Damage control surgery in non-traumatic abdominal emergencies: prognostic value of SOFA, APACHEII, and Mannheim peritonitis index.

This study aimed to analyze the prognostic value of the SOFA, APACHE II, and MPI (Mannheim Peritonitis Index) scores in the indication for Damage Control Surgery (DCS) in non-trauma. Retrospective analysis of patients undergoing DCS between 2014 and 2019. SOFA and APACHE II scores were calculated using parameters preceding DCS, while MPI was based on surgical descriptions. Statistical analysis: Qualitative variables were compared using the Chi-square test or Fisher's exact test, and quantitative variables using Pearson's correlation coefficient. The Student's T test was employed for mean comparisons. The sample comprised 104 patients (59 males), with a median age of 63.5 years, of whom 52 (50%) were ASA IV. Operative findings leading to DCS included peritonitis (54; 51.9%), intestinal ischemia (39; 37.5%), inability to close the abdomen (8; 7.6%), and bleeding (3; 2.9%). The mortality rate was 75% (78/104). Thirty patients (28.8%) died after DCS; the remainder underwent one (35; 33.6%), two (21; 20.2%); three (8; 7.7%), and four or more (10;9.7%) revision procedures. The median lengths of ICU and hospital stays were 12.5 and 20.5 days, respectively. The median score values were as follows: SOFA: 12 (0-38), APACHE II: 25 (2-47), and MPI: 26 (8-43). Besides ASA classification (p = 0.03), mortality risk was influenced by: age (≤ 65 years vs. > 65 years; p = 0.04), SOFA (≤ 10 vs. > 10; p = 0.03), APACHE II (≤ 25 vs. > 25; p = 0.04), and MPI (≤ 25 vs. > 25; p = 0.003). The SOFA, APACHE II, and MPI scores proved to be valuable tools in the prognostic assessment of patients undergoing DCS in non-traumatic abdominal emergencies.

Low-cost wound protector for laparoscopic surgeries.

The role of wound protectors in laparoscopic surgeries is highly controversial in the literature. Some studies demonstrate their benefit in reducing the rate of surgical site infections; however, these results are not reproducible across all procedures. In addition to protecting the operative wound, these devices can be used at sites of surgical specimen extraction in laparoscopic procedures. Several commercially available devices serve this purpose but are scarcely available in resource-limited settings. One of the reasons for this limitation is the cost of the device. In this technical note, we aim to provide a cost-effective option utilizing materials readily available in the operating room and with a simple fabrication process.

Quality of emergency oncological surgery: time for advanced oncological life support.

OBJECTIVE: In the emergency care of cancer patients, in addition to cancer-related factors, two aspects influence the outcome: (1) where the patient is treated and (2) who will perform the surgery. In Brazil, a significant proportion of patients with surgical oncological emergencies will be operated on in general hospitals by surgeons without training in oncological surgery. OBJECTIVE: The objective was to discuss quality indicators and propose the creation of an urgent oncological surgery advanced life support course. METHODS: Review of articles on the topic. RESULTS: Generally, nonelective resections are associated with higher rates of morbidity and mortality, as well as lower rates of cancer-specific survival. In comparison to elective procedures, the reduced number of harvested lymph nodes and the higher rate of positive margins suggest a compromised degree of radicality in the emergency scenario. CONCLUSION: Among modifiable factors is the training of the emergency surgeon. Enhancing the practice of oncological surgery in emergency settings constitutes a formidable undertaking that entails collaboration across various medical specialties and warrants endorsement and support from medical societies and educational institutions. It is time to establish a national registry encompassing oncological emergencies, develop quality indicators tailored to the national context, and foster the establishment of specialized training programs aimed at enhancing the proficiency of physicians serving in emergency services catering to cancer patients.

Surgical complications in the first and second semesters of the general surgery medical residence. A study of 14063 cases.

