Acute cholecystitis management in high-risk, critically ill, and unfit-for-surgery patients: the Italian Society of Emergency Surgery and Trauma (SICUT) guidelines.

Dealing with acute cholecystitis in high-risk, critically ill, and unfit-for-surgery patients is frequent during daily practice and requires complex management. Several procedures exist to postpone and/or prevent surgical intervention in those patients who temporarily or definitively cannot undergo surgery. After a systematic review of the literature, an expert panel from the Italian Society of Emergency Surgery and Trauma (SICUT) discussed the different issues and statements in subsequent rounds. The final version of the statements was discussed during the annual meeting in Rome (September 2022). The present paper presents the definitive conclusions of the discussion. Fifteen statements based on the literature evidence were provided. The statements gave precise indications regarding the decisional process and the management of patients who cannot temporarily or definitively undergo cholecystectomy for acute cholecystitis. Acute cholecystitis management in high-risk, critically ill, and unfit-for-surgery patients should be multidisciplinary. The different gallbladder drainage methods must be tailored according to each patient and based on the expertise of the hospital. Percutaneous gallbladder drainage is recommended as the first choice as a bridge to surgery or in severely physiologically deranged patients. Endoscopic gallbladder drainage (cholecystoduodenostomy and cholecystogastrostomy) is suggested as a second-line alternative especially as a definitive procedure for those patients not amenable to surgical management. Trans-papillary gallbladder drainage is the last option to be reserved only to those unfit for other techniques. Delayed laparoscopic cholecystectomy in patients with percutaneous gallbladder drainage is suggested in all those patients recovering from the conditions that previously discouraged surgical intervention after at least 6 weeks from the gallbladder drainage.

Perforated peptic ulcer (PPU) treatment: an Italian nationwide propensity score-matched cohort study investigating laparoscopic vs open approach.

BACKGROUND: Perforated peptic ulcer (PPU) remain a surgical emergency accounting for 37% of all peptic ulcer-related deaths. Surgery remains the standard of care. The benefits of laparoscopic approach have been well-established even in the elderly. However, because of inconsistent results with specific regard to some technical aspects of such technique surgeons questioned the adoption of laparoscopic approach. This leads to choose the type of approach based on personal experience. The aim of our study was to critically appraise the use of the laparoscopic approach in PPU treatment comparing it with open procedure. METHODS: A retrospective study with propensity score matching analysis of patients underwent surgical procedure for PPU was performed. Patients undergoing PPU repair were divided into: Laparoscopic approach (LapA) and Open approach (OpenA) groups and clinical-pathological features of patients in the both groups were compared. RESULTS: A total of 453 patients underwent PPU simple repair. Among these, a LapA was adopted in 49% (222/453 patients). After propensity score matching, 172 patients were included in each group (the LapA and the OpenA). Analysis demonstrated increased operative times in the OpenA [OpenA: 96.4 ± 37.2 vs LapA 88.47 ± 33 min, p = 0.035], with shorter overall length of stay in the LapA group [OpenA 13 ± 12 vs LapA 10.3 ± 11.4 days p = 0.038]. There was no statistically significant difference in mortality [OpenA 26 (15.1%) vs LapA 18 (10.5%), p = 0.258]. Focusing on morbidity, the overall rate of 30-day postoperative morbidity was significantly lower in the LapA group [OpenA 67 patients (39.0%) vs LapA 37 patients (21.5%) p = 0.002]. When stratified using the Clavien-Dindo classification, the severity of postoperative complications was statistically different only for C-D 1-2. CONCLUSIONS: Based on the present study, we can support that laparoscopic suturing of perforated peptic ulcers, apart from being a safe technique, could provide significant advantages in terms of postoperative complications and hospital stay.

Impact of COVID-19 on surgical activities and personnel: lessons for the future.

