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BACKGROUND: 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. METHODS: 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. DISCUSSION: 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).
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Antibacterianos , Apendicite , Adulto , Antibacterianos/uso terapêutico , Apendicectomia , Apendicite/tratamento farmacológico , Apendicite/cirurgia , Estudos de Equivalência como Asunto , Humanos , Tempo de Internação , Estudos Prospectivos , Ensaios Clínicos Controlados Aleatórios como AssuntoRESUMO
BACKGROUND: 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. METHODS: Patients with uncomplicated acute appendicitis on CT and who underwent appendicectomy in 2014-2015 were analysed for patient characteristics, preoperative delay and outcomes. RESULTS: 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. CONCLUSION: 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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Apendicite/epidemiologia , Perfuração Intestinal/epidemiologia , Tomografia Computadorizada por Raios X , Doença Aguda , Adulto , Idoso , Apendicectomia , Apendicite/diagnóstico por imagem , Apendicite/cirurgia , Progressão da Doença , Feminino , Finlândia/epidemiologia , Humanos , Perfuração Intestinal/diagnóstico por imagem , Perfuração Intestinal/cirurgia , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Ruptura Espontânea , Fatores de TempoRESUMO
BACKGROUND AND AIMS: Blunt abdominal trauma can lead to substantial organ injury and hemorrhage necessitating open abdominal surgery. Currently, the trend in surgeon training is shifting away from general surgery and the surgical treatment of blunt abdominal trauma patients is often done by sub-specialized surgeons. The aim of this study was to identify what emergency procedures are needed after blunt abdominal trauma and whether they can be performed with the skill set of a general surgeon. MATERIALS AND METHODS: The records of blunt abdominal trauma patients requiring emergency laparotomy (n = 100) over the period 2006-2016 (Helsinki University Hospital Trauma Registry) were reviewed. The organ injuries and the complexity of the procedures were evaluated. RESULTS: A total of 89 patients (no need for complex skills, NCS) were treated with the skill set of general surgeons while 11 patients required complex skills. Complex skills patients were more severely injured (New Injury Severity Score 56.4 vs 35.9, p < 0.001) and had a lower systolic blood pressure (mean: 89 vs 112, p = 0.044) and higher mean shock index (heart rate/systolic blood pressure: 1.43 vs 0.95, p = 0.012) on admission compared with NCS patients. The top three NCS procedures were splenectomy (n = 33), bowel repair (n = 31), and urinary bladder repair (n = 16). In patients requiring a complex procedure (CS), the bleeding site was the liver (n = 7) or a major blood vessel (n = 4). CONCLUSION: The majority of patients requiring emergency laparotomy can be managed with the skills of a general surgeon. Non-responder blunt abdominal trauma patients with positive ultrasound are highly likely to require complex skills. The future training of surgeons should concentrate on NCS procedures while at the same time recognizing those injuries requiring complex skills.
Assuntos
Traumatismos Abdominais/cirurgia , Competência Clínica/normas , Cirurgia Geral/normas , Laparotomia/normas , Especialidades Cirúrgicas/normas , Ferimentos não Penetrantes/cirurgia , Traumatismos Abdominais/complicações , Traumatismos Abdominais/diagnóstico por imagem , Traumatismos Abdominais/epidemiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Competência Clínica/estatística & dados numéricos , Tomada de Decisão Clínica , Emergências/epidemiologia , Feminino , Finlândia/epidemiologia , Avaliação Sonográfica Focada no Trauma , Cirurgia Geral/estatística & dados numéricos , Humanos , Laparotomia/classificação , Laparotomia/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Sistema de Registros/estatística & dados numéricos , Estudos Retrospectivos , Especialidades Cirúrgicas/estatística & dados numéricos , Centros de Traumatologia/estatística & dados numéricos , Ferimentos não Penetrantes/complicações , Ferimentos não Penetrantes/diagnóstico por imagem , Ferimentos não Penetrantes/epidemiologia , Adulto JovemRESUMO
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.
