The Role of Laparoscopic Ultrasonography in the Evaluation of Suspected Choledocholithiasis. A Single-Center Experience.

Background and objectives: Opinions differ regarding the optimal diagnostic methods for patients with suspected choledocholithiasis. The aim of this study was to assess the diagnostic accuracy of laparoscopic ultrasonography (LUS) and compare it to pre-operative magnetic resonance cholangio-pancreatography (MRCP); Materials and Methods: In all patients with suspected choledocholithiasis LUS was performed during laparoscopic cholecystectomy to evaluate biliary stones. According to availability, part of the patients had pre-operative MRCP. Data for diagnostic accuracy and main outcomes were collected prospectively and analyzed retrospectively; Results: Choledocholithiasis was detected in 178 of 297 patients by LUS (59.93%) and in 39 of 87 patients by MRCP (44.8%), p = 0.041. LUS yielded a sensitivity of 99.4%, a specificity of 94.3%, a positive predictive value of 96.1% and a negative predictive value of 99.1%. However, pre-operative MRCP had a sensitivity of 61.7%, a specificity of 92.3%, a positive predictive value of 94.9% and a negative predictive value of 51.1%. Moreover, of the 47 patients with no choledocholithiasis by MRCP, in 23 cases it was later detected by LUS (a false negative MRCP finding-38.3%), p < 0.001. Median duration of hospitalization was significantly shorter in patients evaluated without pre-operative MRCP-8 days (interquartile range - IQR 11-6) vs. 11 days (IQR 14-9), p = 0.001; Conclusions: LUS may reduce the role of pre-operative MRCP and can become a rational alternative to MRCP as a primary imaging technique for the detection of choledocholithiasis.

Endoscopic hemostasis followed by preventive transarterial embolization in high-risk patients with bleeding peptic ulcer: 5-year experience.

Background: Upper gastrointestinal bleeding (UGIB) due to peptic ulcer disease is one of the leading causes of death in patients with non-variceal bleeding, resulting in up to 10% mortality rate, and the patient group at high risk of rebleeding (Forrest IA, IB, and IIA) often requires additional therapy after endoscopic hemostasis. Preventive transarterial embolization (P-TAE) after endoscopic hemostasis was introduced in our institution in 2014. The aim of the study is an assessment of the intermediate results of P-TAE following primary endoscopic hemostasis in patients with serious comorbid conditions and high risk of rebleeding. Methods: During the period from 2014 to 2018, a total of 399 patients referred to our institution with a bleeding peptic ulcer, classified as type Forrest IA, IB, or IIA with the Rockall score ≥ 5, after endoscopic hemostasis was prospectively included in two groups-P-TAE group and control group, where endoscopy alone (EA) was performed. The P-TAE patients underwent flow-reducing left gastric artery or gastroduodenal artery embolization according to the ulcer type. The rebleeding rate, complications, frequency of surgical interventions, transfused packed red blood cells (PRBC), amount of fresh frozen plasma (FFP), and mortality rate were analyzed. Results: From 738 patients with a bleeding peptic ulcer, 399 were at high risk for rebleeding after endoscopic hemostasis. From this cohort, 58 patients underwent P-TAE, and 341 were allocated to the EA. A significantly lower rebleeding rate was observed in the P-TAE group, 3.4% vs. 16.2% in the EA group; p = 0.005. The need for surgical intervention reached 10.3% vs. 20.6% in the P-TAE and EA groups accordingly; p = 0.065. Patients that underwent P-TAE required less FFP, 1.3 unit vs. 2.6 units in EA; p = 0.0001. The mortality rate was similar in groups with a tendency to decrease in the P-TAE group, 5.7% vs. 8.5% in EA; p = 0.417. Conclusion: P-TAE is a feasible and safe procedure, and it may reduce the rebleeding rate and the need for surgical intervention in patients with a bleeding peptic ulcer when the rebleeding risk remains high after primary endoscopic hemostasis.

2018 WSES/SIS-E consensus conference: recommendations for the management of skin and soft-tissue infections.

Skin and soft-tissue infections (SSTIs) encompass a variety of pathological conditions that involve the skin and underlying subcutaneous tissue, fascia, or muscle, ranging from simple superficial infections to severe necrotizing infections. SSTIs are a frequent clinical problem in surgical departments. In order to clarify key issues in the management of SSTIs, a task force of experts met in Bertinoro, Italy, on June 28, 2018, for a specialist multidisciplinary consensus conference under the auspices of the World Society of Emergency Surgery (WSES) and the Surgical Infection Society Europe (SIS-E). The multifaceted nature of these infections has led to a collaboration among general and emergency surgeons, intensivists, and infectious disease specialists, who have shared these clinical practice recommendations.

