[Emergency surgery in Russian Federation (in Russian only)]. / Sostoianie ékstrennoi khirurgicheskoi pomoshchi v Rossiiskoi Federatsii.

In the following article, we present the key trends in emergency surgical care in the Russian Federation between 2000 and 2017. The study used data from federal statistical observations and a survey of state medical institutions in 80 regions encompassing 99.3% of the country's population. We discovered a change in the correlation between acute abdominal diseases, particularly a significant reduction in the occurrence of acute appendicitis and perforated peptic ulcer. Reduction in the number of emergency surgeries by 27.8% annually was also observed. Mortality rate decreased in cases of strangulated hernia, acute cholecystitis and acute pancreatitis, while it is stable for bowel obstruction and acute appendicitis and increasing in perforated peptic ulcer cases. The total annual number of lethal outcomes due to acute abdominal diseases was decreased by 1900 cases. Significant changes were observed in mortality rate and minimally invasive surgeries proportions between federal districts and individual regions of the country. The range of administrative measures was proposed.

Variability in mortality following caesarean delivery, appendectomy, and groin hernia repair in low-income and middle-income countries: a systematic review and analysis of published data.

BACKGROUND: Surgical interventions occur at lower rates in resource-poor settings, and complication and death rates following surgery are probably substantial but have not been well quantified. A deeper understanding of outcomes is a crucial step to ensure that high quality accompanies increased global access to surgical care. We aimed to assess surgical mortality following three common surgical procedures--caesarean delivery, appendectomy, and groin (inguinal and femoral) hernia repair--to quantify the potential risks of expanding access without simultaneously addressing issues of quality and safety. METHODS: We collected demographic, health, and economic data for 113 countries classified as low income or lower-middle income by the World Bank in 2005. We did a systematic review of Ovid, MEDLINE, PubMed, and Scopus from Jan 1, 2000, to Jan 15, 2015, to identify studies in these countries reporting all-cause mortality following the three commonly undertaken operations. Reports from governmental and other agencies were also identified and included. We modelled surgical mortality rates for countries without reported data using a two-step multiple imputation method. We first used a fully conditional specification (FCS) multiple imputation method to establish complete datasets for all missing variables that we considered potentially predictive of surgical mortality. We then used regression-based predictive mean matching imputation methods, specified within the multiple imputation FCS method, for selected predictors for each operation using the completed dataset to predict mortality rates along with confidence intervals for countries without reported mortality data. To account for variability in data availability, we aggregated results by subregion and estimated surgical mortality rates. FINDINGS: From an initial 1302 articles and reports identified, 247 full-text articles met our inclusion criteria, and 124 provided data for surgical mortality for at least one of the three selected operations. We identified 42 countries with mortality data for at least one of the three procedures. Median reported mortality was 7·9 per 1000 operations for caesarean delivery (IQR 2·8-19·9), 2·2 per 1000 operations for appendectomy (0·0-17·2), and 4·9 per 1000 operations for groin hernia (0·0-11·7). Perioperative mortality estimates by subregion ranged from 2·8 (South Asia) to 50·2 (East Asia) per 1000 caesarean deliveries, 2·4 (South Asia) to 54·0 (Central sub-Saharan Africa) per 1000 appendectomies, and 0·3 (Andean Latin America) to 25·5 (Southern sub-Saharan Africa) per 1000 hernia repairs. INTERPRETATION: All-cause postoperative mortality rates are exceedingly variable within resource-constrained environments. Efforts to expand surgical access and provision of services must include a strong commitment to improve the safety and quality of care. FUNDING: None.

Large-bowel disease presenting as small-bowel obstruction is associated with a poor prognosis.

INTRODUCTION: Small-bowel obstruction (SBO) is a common cause of admission to the surgical service. On rare occasions, a diagnosed SBO is actually due to large-bowel pathology combined with an incompetent ileocecal valve. The purpose of this study was to investigate this phenomenon. METHODS: We performed a retrospective medical record review of patients that were admitted with a diagnosis of SBO at University of Louisville hospital and the Veterans Affairs hospitals in Louisville, KY, from 2006 until 2014. RESULTS: A total of 498 patients were admitted with SBO during this time period. Forty-one patients were found to have an underlying large-bowel disease. The most common large-bowel pathologies included malignancy (51%), inflammation (15%), and infection (15%). Fifteen (43%) of these patients died during admission; 93% of these were due to either their bowel obstruction or the underlying disease state. This was significantly higher than the general population (9.4% mortality, 6% due to underlying disease). CONCLUSIONS: Patients that present with SBO due to a large-bowel source have a much higher mortality rate than those that present with other causes. Rapid identification of these patients will allow for more timely and appropriate treatment.