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Traumatismos Abdominais/terapia , Ferimentos não Penetrantes/terapia , Ferimentos Penetrantes/terapia , Traumatismos Abdominais/diagnóstico por imagem , Humanos , Ferimentos não Penetrantes/diagnóstico por imagem , Ferimentos Penetrantes/diagnóstico por imagemRESUMO
BACKGROUND: Opportunities to improve emergency surgery outcomes exist through guided better practice and reduced variability. Few attempts have been made to define optimal care in emergency surgery, and few clinically derived key performance indicators (KPIs) have been published. A summit was therefore convened to look at resources for optimal care of emergency surgery. The aim of the Donegal Summit was to set a platform in place to develop guidelines and KPIs in emergency surgery. METHODS: The project had multidisciplinary global involvement in producing consensus statements regarding emergency surgery care in key areas, and to assess feasibility of producing KPIs that could be used to monitor process and outcome of care in the future. RESULTS: Forty-four key opinion leaders in emergency surgery, across 7 disciplines from 17 countries, composed evidence-based position papers on 14 key areas of emergency surgery and 112 KPIs in 20 acute conditions or emergency systems. CONCLUSIONS: The summit was successful in achieving position papers and KPIs in emergency surgery. While position papers were limited by non-graded evidence and non-validated KPIs, the process set a foundation for the future advancement of emergency surgery.
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Lesões Encefálicas Traumáticas/cirurgia , Pediatria/métodos , Acidentes por Quedas/mortalidade , Acidentes por Quedas/estatística & dados numéricos , Acidentes de Trânsito/mortalidade , Acidentes de Trânsito/estatística & dados numéricos , Adolescente , Mundo Árabe , Lesões Encefálicas Traumáticas/epidemiologia , Criança , Pré-Escolar , Técnica Delphi , Feminino , Humanos , Lactente , Masculino , Oriente Médio/epidemiologia , Pediatria/tendências , Estudos Retrospectivos , Centros de Traumatologia/organização & administração , Centros de Traumatologia/estatística & dados numéricos , Resultado do TratamentoRESUMO
[This corrects the article DOI: 10.1186/s13017-017-0141-6.].
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BACKGROUND AND AIMS: Implementation of a clinical risk score into diagnostics of acute appendicitis may provide accurate diagnosis with selective use of imaging studies. The aim of this study was to prospectively validate recently described diagnostic scoring system, Adult Appendicitis Score, and evaluate its effects on negative appendectomy rate. MATERIAL AND METHODS: Adult Appendicitis Score stratifies patients into three groups: high, intermediate, and low risk of appendicitis. The score was implemented in diagnostics of adult patients suspected of acute appendicitis in two university hospitals. We analyzed the effects of Adult Appendicitis Score on diagnostic accuracy, imaging studies, and treatment. The study population was compared with a reference population of 829 patients suspected of acute appendicitis originally enrolled for the study of construction of the Adult Appendicitis Score. RESULTS: This study enrolled 908 patients of whom 432 (48%) had appendicitis. The score stratified 49% of all appendicitis patients into high-risk group with specificity of 93.3%. In the low-risk group, prevalence of appendicitis was 7%. The histologically confirmed negative appendectomy rate decreased from 18.2% to 8.7%, p<0.001, compared to the original dataset. CONCLUSION: Adult Appendicitis Score is a reliable tool for stratification of patients into selective imaging, which results in low negative appendectomy rate.
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Apendicectomia , Apendicite/diagnóstico , Técnicas de Apoio para a Decisão , Doença Aguda , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Apendicite/cirurgia , Reações Falso-Positivas , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Medição de Risco , Sensibilidade e Especificidade , Adulto JovemRESUMO
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.