Knowledge, awareness, and attitude towards infection prevention and management among surgeons: identifying the surgeon champion.

Despite evidence supporting the effectiveness of best practices of infection prevention and management, many surgeons worldwide fail to implement them. Evidence-based practices tend to be underused in routine practice. Surgeons with knowledge in surgical infections should provide feedback to prescribers and integrate best practices among surgeons and implement changes within their team. Identifying a local opinion leader to serve as a champion within the surgical department may be important. The "surgeon champion" can integrate best clinical practices of infection prevention and management, drive behavior change in their colleagues, and interact with both infection control teams in promoting antimicrobial stewardship.

Preventive transarterial embolization in upper nonvariceal gastrointestinal bleeding.

BACKGROUND: Transarterial embolization (TAE) is a therapeutic option for patients with a high risk of recurrent bleeding after endoscopic haemostasis. The aim of our prospective study was a preliminary assessment of the safety, efficacy, and clinical outcomes following preventive TAE in patients with non-variceal acute upper gastrointestinal bleeding (NVUGIB) with a high risk of recurrent bleeding after endoscopic haemostasis. METHODS: Preventive visceral angiography and TAE were performed after endoscopic haemostasis on patients with NVUGIB who were at a high risk of recurrent bleeding (PE+ group). The comparison group consisted of similar patients who only underwent endoscopic haemostasis, without preventive TAE (PE- group). The technical success of preventive TAE, the completeness of haemostasis, the incidence of rebleeding and the need for surgical intervention and the main outcomes were compared between the groups. RESULTS: The PE+ group consisted of 25 patients, and the PE- group of 50 patients, similar in age (median age 66 vs. 63 years), gender and comorbid conditions. The ulcer size at endoscopy was not significantly different (median of 152 mm vs. 127 mm). The most frequent were Forest II type ulcers, 44% in both groups. The distribution of the Forest grade was even. The median haemoglobin on admission was 8, 2 g/dl vs. 8,7 g/dl, p = 0,482, erythrocyte count was 2,7 × 1012/L vs. 2,9 × 1012/L, p = 0,727. The shock index and Rockall scores were similar, as well as and transfusion - on average, four units of packed red blood cells for the majority of patients in both groups, however, significantly more fresh frozen plasma was transfused in the PE- group, p = 0,013. The rebleeding rate was similar, while surgical treatment was needed notably more often in the PE- group, 8% vs. 35% accordingly, p = 0,012. The median ICU stay was 3 days, hospital stay - 6 days vs. 9 days, p = 0.079. The overall mortality reached 20%; in the PE+ group it was 4%, not reaching a statistically significant difference. CONCLUSION: Preventive TAE is a feasible, safe and effective minimally invasive type of haemostasis decreasing the risk of repeated bleeding and preparing the patient for the definitive surgical intervention when indicated.

Rockall Score Larger Than 7 as a Reliable Criterion for the Selection of Indications for Preventive Transarterial Embolization in a Subgroup of High-Risk Elderly Patients After Primary Endoscopic Hemostasis for Non-Variceal Upper Gastrointestinal Bleeding.

BACKGROUND: Transarterial embolization (TAE) is an alternative procedure to repeat endoscopy or surgical intervention in the case of re-bleeding after primary endoscopic treatment. The aim of the study was to assess the Rockall score as a criterion for TAE in the case of re-bleeding after endoscopic treatment of non-variceal upper gastrointestinal bleeding (NVUGIB). METHODS: Out of the 673 patients who underwent emergent endoscopic hemostasis due to NVUGIB, 111 had a high risk of re-bleeding having a Forrest I-IIb ulcer and the Rockall score ≥ 5. From 111 patients, 37 accepted preventive TAE (PE+ group). The control group consisted of 74 patients who underwent standard treatment (PE- group). RESULTS: There were no differences in the demographic status between both groups, nor in the main clinical data on admission. The performance of TAE resulted in a significantly lower re-bleeding rate (1 (4.8%) vs. 11 (33%), P = 0.018). No patient who underwent TAE with the Rockall score ≥ 7 required surgery, resulting in only one re-bleeding episode (P = 0.004). Mortality reached 5% and 11% in the PE+ and PE- groups accordingly. CONCLUSION: The Rockall score ≥ 7 could be a reliable predictor of re-bleeding after primary endoscopic hemostasis as one criterion for the selection of indications for preventive TAE.