Deaths Following Cholecystectomy and Herniotomy: An Analysis of Nationwide German Hospital Discharge Data From 2009 to 2013.

BACKGROUND: In 2010, 158 000 cholecystectomies and 207 000 herniotomies (without bowel surgery) were performed in Germany as inpatient procedures, generally on a routine, elective basis. Deaths following such operations are rare events. We studied the potential association of death after cholecystectomy or herniotomy with risk factors that could have been detected beforehand, and we examined the types of complications that were documented in these cases. METHODS: Using nationwide hospital discharge data (DRG statistics) for the years 2009-2013, we analyzed the characteristics of patients who died in the hospital after undergoing a cholecystectomy for cholelithiasis or the repair of an inguinal, femoral, umbilical, or abdominal wall hernia. We compared these data with those of patients who survived and studied the impact of the coded comorbidities on the risk of death. RESULTS: In Germany, in the years 2009-2013, there were 2957 deaths after a total of 731 000 cholecystectomies (in-hospital mortality, 0.4%) and 1316 deaths after a total of 1 023 000 herniotomies without bowel surgery (0.13%). The patients who died were markedly older than those who did not, and they more commonly had comorbidities. Factors associated with a higher risk of death were age over 65 years, and comorbidities such as congestive heart failure, chronic pulmonary or hepatic disease, or poor nutritional status. Complications were coded much more often for the patients who died than for those who did not. CONCLUSION: These findings suggest that there is potential for improvement in preoperative risk identification, complication avoidance, and the early recognition and treatment of complications, as well as in safe surgical technique. Measures to lower the mortality associated with herniotomy and cholecystectomy would lessen patients' individual risk and thereby improve patient safety.

Laparoscopic Roux-en-Y gastric bypass: significant long-term weight loss, improvement of obesity-related comorbidities and quality of life.

OBJECTIVE: To present long-term results of a large series of patients submitted to laparoscopic Roux-en-Y gastric bypass (RYGBP) for morbid obesity. BACKGROUND: Reports on long-term results of RYGBP are scarce and focus primarily on weight loss. Our aim is to provide mid- to long-term data of RYGBP, with detailed results on weight loss, evolution of comorbidities and quality of life, also using the BAROS score. METHODS: All patients who underwent a primary RYGBP for morbid obesity in our 2 hospitals between 1999 and August 2008 were included. Data were collected prospectively in a computerized database, and reviewed for the purpose of this study. RESULTS: A total of 379 patients were included in the analysis of long-term results, 282 women, and 97 men, with a mean BMI of 46.3 kg/m². After 5 years, 74.9% of the patients achieved an excess weight loss of at least 50%, with a mean of 62.7% and 76.8% achieved a BMI <35 kg/m². The corresponding figures after 7 years were 64.9, 58.1, and 71.9, respectively. There was a small but significant long-term weight regain. All comorbidities improved markedly in the vast majority of patients, with no significant difference between the 3- and 5-year terms. Quality of life also improved markedly, and more than 95% of the patients had a good to excellent 5-year overall result according to the BAROS score. CONCLUSIONS: Laparoscopic RYGBP for morbid obesity results in good and maintained weight loss up to 7 years in the majority of patients, improves quality of life and markedly improves all the evaluated comorbidities, resulting in good to excellent overall 5-year results in 97% of the patients according to the BAROS score.

Renal paratransplant hernia: a surgical complication of kidney transplantation.

INTRODUCTION: Renal paratransplant hernia is an uncommon and potentially fatal complication of renal transplantation. In this condition, bowel herniates through a defect in the peritoneum over the transplanted kidney and becomes trapped. CASE REPORT: Six cases have been reported previously, and we herein report three cases encountered in 668 kidney recipients. Abdominal pain and distention with or without vomiting were the main symptoms, presenting within 4 days after surgery. Abdominal CT scan confirmed the presence of bowel obstruction and paratransplant hernia. All three patients underwent emergent laparotomy, and resection of necrotic bowel was required in one patient who died of multiple organ failure 1 week after laparotomy. CONCLUSION: Renal paratransplant hernia is uncommon and potentially fatal, thus, prompt diagnosis and early surgical intervention are critical. Additionally, meticulous surgical technique during transplantation may help avoid this complication.