Assuntos
Obstrução Intestinal/cirurgia , Intestino Delgado/cirurgia , Laparoscopia , Complicações Pós-Operatórias/cirurgia , Doença Aguda , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Obstrução Intestinal/etiologia , Masculino , Análise por Pareamento , Pessoa de Meia-Idade , Pontuação de Propensão , Estudos Retrospectivos , Aderências Teciduais/etiologia , Aderências Teciduais/cirurgia , Resultado do TratamentoRESUMO
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.
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Causas de Morte , Infarto do Miocárdio/diagnóstico por imagem , Infarto do Miocárdio/epidemiologia , Troponina T/sangue , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Distribuição por Idade , Idoso , Estudos de Coortes , Angiografia Coronária/métodos , Procedimentos Cirúrgicos do Sistema Digestório/efeitos adversos , Procedimentos Cirúrgicos do Sistema Digestório/métodos , Eletrocardiografia/métodos , Feminino , Humanos , Incidência , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/etiologia , Período Perioperatório , Valor Preditivo dos Testes , Modelos de Riscos Proporcionais , Estudos Prospectivos , Curva ROC , Medição de Risco , Índice de Gravidade de Doença , Distribuição por Sexo , Análise de Sobrevida , Procedimentos Cirúrgicos Torácicos/efeitos adversos , Procedimentos Cirúrgicos Torácicos/métodos , Procedimentos Cirúrgicos Vasculares/métodosRESUMO
[This corrects the article DOI: 10.1186/s13017-016-0082-5.].
RESUMO
Acute calculus cholecystitis is a very common disease with several area of uncertainty. The World Society of Emergency Surgery developed extensive guidelines in order to cover grey areas. The diagnostic criteria, the antimicrobial therapy, the evaluation of associated common bile duct stones, the identification of "high risk" patients, the surgical timing, the type of surgery, and the alternatives to surgery are discussed. Moreover the algorithm is proposed: as soon as diagnosis is made and after the evaluation of choledocholitiasis risk, laparoscopic cholecystectomy should be offered to all patients exception of those with high risk of morbidity or mortality. These Guidelines must be considered as an adjunctive tool for decision but they are not substitute of the clinical judgement for the individual patient.
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BACKGROUND: In 2009, a classification system for the open abdomen was introduced. The aim of such a classification is to aid the (1) description of the patient's clinical course; (2) standardization of clinical guidelines for guiding open abdomen management; and (3) facilitation of comparisons between studies and heterogeneous patient populations, thus serving as an aid in clinical research. METHODS: As part of the revision of the definitions and clinical guidelines performed by the World Society of the Abdominal Compartment Syndrome, this 2009 classification system was amended following a review of experiences in teaching and research and published as part of updated consensus statements and clinical practice guidelines in 2013. Among 29 articles citing the 2009 classification system, nine were cohort studies. They were reviewed as part of the classification revision process. A total of 542 patients (mean: 60, range: 9-160) had been classified. Two problems with the previous classification system were identified: the definition of enteroatmospheric fistulae, and that an enteroatmospheric fistula was graded less severe than a frozen abdomen. RESULTS: The following amended classification was proposed: Grade 1, without adherence between bowel and abdominal wall or fixity of the abdominal wall (lateralization), subdivided as follows: 1A, clean; 1B, contaminated; and 1C, with enteric leak. An enteric leak controlled by closure, exteriorization into a stoma, or a permanent enterocutaneous fistula is considered clean. Grade 2, developing fixation, subdivided as follows: 2A, clean; 2B, contaminated; and 2C, with enteric leak. Grade 3, frozen abdomen, subdivided as follows: 3A clean and 3B contaminated. Grade 4, an established enteroatmospheric fistula, is defined as a permanent enteric leak into the open abdomen, associated with granulation tissue. CONCLUSIONS: The authors believe that, with these changes, the requirements on a functional and dynamic classification system, useful in both research and training, will be fulfilled. We encourage future investigators to apply the system and report on its merits and constraints.
