Differential impact of bypass surgery and angioplasty on angiosome-targeted infrapopliteal revascularization.

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.

A traffic-light coding system to organize emergency surgery across surgical disciplines.

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.

Vacuum and mesh-mediated fascial traction for primary closure of the open abdomen in critically ill surgical patients.

BACKGROUND: Several temporary abdominal closure techniques have been used in the management of open abdomen. Failure to achieve delayed primary fascial closure results in a large ventral hernia. This retrospective analysis evaluated whether the use of vacuum-assisted closure and mesh-mediated fascial traction (VACM) as temporary abdominal closure improved the delayed primary fascial closure rate compared with non-traction methods. METHODS: Patients treated with an open abdomen between 2004 and 2010 were analysed. RESULTS: Among 50 patients treated with VACM and 54 using non-traction techniques (control group), the delayed primary fascial closure rate was 78 and 44 per cent respectively (P < 0·001); rates among those who survived to abdominal closure were 93 and 59 per cent respectively. Independent predictors of delayed primary fascial closure in multivariable logistic regression analysis were the use of VACM (odds ratio (OR) 4·43, 95 per cent confidence interval 1·64 to 11·99) and diagnosis other than peritonitis, severe acute pancreatitis or ruptured abdominal aortic aneurysm (OR 3·45, 1·07 to 11·04), which represented the main diagnoses. Prophylactic open abdomen was used to inhibit the development of intra-abdominal hypertension more frequently in the VACM group (28 versus 7 per cent; P = 0·008). Twelve per cent of patients in the VACM group developed an enteroatmospheric fistula compared with 19 per cent of control patients. Among survivors, three of 31 treated with VACM and 17 of 36 controls were left with a planned ventral hernia (P = 0·001). CONCLUSION: The indication for open abdomen contributed to the probability of delayed primary fascial closure. VACM resulted in a higher fascial closure rate and lower planned hernia rate than methods that did not provide fascial traction.

Reconstruction of extensive abdominal wall defects with microvascular tensor fasciae latae flap.

BACKGROUND: Most abdominal wall defects can be repaired with a mesh, components separation technique or pedicle flaps, but a free flap reconstruction might be the only option for large epigastric or non-midline defects. This retrospective study reviewed the results of consecutive patients who had extensive full-thickness abdominal wall defects reconstructed with a large, microvascular tensor fasciae latae (TFL) flap. METHODS: A 30-35 × 15-20-cm TFL flap was harvested and microvascular anastomoses were performed using a saphenous arteriovenous loop. RESULTS: From 1995 to 2009, 20 patients were operated on with a TFL flap. The repair was combined with a mesh in nine patients, components separation in one patient, and both techniques were used in one patient. The median follow-up was 2 (range 0·5-13) years. There were no perioperative deaths, or intra-abdominal or deep surgical-site infections. The flap failed in one patient, two patients had minor distal tip necrosis of the flap and one developed a recurrent hernia 3 months after TFL repair. CONCLUSION: A microvascular TFL flap is a feasible option for reconstruction of exceptionally large abdominal wall defects if other means of reconstruction have already been used or are insufficient. It can also be combined with other methods of reconstruction. A close collaboration between plastic and abdominal surgeons is important. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Perforation rate after a diagnosis of uncomplicated appendicitis on CT.

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.

Role of delay and antibiotics on PERForation rate while waiting appendicECTomy (PERFECT): a protocol for a randomized non-inferiority trial.

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).

Blunt Abdominal Trauma in a European Trauma Setting: Need for Complex or Non-Complex Skills in Emergency Laparotomy.

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.

Vein patch angioplasty with non-penetrating titanium clips. Comparison to standard suture technique.

Our purpose was to compare the Vascular Closure Staples (VCS) clips to a standard suture technique for vein patch angioplasty in a porcine model. Six female pigs underwent vein patch angioplasty of the common iliac arteries with either VCS clips or continuous suturing. The reconstructed vessels were evaluated macroscopically, angiographically and histologically after two months by re-operation. There was a non significant trend towards shorter reconstruction (6.5 +/- 1.8 min. for clips vs. 8.5 +/- 1.7 min. for sutures, p = 0.15) and clamp times when clips were used (8.4 +/- 1.5 min. vs. 10.1 +/- 1.3 min., p = 0.15). At re-operation all vessels were found patent without significant histological differences regarding the intimal reaction. VCS clips are a reliable alternative to sutures for vein patch angioplasty.

Nonoperative management of solid abdominal organ injuries: From past to present.

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.

Organ dysfunction and long term outcome in secondary peritonitis.