Safe laparoscopic clearance of the common bile duct in emergently admitted patients with choledocholithiasis and cholangitis.

BACKGROUNDS/AIMS: Laparoscopic treatment of patients with choledocholithiasis and cholangitis is challenging due to mandatory recovery of the biliary drainage and clearance of the common bile duct (CBD). The aim of our study was to assess postoperative course of cholangitis and biliary sepsis after laparoscopic clearance of the CBD in emergently admitted patients with choledocholithiasis and cholangitis. METHODS: Emergently admitted patients who underwent laparoscopic clearance of the CBD were included prospectively and stratified in 2 groups i.e., cholangitis positive (CH+) or negative (CH-) group. Patient demographics, comorbidities, preoperative imaging data, inflammatory response, surgical intervention, complication rate and outcomes were compared between groups. RESULTS: Ninety-nine of a total 320 patients underwent laparoscopic clearance of the CBD, of which, 60 belonged to the acute cholangitis group (CH+) and 39 to the cholangitis negative group (CH-). Interventions were done on average 4 days after admission, operation duration was 95-105 min, and the conversion rate was 3-7% without differences in the groups. Preoperative inflammatory response was markedly higher in the CH+ group. Inflammation signs on intraoperative choledochoscopy were more evident in patients with cholangitis. Postoperative inflammatory response did not differ between the groups. The overall complication rate was 8.3% and 5.1%, respectively. Laparoscopic clearance of the CBD resulted in 1 lethal case (CH+ group), resulting in 1% mortality rate and a similar 12-month readmission rate. CONCLUSIONS: Single-stage laparoscopic intraoperative US and choledochoscopy-assisted clearance of the CBD is feasible in emergently admitted patients with choledocholithiasis and cholangitis.

Ultrasound-assisted focused open necrosectomy in the treatment of necrotizing pancreatitis.

CONTEXT: The surgical treatment of necrotizing pancreatitis includes percutaneous drainage of acute necrotic collections and sequestrectomy in the late phase of the disease. OBJECTIVE: The aim of the study was to compare the conventional open necrosectomy (CON) approach with the alternative focused open necrosectomy (FON) approach in patients with infected necrosis and progression of sepsis. METHODS: Patients with acute necrotizing pancreatitis were included in the study prospectively from January 2004 to July 2014. All patients had been admitted with the first or a new episode of disease. Symptomatic large fluid collections were drained percutaneously. The step-up approach was used in patients with several distant localizations of infected necrosis. The methods were analysed by comparing the individual severity according to the ASA, APACHE II and SOFA scores, infection rate, postoperative complication rate and mortality. RESULTS: A total of 31 patients were included in the FON group and 39 in the CON group. The incidence of infection was similar in groups. More ASA III comorbid conditions, a higher APACHE II score, a more frequent need for renal replacement therapy was observed in the CON group. The postoperative complication rate was in the range of 32% to 44%; mortality reached 6.5% in the FON group and 12.8% in the CON group. CONCLUSIONS: Comorbid conditions, organ failure, and infection are the main risk factors in patients with necrotizing pancreatitis. The step-up approach and perioperative ultrasonography navigation improves the clinical outcome and reduces the extent of invasive surgical intervention in patients unsuited to other minimally invasive procedures.

Serum procalcitonin is a sensitive marker for septic shock and mortality in secondary peritonitis.

BACKGROUND: Serum procalcitonin (PCT) is considered to be a sensitive marker for the early recognition of severe infection. The aim of this study was to review the diagnostic accuracy of serum procalcitonin levels to predict the risk of septic shock and mortality in patients with secondary peritonitis. METHODS: We carried out a retrospective review of patients (November 2010 to November 2012) admitted to the surgical intensive care unit (ICU) with secondary peritonitis classified into localised peritonitis (LP) or diffuse peritonitis (DP) groups. Organ dysfunction was assessed with the SOFA score. Demographic data was collected as well as results for neutrophil count, C- reactive protein, blood lactate, and PCT levels. The primary end-point was ICU mortality. RESULTS: From a total of 222 patients, 123 were allocated to the LP group and 99 to the DP group. Severe sepsis was observed in 41.9% of all patients in the DP group. The PCT levels increased significantly in the DP group, with the development of septic shock in 29 patients. Higher PCT levels were associated with an increased risk for septic shock with a cut-off value of 15.3 ng mL⁻¹ and an increased risk for mortality with a cut-off value 19.6 ng mL⁻¹. A total of 59.1% of those who developed septic shock died. CONCLUSION: An increase in PCT levels is an indirect sign of diffuse secondary peritonitis and this is associated with an increased risk of septic shock. Increased PCT level on admission is associated with an increased risk of mortality in this category of patients.