BACKGROUND: COVID-19 pandemic has impacted professional, economic and social activities. In the surgical field, it has brought changes to operating activities, the organization of workforces, the protection measures for patients and personnel against possible intraoperative transmissions as well as training young surgeons. This study intends to assess the extent of this impact in our institution. METHODS: The patients operated on in nine Operating Units (OUs) in the period February 1 - March 31, 2020, with follow-ups on April 30, 2020, were evaluated both retrospectively and prospectively. Organizational, clinical and impact parameters on staff were evaluated. RESULTS: Of the 833 consecutive admitted patients, 742 were operated on, 705 of whom were recruited for the study. Compared to the same period in 2019 there was a decrease in the number of operations (742 compared to 1187), similar use of intensive care unit (ICU), a diagnostic activity only for symptomatic patients, heterogeneity in organizational behaviors, an impact on staff who highlighted concerns about getting sick or passing the infection on to others (87.64%) or their family members (75.14%). CONCLUSIONS: The present study made it possible to detect the need to make significant changes in the clinical, organizational and teaching fields, for which some operational proposals are suggested.

Bowel ischemia as onset of COVID-19 in otherwise asymptomatic patients with persistently negative swab.

BACKGROUND: Asymptomatic patients with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) can develop hypercoagulable conditions and acute vascular events. The objective of this study is to determine whether SARS-CoV-2 was present in resected specimens from patients with acute bowel ischemia, but asymptomatic for Coronavirus Disease 2019 (COVID-19) and with persistently real-time polymerase chain reaction negative pharyngeal swab. METHODS: Three consecutive patients presented severe abdominal symptoms due to extensive ischemia and necrosis of the bowel, with co-existent thrombosis of abdominal blood vessels. None had the usual manifestations of COVID-19, and repeated pharyngeal swabs tested negative. They underwent emergency surgery with intestinal resection. Immunohistochemical testing for SARS-CoV-2 on resected tissue was performed. RESULTS: All tested samples were strongly positive for SARS-CoV-2. CONCLUSIONS: This is the first case report in which patients with severe intestinal symptoms presented a marked SARS-CoV-2 positivity in the resected tissues, without any usual clinical manifestations of COVID-19. These results suggest that the patients might be infected with SARS-CoV-2 presenting acute abdominal distress but without respiratory or constitutional symptoms.

Relevance of VEGF and CD147 in different SARS-CoV-2 positive digestive tracts characterized by thrombotic damage.

Several evidence suggests that, in addition to the respiratory tract, also the gastrointestinal tract is a main site of severe acute respiratory syndrome CoronaVirus 2 (SARS-CoV-2) infection, as an example of a multi-organ vascular damage, likely associated with poor prognosis. To assess mechanisms SARS-CoV-2 responsible of tissue infection and vascular injury, correlating with thrombotic damage, specimens of the digestive tract positive for SARS-CoV-2 nucleocapsid protein were analyzed deriving from three patients, negative to naso-oro-pharyngeal swab for SARS-CoV-2. These COVID-19-negative patients came to clinical observation due to urgent abdominal surgery that removed different sections of the digestive tract after thrombotic events. Immunohistochemical for the expression of SARS-CoV-2 combined with a panel of SARS-CoV-2 related proteins angiotensin-converting enzyme 2 receptor, cluster of differentiation 147 (CD147), human leukocyte antigen-G (HLA-G), vascular endothelial growth factor (VEGF) and matrix metalloproteinase-9 was performed. Tissue samples were also evaluated by electron microscopy for ultrastructural virus localization and cell characterization. The damage of the tissue was assessed by ultrastructural analysis. It has been observed that CD147 expression levels correlate with SARS-CoV-2 infection extent, vascular damage and an increased expression of VEGF and thrombosis. The confirmation of CD147 co-localization with SARS-CoV-2 Spike protein binding on gastrointestinal tissues and the reduction of the infection level in intestinal epithelial cells after CD147 neutralization, suggest CD147 as a possible key factor for viral susceptibility of gastrointestinal tissue. The presence of SARS-CoV-2 infection of gastrointestinal tissue might be consequently implicated in abdominal thrombosis, where VEGF might mediate the vascular damage.