BACKGROUND AND AIMS: Secondary peritonitis is still associated with high mortality, especially when multiorgan dysfunction complicates the disease. Good prognostic tools to predict long term outcome in individual patients are lacking and therefore require further study. PATIENTS AND METHODS: 163 consecutive patients with secondary peritonitis were included, except those with postoperative or traumatic peritonitis. In 58 patients treated in the intensive care unit (ICU), organ dysfunction was quantified using Sequential Organ Failure Assessment (SOFA) score in the first 4 days. Predictive factors for poor outcome were evaluated in all patients. Hospital and 1-year mortality was assessed. RESULTS: Hospital mortality was 19% and 1-year mortality 23%. Acute physiology and chronic health evaluation II (APACHE II), previous functional status, and sepsis category were predictive of fatal outcome in the total cohort (p = 0.034, p < 0.001, and p < 0.001). In patients treated in the ICU, advanced age and admission SOFA score were independent predictors of death (p = 0.014, p < 0.0001). The SOFA score showed the best discriminative ability for poor outcome (AuROC 0.78). CONCLUSION: Degree of organ dysfunction measured using SOFA score was the best predictor of hospital mortality in patients suffering from secondary peritonitis.

The Introduction of Adult Appendicitis Score Reduced Negative Appendectomy Rate.

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.

Laparoscopic versus Open Surgery for Acute Adhesive Small-Bowel Obstruction: A Propensity Score-Matched Analysis.

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.

Perioperative Myocardial Infarction in Non-Cardiac Surgery Patients: A Prospective Observational Study.

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.

Proceedings of resources for optimal care of acute care and emergency surgery consensus summit Donegal Ireland.

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.

Erratum to: The management of intra-abdominal infections from a global perspective: 2017 WSES guidelines for management of intra-abdominal infections.

[This corrects the article DOI: 10.1186/s13017-017-0141-6.].

Patterns of injuries and motor-vehicle traffic accidents in Athens.

The extremely high cost of motor-vehicle accidents in public health leads to the necessity of a better injury data collection in the Accident and Emergency Hospital Departments. The 'Asclepeion' of Voula Hospital covers the southeastern suburban areas of the greater Athens area (1,000,000 population). The aim of this study is to present information on the pattern of injuries in Athens, in order to understand the magnitude of the problem and develop rational prevention programmes. Specially trained health visitors of the Emergency Department Injury Surveillance System (EDISS) interviewed in person every injured victim who was brought into the Emergency Service of the 'Asclepeion' of Voula Hospital. The study was performed during a 3-year period, from 1996 to 1998; 4564 persons were interviewed. Traffic accidents were more frequent on weekdays with a seasonal peak in July and among young Greeks (aged 25 - 34 years). The usual type of injuries seen in vehicle-accident victims were cerebral contusion and concussion, while in motorcycle-accident victims, head contusion and fractures. The most common reasons for the accident were excessive speed, poor condition of road, inattention, abstraction or drowsiness and drug effects. A total of 29.8% of motorcycle drivers and 5.7% of motorcycle passengers wore a helmet and 26.3% of car drivers and 14.1% of car passengers were using seatbelts. The identification of road traffic injury patterns can contribute to the development of injury prevention measures and guide rational preventive interventions that can reduce the incidence of these injuries. The EDISS system established at 'Asclepeion' of Voula Emergency Service can provide useful and accurate information about this serious and multidimensional problem of Greek Public Health.

Expanding ulnar artery aneurysm presenting with signs of threatened rupture.

The case of a 25-year-old man admitted with an ulnar artery aneurysm of the wrist is presented. The size of the aneurysm (1.5 x 2.7 cm) and progressive pain gave the impression of a threatened rupture. Radiologic examinations confirmed the existence of a non-thrombosed ulnar artery aneurysm with occlusion of the 4th and 5th digital arteries. During an urgent surgical exploration a pseudo-aneurysm was found and resected and the artery was repaired. Thrombolysis of the digital arteries was performed with a good result. The combination of a large-sized pseudo-aneurysm, lack of a history of penetrating trauma and presentation of threatened rupture are unique and not reported previously in the literature.

Simultaneous surgical treatment of abdominal aortic aneurysm and bilateral aneurysms of the internal iliac artery.

INTRODUCTION: The purpose of this study is to present our experience in the management of patients with abdominal aortic aneurysms (AAA) and aneurysms in both the internal iliac arteries (IIA) at the same time. METHODS: Between 2000 and 2005, a series of 13 patients with AAA and also aneurysms in both the IIA, were treated in our clinic. They were all men with a mean age of 74 years. The size of the IIA aneurysms (IIAA) ranged from 2.0 to 8.0 cm (mean, 3.4 cm). All patients underwent an aneurysmatectomy of the AAA and placement of a prosthetic bifurcated aorto-biiliac or -bifemoral bypass, by a transperitoneal approach. The management of one of the two IIAA was the aneurysmatectomy and the direct revascularization of the healthy peripheral portion of the remaining IIA with the ipsilateral leg of the aorto-biiliac bypass. The other IIAA was treated with proximal ligation of its neck and aneurysmorraphy. RESULTS: No patient died during the first 30 postoperative days. Morbidity was about 7.7% (one patient suffered from 'trash foot', which was treated successfully with conservative measures). Finally, the mean stay in hospital was 7 days and no patient clinically presented symptoms of pelvic or colonic ischaemia. CONCLUSIONS: Simultaneous treatment of AAA and bilateral IIA aneurysms is a technically difficult, but safe procedure, if it is performed meticulously. Revascularization of at least one internal iliac artery is strongly recommended in order to avoid dangerous complications, such as pelvic or colonic ischaemia.