Focused open necrosectomy in necrotizing pancreatitis.

BACKGROUND: The control of sepsis is the primary goal of surgical intervention in patients with infected necrosis. Simple surgical approaches that are easy to reproduce may improve outcomes when specialists in endoscopy are not available. The aim of the present study was to describe the experience with a focused open necrosectomy (FON) in patients with infected necrosis. METHOD: A prospective pilot study conducted to compare a semi-open/closed drainage laparotomy and FON with the assistance of peri-operative ultrasound. The incidence of sepsis, dynamics of C-reactive protein (CRP), intensive care unit (ICU)/hospital stay, complication rate and mortality were compared and analysed. RESULTS: From a total of 58 patients, 36 patients underwent a conventional open necrosectomy and 22 patients underwent FON. The latter method resulted in a faster resolution of sepsis and a significant decrease in mean CRP on Day 3 after FON, P = 0.001. Post-operative bleeding was in 1 versus 7 patients and the incidence of intestinal and pancreatic fistula was 2 versus 8 patients when comparing FON to the conventional approach. The median ICU stay was 11.6 versus 23 days and the hospital stay was significantly shorter, 57 versus 72 days, P = 0.024 when comparing FON versus the conventional group. One patient died in the FON group and seven patients died in the laparotomy group, P = 0.139. DISCUSSION: FON can be an alternative method to conventional open necrosectomy in patients with infected necrosis and unresolved sepsis.

Early continuous veno-venous haemofiltration in the management of severe acute pancreatitis complicated with intra-abdominal hypertension: retrospective review of 10 years' experience.

BACKGROUND: Conservative treatment of patients with severe acute pancreatitis (SAP) may be associated with development of intra-abdominal hypertension (IAH), deterioration of visceral perfusion and increased risk of multiple organ dysfunction. Fluid balance is essential for maintenance of adequate organ perfusion and control of the third space. Timely application of continuous veno-venous haemofiltration (CVVH) may help in balancing fluid replacement and removal of cytokines from the blood and tissue compartments. The aim of the present study was to determine whether CVVH can be recommended as a constituent of conservative treatment in patients with SAP who suffer IAH. METHODS: A retrospective analysis of 10 years' experience with low-flow CVVH application in patients with SAP who develop IAH was. In all patients, measurement of the intra-abdominal pressure (IAP) was done indirectly through the urinary bladder. Sequential organ failure assessment (SOFA) score was calculated for severity assessment, and necrotizing forms were verified by contrast-enhanced computed tomography. Dynamics of IAP were analysed in parallel with signs of systemic inflammation, dynamics of C-reactive protein and cumulative fluid balance. All variables, complication rate and outcomes were analysed in the whole group and in patients with IAH (CVVH and no-CVVH groups). RESULTS: From the total of 130 patients, 75 were treated with application of CVVH and 55 without CVVH. Late hospitalization was associated with application of CVVH. Infection was observed in 28.5% of cases regardless of the type of treatment received, with a similar necessity for surgical intervention. IAH was observed in 68.5% of patients, and they had significantly higher SOFA scores compared to patients with normal IAP. CVVH treatment resulted in negative cumulative fluid balance starting from day 5 in patients with IAH, whereas without this treatment, fluid balance remained increasingly positive after a week. Finally, application of CVVH resulted in a lower infection rate and shorter hospital stay, 26.7% vs. 37.9%, and a median of 32 (interquartile range (IQR) = 60 to 12) days vs. 24 (IQR = 34 to 4) days, p = 0.05, comparing CVVH vs. no-CVVH group. Mortality rate reached 11.7% in the CVVH group and 13.8% in the no-CVVH group. CONCLUSIONS: Early application of CVVH facilitates negative fluid balance and reduction of IAH in patients with SAP; it is not associated with increased infection or mortality rate and may reduce hospital stay.

Abdominal negative-pressure therapy: a new method in countering abdominal compartment and peritonitis - prospective study and critical review of literature.