Post-Operative All-Cause Mortality in Elderly Patients Undergoing Abdominal Emergency Surgery: Role of Charlson Comorbidity Index.

(1) Background: The Charlson comorbidity index (CCI) score has been shown to predict 10-year all-cause mortality, but its validity is a matter of debate in surgical patients. We wanted to evaluate CCI on predicting all-cause mortality in elderly patients undergoing emergency abdominal surgery (EAS); (2) Methods: This retrospective single center study included all patients aged 65 years or older consecutively admitted from January 2017 to December 2019, who underwent EAS and were discharged alive. CCI was calculated by using of the International Classification of Diseases, 9th Revision, Clinical Modification codes. Our outcome was all-cause death recorded during the 20.8 ± 8.8 month follow-up; (3) Results: We evaluated 197 patients aged 78.4 ± 7.2 years of whom 47 (23.8%) died. Mortality was higher in patients who underwent open abdominal surgery than in those treated with laparoscopic procedure (74% vs. 26%, p < 0.001), and in those who needed colon, small bowel, and gastric surgery. Mean CCI was 4.98 ± 2.2, and in subjects with CCI ≥ 4 survival was lower. Cox regression analysis showed that CCI (HR 1.132, 95% CI 1.009-1.270, p = 0.035), and open surgery (HR 10.298, 95%CI 1.409-75.285, p = 0.022) were associated with all-cause death independently from age and sex; (4) Conclusions: Calculation of CCI, could help surgeons in the preoperative stratification of risk of death after discharge in subjects aged ≥65 years who need EAS. CCI ≥ 4, increases the risk of all-causes mortality independently from age.

The Surgical Management of Acute Gastric Volvulus: Clinical Outcomes and Quality of Life Assessment.

Background: Surgery is the mainstay of treatment for gastric volvulus. Despite its rarity, early experience from recent publications suggests that laparoscopy is a safe and effective approach for the treatment of acute gastric volvulus. Yet, more data focusing on patients' postoperative quality of life (QoL) is needed. The aim of this study is to report our institutional experience with the management of acute gastric volvulus, assessing surgical outcomes and postoperative QoL. Materials and Methods: We performed a retrospective review of a prospectively maintained database, looking for patients with gastric volvulus, requiring emergency laparotomic or laparoscopic surgery, between 2016 and 2018. Follow-up included clinical evaluation, barium swallow X-ray, and two QoL questionnaires-Gastroesophageal Reflux Disease-Health-Related Quality of Life and Gastrointestinal Symptom Rating Scale. Results: Over a 3-year period, 9 patients underwent emergency surgery for acute gastric volvulus, 5 (55%) of which were performed laparoscopically. In this group, the only postoperative complication was found in 1 (20%) patient who presented mild delayed gastric empty. In the laparotomic group, 3 patients (75%) had immediate (30-day) postoperative complications-1 pneumonia, 1 bowel obstruction, and 1 sepsis with multiorgan failure. At a median follow-up of 25 (15-48) months, hiatal hernia recurred in 1 (20%) patient after laparoscopic repair. No recurrence occurred in the open group. With a 100% response rate, QoL questionnaires revealed that 80% of the subjects treated laparoscopically were fully satisfied of the surgical approach, reporting slightly better QoL scores than the open surgery group. Conclusions: Improved postoperative clinical outcomes and QoL after laparoscopic repair of acute gastric volvulus provide encouraging evidence in support of this minimally invasive approach as an alternative to laparotomy.

Segmental saphenous ablation for chronic venous disease treatment.