Mortality following emergency groin hernia surgery in Denmark.

PURPOSE: The mortality following emergency groin hernia repair in Denmark is more than twice as high (7%) as in comparable countries. This article describes in detail the population that died following emergency herniotomy in order to identify aspects of care that may improve outcome. METHODS: Patients > or =18 years of age who died within 30 days following emergency hernia surgery from June 2003 through June 2008 were identified using the Danish Hernia Database (DHDB) and the Danish National Hospital Registry (n = 158). In total, 156 records were collected and reviewed. RESULTS: The median age of the patients was 83 years (range 54-97) and 80% had co-morbidity. There was an almost equal distribution of men and women and inguinal and femoral hernias. More than 60% of the patients with a hernia upon admission had symptoms lasting > or =48 h prior to admission and 41% were not examined for hernia at admission and had delayed diagnosis. Only 23% underwent surgery within 8 h of admission and 35% of the patients were admitted to a medical or non-abdominal surgical ward. Laparotomy and bowel resections were frequent (53.1 and 49.2%, respectively). CONCLUSION: Delay to admission, diagnosis and surgery are common in patients undergoing emergency groin hernia surgery in Denmark. Patients admitted with acute abdominal symptoms should be examined for a hernia and operated on soon after admission.

[Treatment of incisional hernias]. / Traitement des eventrations post-opratoires.

Several therapeutic processes were proposed in the repair of incisional hernia, on the basis of simple joining suture go to the installation of prosthetic mesh while passing by aponeurotic autoplasty according to Welti-Eudel technique. The aim of this study was to report the results of our experiment in the treatment of incisional hernias. It was a retrospective study carried out of January 11th 1996 to December 31, 2000, concerning 35 cases of incisional hernias operated during the study period. The following parameters were studied: age, sex, diameter, technique of repair, morbidty, mortality and the remote follow-up. Average age of our patients was 33 years with extremes of 13 and 53 years. It include 30 womens and 5 mens. The initial operation were dominated by Caesarean (57%). The diameter of incisional hernia varied between 3 and 5 cm in 22.9% of patients, between 5 and 10 cm in 62.8% of paitents, higher than 10 cm in 14.3% of patients. The simple joining suture was carried out in 22.9% of cases, the Welti-Eudel technique in 42.9% of cases and the installation of prosthetic mesh in 34.2% of the cases. Mortality was 5.1% and the morbidity was 34.2% made exclusively by suppuration including 5.1% on prosthetic material. We noted 14.3% of recurence which has occured after repair by simple joining. The Welti-Eudel procedure gives good results in the repair of incisional hernia with small and average dimensions. The installation of prosthetic mesh constitute the treatment of choice because the rate of recurence is weak even null.

Deaths following hernia surgery: room for improvement.

BACKGROUND: Abdominal wall herniae are common and may well lead to death. The aim of this study was to examine the deaths of patients with an inguinal, femoral or incisional hernia to identify aspects of management which could be improved upon. METHOD: Data collected by the Scottish Audit of Surgical Mortality 1994-1997 was analysed by interrogation of the database for all deaths on a surgical ward or within 30 days of surgery where the principle diagnosis was inguinal, fermoral or incisional hernia. RESULTS: There were 133 deaths out of 31,525 operations over the 4-year period. Mortality was highest among femoral hernia operations in women (37 deaths/1184 operations; 3.1%) and 59% of femoral hernia surgery was performed outwith normal working hours. The 133 patients were elderly (mean age 79 years) and unfit, but less than half the operations involved consultant anaesthetists or consultant surgeons. Delay in referral contributed to death in 15/133 patients and adverse factors in management, particularly in the perioperative period, caused the death of 2 patients and contributed to the death of a further 29/133. CONCLUSIONS: Herniae carry a significant mortality in elderly, unfit patients who require close attention to perioperative management. These patients should be anaesthetised and operated upon by consultant staff during the normal working day.

[Abdominal surgery in advanced age. Indications and prognosis exemplified by stomach, bile duct, colon and hernia surgery]. / Abdominalchirurgie im Alter. Indikation und Prognose am Beispiel der Magen-, Gallenwegs-, Kolon- und Hernienchirurgie.