BACKGROUND: Application of abdominal negative-pressure therapy (NPT) is lifesaving when conservative measures fail to reduce sustained increase of the intra-abdominal pressure and it is impossible to achieve source control in a single operation due to severe peritonitis. The aim of this study is to share the initial experience with abdominal NPT in Latvia and provide a review of the relevant literature. METHODS: In total, 22 patients were included. All patients were treated with KCI® ABThera™ NPT systems. Acute Physiology and Chronic Health Evaluation II (APACHE II) score on admission, daily sequential organ failure assessment score and Mannheim peritonitis index (MPI) were calculated for severity definition. The frequency of NPT system changes, daily amount of aspirated fluid effluent and the time of abdominal closure were assessed. The overall hospital and ICU stay, as well as the outcomes and the complication rate, were analysed. RESULTS: A complicated intra-abdominal infection was treated in 18 patients. Abdominal compartment syndrome due to severe acute pancreatitis (SAP), secondary ileus and damage control in polytrauma were indications for NPT in four patients. The median age of the patients was 59 years (range, 28 to 81), median APACHE II score was 15 points (range, 9 to 32) and median MPI was 28 points (range, 21 to 40), indicating a prognostic mortality risk of 60%. Sepsis developed in all patients, and in 20 of them, it was severe. NPT systems were changed on a median of every 4 days, and abdominal closure was feasible on the seventh postoperative day without needing a repeated laparotomy. Two NPT systems were removed due to bleeding from the retroperitoneal space in patients with SAP. Intestinal fistulae developed in three patients that were successfully treated conservatively. Incisional hernia occurred in three patients. The overall ICU and hospital stay were 14 (range, 5 to 56) and 25 days (range, 10 to 87), respectively. Only one patient died, contributing to the overall mortality of 4.5%. CONCLUSIONS: Application of abdominal NPT could be a very promising technique for the control of sustained intra-abdominal hypertension and management of severe sepsis due to purulent peritonitis. Further trials are justified for a detailed evaluation of abdominal NPT indications.

Surgical treatment of neurogenic thoracic outlet syndrome secondary to the clavicle haematogenic subacute osteomyelitis.

A rare case of neurogenic thoracic outlet syndrome secondary to subacute osteomyelitis (SOM) of clavicle is presented. It was treated successfully with scalenectomy combined with clavicle and first rib resection and reconstruction of the clavicle using vascularised seventh rib transfer. Various issues involved in the diagnosis and management of such a case are discussed.

Postoperative enteral stimulation by gut feeding improves outcomes in severe acute pancreatitis.

OBJECTIVE: We assessed the clinical effectiveness of postoperative enteral stimulation by gut feeding in patients with severe acute pancreatitis (SAP). METHODS: Medical records of 63 patients who were operated on within the past 4 y due to deterioration of SAP were included in this retrospective study. Patients were stratified in gut feeding (GF; n = 33) and standard therapy (ST; n = 30) groups according to the postoperative therapy provided. The GF group received postoperative standard therapy and enteral stimulation by gut feeding, and the ST group received standard therapy only. The Acute Physiology and Chronic Health Evaluation II score, incidence of the systemic inflammatory response syndrome (SIRS), multiple organ dysfunction syndrome (MODS), daily calories supply, complication rate, and outcomes were analyzed. RESULTS: Patient characteristics did not differ between groups when considering age and severity of the disease. All patients underwent similar surgical interventions. SIRS and MODS were observed initially with the same frequency in both groups. Regression of MODS and a lower postoperative complication rate was observed more often in the GF group. Development of early pulmonary complications was observed in 12.1% to 13.3% in both groups, irrespective of the time of surgery. Subsequently, pulmonary complications developed in 15.2% of GF patients compared with 43.3% of ST patients (P <0.05). Acute renal insufficiency developed similarly in 33.3% of the GF patients and in 26.7% of the ST patients within 3 d after admission. Acute renal insufficiency developed later on only in the ST group (26.7%, P <0.05). Wound- and catheter-related septic complications were considerably more frequent in the ST group (30.0%) than in the GF group (9.1%, P <0.05). Intensive care and hospital stays did not differ. Postoperative gut feeding was associated with 6.1% mortality in the GF compared with 26.7% in the ST (P <0.05). CONCLUSIONS: Enteral stimulation by gut feeding is an effective supplement in the postoperative therapy of patients with SAP.