BACKGROUND: Endovenous thermal ablation for chronic venous disease treatment is recommended over traditional surgery. The present investigation compares endovenous laser ablation (EVLA) with radiofrequency (RF) for segmental endovenous sapheno-femoral junction ablation. METHODS: This is a retrospective study in which 79 patients underwent a 6 cm great saphenous vein ablation by RF or by EVLA.Primary outcome was occlusion rate. Secondary outcomes included Venous Clinical Severity Score (VCSS), Aberdeen Varicose Vein Questionnaire (AVVQ) score, peri-procedural pain, aesthetic satisfaction. RESULTS: At 12 ± 1 months recanalization of shrunk tract was recorded in 5/85 (5.8%) cases (2 RF, 3 EVLA) [OR: 1.6; 95%CI: 0.2-10.4; P = 0.6689]. Two cases (1/44 RF group and 1/38 EVLA group) also showed reflux recurrence [OR: 1.0; 95%CI: 0.06-17.8; P = 1.0000]. No significant differences between groups were found in AVVQ, VCSS, peri-procedural pain, or aesthetic satisfaction. CONCLUSION: Saphenous sparing is feasible and effective by means of both EVLA and RF, representing a possible alternative to surgery.

Delayed Rupture of a Normal Appearing Spleen After Trauma: Is Our Knowledge Enough? Two Case Reports.

BACKGROUND Non-operative management is considered the gold standard for hemodynamically stable patients with splenic injuries. Delayed splenic rupture is a well-known complication of non-operative management in splenic trauma, with a relevant impact on mortality and morbidity. Most of the reported cases of delayed splenic rupture presented splenic injury at admission imaging or no imaging investigations were performed. We report 2 cases of delayed splenic rupture after blunt trauma, in which multidetector computed tomography (CT) scan at admission did not show any splenic injury.   CASE REPORT Two patients were admitted to our emergency surgery unit after abdominal trauma with left rib fractures, but no solid organ injuries were detected at CT scan. Some days after the trauma, both patients suddenly developed hemorrhagic shock due to splenic rupture and required emergency splenectomy. CONCLUSIONS Trauma patients' management and follow-up remains challenging for surgeons, because of sudden clinical changes that can occur. Delayed splenic rupture with inconspicuous admission CT scan is a rare event. In some cases, it seems to be related to a poor CT quality, but this explanation cannot be adopted in all cases. Moreover, there is no standardization for imaging follow-up in the case of a normal CT scan at admission, in order to prevent delayed hemorrhage. In this context, every element that can identify patients with higher risk of delayed splenic rupture is of great importance. We suggest that lower left rib fractures can be associated with delayed splenic rupture, and we propose some explaining hypothesis.

The need for red blood cell transfusions in the emergency department as a risk factor for failure of non-operative management of splenic trauma: a multicenter prospective study.

INTRODUCTION: The majority of patients with splenic trauma undergo non-operative management (NOM); around 15% of these cases fail NOM and require surgery. The aim of the current study is to assess whether the hemodynamic status of the patient represents a risk factor for failure of NOM (fNOM) and if this may be considered a relevant factor in the decision-making process, especially in Centers where AE (angioembolization), intensive monitoring and 24-h-operating room are not available. Furthermore, the presence of additional risk factors for fNOM was investigated. MATERIALS AND METHODS: This is a multicentre prospective observational study, including patients presenting with blunt splenic trauma older than 17 years, managed between 2014 and 2016 in two Italian trauma centres (ASST Papa Giovanni XXIII in Bergamo and Sant'Anna University Hospital in Ferrara-Italy). The risk factors for fNOM were analyzed with univariate and multivariate analyses. RESULTS: In total, 124 patients were included in the study. In univariate analysis, the risk factors for fNOM were AAST grade > 3 (fNOM 37.5% vs 9.1%, p = 0.024), and the need of red blood cell (RBC) transfusion in the emergency department (ED) (fNOM 42.9% vs 8.9%, p = 0.011). Multivariate analysis showed that the only significant risk factor for fNOM was the need for RBC transfusion in the ED (p = 0.049). CONCLUSIONS: The current study confirms the contraindication to NOM in case of hemodynamically instability in case of splenic trauma, as indicated by the most recent guidelines; attention should be paid to patients with transient hemodynamic stability, including patients who require transfusion of RBC in the ED. These patients could benefit from AE; in centers where AE, intensive monitoring and an 24-h-operating room are not available, this particular subgroup of patients should probably be treated with operative management.