortality and major morbidity in terms of delayed primary fascial closure and enteroatmospheric fistula rates.
This was a single-academic-center retrospective study of consecutive patients with diffuse peritonitis, OA, and VAWCM between years 2008 and 2016. Descriptive and univariate analyses were performed.
Forty-one patients were identified and analyzed. Median age was 59 years, preoperative septic shock was diagnosed in 54% (n = 22), and 59% (n = 24) had a postoperative peritonitis. Mortality was 29% (n = 12), and 76% (n = 31) of patients were admitted in the intensive care unit. The median duration of OA was 7 days with a median of two dressing changes. Delayed primary fascial closure rate among survivors was 92% (n = 33), and enteroatmospheric fistulas developed in 7% (n = 3). In a subgroup analysis, patients with OA in the primary laparotomy for peritonitis (n = 27) were compared with patients with OA in the subsequent laparotomies (n = 14). There were no significant differences between groups.
The VAWCM technique in patients with complicated secondary diffuse peritonitis and OA yields excellent results in terms of delayed primary fascial closure rate and a low number of enteroatmospheric fistulas. It seems to be safe to close the abdomen at the index laparotomy, if possible, even if there is a risk of a need of OA later.
Therapeutic/care management study, level IV.
Despite modern advances in diagnosis and treatment, acute arterial mesenteric ischaemia (AMI) remains a high mortality disease. One of the key modifiable factors in AMI is the first door to operation ...time, but the factors attributing to this parameter are largely unknown. The aim of this study was to evaluate the factors affecting delay, with special focus on the pathways to treatment.
This was a single academic centre retrospective study. Patients undergoing intervention for AMI caused by thrombosis or embolism of the superior mesenteric artery between 2006 and 2015 were identified from electronic patient records. Patients not eligible for intervention or with chronic, subacute onset, colonic only, venous, or non-occlusive mesenteric ischaemia were excluded. Patients were divided into two groups according to the first speciality examining the patient (surgical emergency room SER, surgeon examining the patient first or non-surgical emergency room non-SER, internist examining the patient first). The primary endpoint was first door to operation time and secondary endpoints were length of stay and 90 day mortality.
Eighty-one patients with AMI were included. Fifty patients (62%) died during the first 30 days and 53 (65%) within 90 days. Presenting first in non-SER (vs. SER) was independently associated with a first door to operation time of over 12 h (OR 3.7 95% CI 1.3–10.2, median time 15.2 h IQR 10.9–21.2 vs. 10.1 h IQR 6.9–18.5, respectively, p = .025). The length of stay was shorter (median 6.5 days 4.0–10.3 vs. 10.8 days 7.0–22.3, p = .045) and 90 day mortality was lower in the SER group (50.0% vs. 74.5%, p = .025).
The first specialty that the patient encounters seems to be crucial for both delayed management and early survival of AMI. Developing fast/direct pathways to a unit with both gastrointestinal and vascular surgeons offers the possibility of improving the outcome of AMI.
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