Assuntos
Técnicas de Fechamento de Ferimentos Abdominais , Fístula Intestinal/classificação , Hipertensão Intra-Abdominal/classificação , Complicações Pós-Operatórias/classificação , Humanos , Fístula Intestinal/diagnóstico , Fístula Intestinal/etiologia , Hipertensão Intra-Abdominal/diagnóstico , Hipertensão Intra-Abdominal/etiologia , Complicações Pós-Operatórias/diagnósticoRESUMO
BACKGROUND AND AIMS: The goal after open abdomen treatment is to reach primary fascial closure. Modern negative pressure wound therapy systems are sometimes inefficient for this purpose. This retrospective chart analysis describes the use of the 'components separation' method in facilitating primary fascial closure after open abdomen. MATERIAL AND METHODS: A total of 16 consecutive critically ill surgical patients treated with components separation during open abdomen management were analyzed. No patients were excluded. RESULTS: Primary fascial closure was achieved in 75% (12/16). Components separation was performed during ongoing open abdomen treatment in 7 patients and at the time of delayed primary fascial closure in 9 patients. Of the former, 3/7 (43%) patients reached primary fascial closure, whereas all 9 patients in the latter group had successful fascial closure without major complications (p = 0.019). CONCLUSION: Components separation is a useful method in contributing to successful primary fascial closure in patients treated for open abdomen. Best results were obtained when components separation was performed simultaneously with primary fascial closure at the end of the open abdomen treatment.
Assuntos
Parede Abdominal/cirurgia , Técnicas de Fechamento de Ferimentos Abdominais , Fáscia , Adulto , Idoso , Estado Terminal , Estudos de Viabilidade , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
Pancreatic injuries are relatively uncommon but present a major challenge to the surgeon in terms of both diagnosis and management. Pancreatic injuries are associated with significant mortality, primarily due to associated injuries, and pancreas-specific morbidity, especially in cases of delayed diagnosis. Early diagnosis of pancreatic trauma is a key for optimal management, but remains a challenge even with more advanced imaging modalities. For both penetrating and blunt pancreatic injuries, the presence of main pancreatic ductal injury is the major determinant of morbidity and the major factor guiding management decisions. For main pancreatic ductal injury, surgery remains the preferred approach with distal pancreatectomy for most injuries and more conservative surgical management for proximal ductal injuries involving the head of the pancreas. More recently, nonoperative management has been utilized, especially in the pediatric population, with the potential for increased rates of pseudocyst and pancreatic fistulae and the potential for the need for further intervention and increased hospital stay. This review presents recent data focusing on the diagnosis, management, and outcomes of blunt pancreatic injury.
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Traumatismos Abdominais/diagnóstico , Amilases/sangue , Colangiopancreatografia Retrógrada Endoscópica , Pâncreas/lesões , Exame Físico , Tomografia Computadorizada por Raios X , Ferimentos não Penetrantes/diagnóstico , Traumatismos Abdominais/patologia , Traumatismos Abdominais/cirurgia , Biomarcadores/sangue , Sistemas de Apoio a Decisões Clínicas , Diagnóstico Precoce , Humanos , Laparotomia/métodos , Pâncreas/anatomia & histologia , Pâncreas/patologia , Pancreatectomia/métodos , Ductos Pancreáticos/anatomia & histologia , Ductos Pancreáticos/lesões , Ductos Pancreáticos/patologia , Guias de Prática Clínica como Assunto , Prognóstico , Índices de Gravidade do Trauma , Ferimentos não Penetrantes/patologia , Ferimentos não Penetrantes/cirurgiaRESUMO
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.