OBJECTIVE: To evaluate whether the rate of surgical complications is higher during the first semester of the General Surgery residency in the largest hospital complex in Latin America. During this period, students are expected to have less experience in carrying out procedures. METHODS: During a period of two years, all General Surgery resident doctors at the Hospital das Clínicas of the Faculty of Medicine of the University of São Paulo, made a notification of all the procedures they performed (n = 14.063), containing information such as name of the procedure, date, who participated, complications, among others. These data were analyzed with the purpose of evaluating the variation in the rate of complications throughout the year. RESULTS: There was a 52 % increase in the rate of complications in the first academic semester when compared to the second semester. This phenomenon was observed in resident doctors in the first and second years of residency. Furthermore, it was observed that second-year residents remain with high rates of complications, in some procedures, for a longer time than first-year residents. Furthermore, the first three months (March, April and May) seem to have the highest complication rates of the entire year. CONCLUSION: The impact of these complications can affect several health services and the increase in surgical complications in the first half of the year must be monitored by institutions, in order to control this phenomenon.

Surgical complications in the first and second semesters of the general surgery medical residence. A study of 14063 cases

Abstract Objective: To evaluate whether the rate of surgical complications is higher during the first semester of the General Surgery residency in the largest hospital complex in Latin America. During this period, students are expected to have less experience in carrying out procedures. Methods: During a period of two years, all General Surgery resident doctors at the Hospital das Clínicas of the Faculty of Medicine of the University of São Paulo, made a notification of all the procedures they performed (n = 14.063), containing information such as name of the procedure, date, who participated, complications, among others. These data were analyzed with the purpose of evaluating the variation in the rate of complications throughout the year. Results: There was a 52 % increase in the rate of complications in the first academic semester when compared to the second semester. This phenomenon was observed in resident doctors in the first and second years of residency. Furthermore, it was observed that second-year residents remain with high rates of complications, in some procedures, for a longer time than first-year residents. Furthermore, the first three months (March, April and May) seem to have the highest complication rates of the entire year. Conclusion The impact of these complications can affect several health services and the increase in surgical complications in the first half of the year must be monitored by institutions, in order to control this phenomenon.

Quality of emergency oncological surgery: time for advanced oncological life support

SUMMARY In the emergency care of cancer patients, in addition to cancer-related factors, two aspects influence the outcome: (1) where the patient is treated and (2) who will perform the surgery. In Brazil, a significant proportion of patients with surgical oncological emergencies will be operated on in general hospitals by surgeons without training in oncological surgery. OBJECTIVE: The objective was to discuss quality indicators and propose the creation of an urgent oncological surgery advanced life support course. METHODS: Review of articles on the topic. RESULTS: Generally, nonelective resections are associated with higher rates of morbidity and mortality, as well as lower rates of cancer-specific survival. In comparison to elective procedures, the reduced number of harvested lymph nodes and the higher rate of positive margins suggest a compromised degree of radicality in the emergency scenario. CONCLUSION: Among modifiable factors is the training of the emergency surgeon. Enhancing the practice of oncological surgery in emergency settings constitutes a formidable undertaking that entails collaboration across various medical specialties and warrants endorsement and support from medical societies and educational institutions. It is time to establish a national registry encompassing oncological emergencies, develop quality indicators tailored to the national context, and foster the establishment of specialized training programs aimed at enhancing the proficiency of physicians serving in emergency services catering to cancer patients.

Association of antimicrobial use and incidence of hospital-acquired pneumonia in critically ill trauma patients with pulmonary contusion: an observational study

Abstract Background: Pneumonia occurs in about 20% of trauma patients with pulmonary contusions. This study aims to evaluate the association between empirical antibiotic therapy and nosocomial pneumonia in this population. Methods: Retrospective cohort of adult patients admitted to a trauma-surgical ICU. The Antibiotic Therapy Group (ATG) was defined by intravenous antibiotic use for more than 48 h starting on hospital admission, while the Conservative Group (CG) was determined by antibiotic use no longer than 48 h. Primary outcome was microbiologically documented nosocomial pneumonia within 14 days after hospital admission. Logistic regression was used to estimate the association between group allocation and primary outcome. Exploratory analyses evaluating the association between resistant strains in pneumonia and antibiotic use were performed. Results: The study included 177 patients with chest trauma and pulmonary contusion on CTscan. ATG were more severely ill than CG, as shown by higher Injury Severity Score, SAPS3, SOFA score, higher rates, and longer duration of mechanical ventilation. In the multivariate analysis, ATG was associated with a lower incidence of primary outcome (OR = 0.25, 95% CI 0.09-0.64; p < 0.01). Similar results were found in the sensitivity analysis with another set of variables. However, each day of antibiotic use was associated with an increased risk of pneumonia by resistant bacteria (OR = 1.18 per day, 95% CI 1.05-1.36; p < 0.01). Conclusions: Empiric antibiotic therapy was independently associated with lower incidence of nosocomial pneumonia in critically ill patients with pulmonary contusion. However, each day of antibiotic use was associated with increased resistant strains in infected patients.