The increased risk of morbidity and mortality associated with abdominal surgery in the aged is determined by the number and severity of accompanying diseases and the emergency situation. Age per se is not a risk factor. Limitation of the risk requires an age-oriented treatment plan, which must take account of the specific problems of the geriatric patient in the pre-, intra-, and postoperative phases. Emergency operations should be avoided as far as possible. The aim of geriatric surgery is not merely to prolong life, but also to secure adequate quality of life. To accomplish this, it may occasionally be necessary to forgo surgical radicality in favor of a palliative procedure. The results of abdominal surgery in the elderly are presented on the basis of exemplary cases of stomach, biliary, colonic and hernial surgery.

Delay in presentation and misdiagnosis of strangulated hernia: prospective study.

The purpose of this study was to examine the presentation and management of strangulated hernia. The clinical course of 54 patients was recorded. Twenty-one patients (39%) presented after 48 h from the onset of symptoms. Fifteen (28%) had a bowel resection and two (4%) died. Twenty (37%) patients had previously consulted their general practitioner about the hernia, but only seven had been referred for surgery. Five (25%) had been warned of the risk of strangulation. In the 32 (59%) patients previously aware of a hernia, delayed presentation was related to ignorance of the risk of strangulation (P less than 0.01). The strangulated hernia was misdiagnosed by the general practitioner in 17 (33%) patients (necessitating a second visit) and by the hospital registrar in eight (15%). We conclude that strangulated hernia is too often misdiagnosed and all patients who present with a hernia must be referred to a surgeon and warned about strangulation.

Fatal tonsillar herniation in pseudotumor cerebri.

A 27-year-old woman with pseudotumor cerebri died after lumbar puncture secondary to tonsillar herniation. Five years earlier she had a respiratory arrest after lumbar puncture. MRI and autopsy ruled out the presence of an Arnold-Chiari malformation or a mass lesion of the posterior fossa, but midsagittal views suggested the presence of low-lying cerebellar tonsils.

[Preventive operations in hernia]. / Prophylaktische Operationen bei Hernien.

Between 1986 and 1990 1311 inguinal or femoral, 215 abdominal-wall, and 20 hiatal hernias were treated operatively at the Department of Surgery in Detmold. The operations were classified as follows: elective in 87.1%, in conjunction with other operations in 6.1%, and as emergency in 6.9%. Postoperative mortality was 0.1% in elective surgery, but rose 85-fold to 8.5% in emergencies. Hernias therefore should nearly always be treated by elective surgery.

The geriatric patient in surgery. Experience with patients over the age of 85 years.

Between 1982 and 1989 hospitalized treatment was applied to 615 patients aged between 85 and 101 years. The average age was 88.8 years. Operations were performed on 406 of them (66.1%). The surgical lethality amounted 16.5%. The lethality in conjunction with emergency operation was as high as 30.8% or as low as 10.7% in the context of elective operations. X-ray findings recorded from heart and lung as well as ECG provided reliable criteria for assessment of the surgical risk.

[The surgery of intestinal obstruction in the elderly]. / Aspecte ale chirurgiei ocluziei intestinale la batrîni.

Out of 301 intestinal obstructions treated at the 1st Surgical Clinic of Iasi in the interval 1970-1987, 58 patients aged between 70 and 90 years (mean age 75 years) were recorded. Anatomo-clinically these 58 cases presented: strangulated hernia (19 cases), strangulated eventration (2 cases), strangulations on cords (4 cases), small intestine volvulus (8 cases), sigmoid colon volvulus (6 cases), volvulus of cecum (1 case), intestinal investigation (1 case), colorectal neoplasm (15 cases), peritoneal carcinomatosis (2 cases). The clinical and therapeutical aspects of these particular forms of obstruction in the elderly are discussed and the severity of their prognosis, given the terrain and late admission of such patients which sometimes make impossible a surgical intervention, is underlined. Ten deaths (17.1%) were recorded, representing a lower percentage as compared to other statistics published in the literature.

Presentation and outcome of strangulated external hernia in a district general hospital.

Two hundred consecutive emergency hernia operations are reviewed. Mortality from this condition has not significantly altered in the past 30 years. Half of the patients presented 48 h or more from the onset of symptoms. Mortality and bowel resection were clearly linked with the duration of symptoms prior to admission. There were no reliable clinical signs to predict the likelihood of bowel strangulation. Recurrent incisional and femoral hernias were associated with high resection rates and mortality. Right-sided hernias appeared to strangulate more frequently than left-sided hernias.