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Angioplastia , Pé/irrigação sanguínea , Pé/cirurgia , Isquemia/cirurgia , Artéria Poplítea/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Angioplastia/métodos , Estudos de Coortes , Feminino , Humanos , Salvamento de Membro/efeitos adversos , Masculino , Pessoa de Meia-Idade , Pontuação de Propensão , Estudos Retrospectivos , Resultado do Tratamento , Enxerto Vascular/métodos , CicatrizaçãoAssuntos
Serviço Hospitalar de Emergência/organização & administração , Tratamento de Emergência/métodos , Procedimentos Cirúrgicos Operatórios/métodos , Emergências , Medicina de Emergência/educação , Europa (Continente) , Cirurgia Geral/educação , Humanos , Procedimentos Cirúrgicos Operatórios/educação , Estados UnidosRESUMO
BACKGROUND: Emergency surgery is associated with night-time procedures and disruption of elective surgery. An analysis was undertaken of the effect of classifying emergency operations uniformly with a three-tier urgency colour code and the use of dedicated daytime operating rooms. METHODS: Observed changes from 2001 to 2012 in the number, timing and ability to meet the urgency-designated colour code deadline were retrieved from the computer-based operating theatre organization system for all emergency operations. RESULTS: The number of emergency operations performed annually ranged from 3330 to 4341, with an increasing trend. The proportion of night-time emergency operations decreased from 27.4 per cent (2563 of 9347) before to 23.5 per cent (7731 of 32,959) after introduction of the colour coding system in 2004 (χ2 = 61.94, 1 d.f., P < 0.001). In 2007, owing to long preoperative delays in patients with acute appendicitis and acute cholecystitis, colour codes for these patients were upgraded from 'orange' to 'red' and from 'yellow' to 'orange' respectively. The proportion of patients operated on with a red code before and after this change increased from 45.2 per cent (5831 of 12,907 operations) to 62.7 per cent (13,020 of 20,778 operations; χ2 = 986.99, 1 d.f., P < 0.001). In 2012, the office-hours raw utilization time for the principal emergency operation theatre was 85.4 per cent. CONCLUSION: The structural separation of elective and emergency surgery, the use of dedicated daytime operating theatres and the implementation of a universal classification of emergency operations reduced night-time surgery, improved the efficiency of operating theatre utilization during daytime, shortened preoperative delay in patients requiring urgent surgery, and enabled monitoring and corrective actions for providing emergency surgery services.
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Codificação Clínica/métodos , Tratamento de Emergência/classificação , Especialidades Cirúrgicas/organização & administração , Procedimentos Cirúrgicos Operatórios/classificação , Cor , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Emergências , Serviço Hospitalar de Emergência/organização & administração , Tratamento de Emergência/estatística & dados numéricos , Estudos de Viabilidade , Humanos , Salas Cirúrgicas/provisão & distribuição , Equipe de Assistência ao Paciente/organização & administração , Especialidades Cirúrgicas/estatística & dados numéricos , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos , Fatores de TempoRESUMO
Complex abdominal wall defects refer to situations where simple ventral hernia repair is not feasible because the defect is very large, there is a concomitant infection or failed previous re-pair attempt, or if there is not enough original skin to cover the repair. Usually a complex abdominal wall repair is preceded by a period of temporary abdominal closure where the short-term aims include closure of the catabolic drain, protection of the viscera and preventing fistula formation, preventing bowel adherence to the abdominal wall, and enabling future fascial and skin closure. Currently the best way to achieve these goals is the vacuum- and mesh-mediated fascial traction method achieving close to 90% fascial closure rates. The long-term aims of an abdominal closure following a planned hernia strategy include intact skin cover, fascial closure at midline (if possible), good functional outcome with innervated abdominal musculature, no pain and good cosmetic result. The main methods of abdominal wall reconstruction include the use of prosthetic (mesh) or autologous material (tissue flaps). In patients with original skin cover over the fascial defect (simple ventral hernia), the most commonly used method is hernia repair with an artificial mesh. For more complex defects, our first choice of reconstruction is the component separation technique, sometimes combined with a mesh. In contaminated fields where component separation alone is not feasible, a combination with a biological mesh can be used. In large defects with grafted skin, a free TFL flap is the best option, sometimes reinforced with a mesh and enhanced with components separation.