Impact of withholding early antibiotic therapy in nonseptic surgical patients with suspected nosocomial infection: a retrospective cohort analysis

Abstract Background: Systemic inflammatory responses mimicking infectious complications are often present in surgical patients. Methods: The objective was to assess the association between withholding early antimicrobial therapy while investigating alternative diagnoses and worse outcomes in nonseptic patients with suspected nosocomial infection in a retrospective cohort of critically ill surgical patients. The initiation of antibiotic therapy within 24 h of the suspicion of infection was defined as the Early Empirical Antibiotic strategy (EEA) group and the initiation after 24 h of suspicion or not prescribed was defined as the Conservative Antibiotic strategy (CA) group. Primary outcome was composite: death, sepsis, or septic shock within 14 days. Main exclusion criteria were sepsis or an evident source of infection at inclusion. Results: Three hundred and forty patients were eligible for inclusion (74% trauma patients). Age, sex, reason for hospital admission, SAPS3 score, SOFA score, and use of vasopressors or mechanical ventilation were not different between the groups. Within 14 days of inclusion, 100% (130/130) of EEA patients received antibiotics compared to 57% (120/210) of CA patients. After adjusting for confounding variables, there was no association between primary outcome and the groups. In a post hoc subgroup analysis including only patients with a posteriori confirmed infection (by microbiological cultures), delay in initiation of adequate antimicrobial therapy was independently associated with the primary outcome (Odds Ratio = 1.19 per day of delay; 95% CI 1.05-1.37). Conclusions: Withholding early empiric antibiotic therapy was not associated with progression of organ dysfunction within 14 days in nonseptic surgical patients with suspected nosocomial infection without an obvious source.

Low-cost wound protector for laparoscopic surgeries / Protetor de ferida operatória de baixo custo para cirurgias laparoscópicas

ABSTRACT The role of wound protectors in laparoscopic surgeries is highly controversial in the literature. Some studies demonstrate their benefit in reducing the rate of surgical site infections; however, these results are not reproducible across all procedures. In addition to protecting the operative wound, these devices can be used at sites of surgical specimen extraction in laparoscopic procedures. Several commercially available devices serve this purpose but are scarcely available in resource-limited settings. One of the reasons for this limitation is the cost of the device. In this technical note, we aim to provide a cost-effective option utilizing materials readily available in the operating room and with a simple fabrication process.

RESUMO O papel dos protetores de ferida operatória em cirurgias laparoscópicas é bastante controverso na literatura. Alguns estudos demonstram seu benefício na redução da taxa de infeções de sítio cirúrgico, porém esses resultados não são reprodutíveis em todos os procedimentos. Além da proteção da ferida operatória, esses dispositivos podem ser utilizados nos sítios de extração de peças cirúrgicas em procedimentos laparoscópicos. Há vários dispositivos comercialmente disponíveis para esse fim, entretanto são pouco disponíveis nos serviços com menos recursos. Um dos motivos dessa limitação é o custo do dispositivo. Nesta nota, buscamos oferecer uma opção barata que utiliza materiais amplamente disponíveis no centro cirúrgico e cuja confecção é simples.

Bilateral inguinal hernia repair and male fertility: a randomized clinical trial comparing Lichtenstein versus laparoscopic transabdominal preperitoneal (TAPP) technique.

BACKGROUND: The effects of hernia repair on testicular function remain uncertain, regardless of the technique used. Studies that analyze testicular volume and flow after hernia repair or hormonal measurements are scarce and show contradictory results. This study aimed to evaluate the impact of bilateral inguinal hernia repair on male fertility in surgical patients in whom the Lichtenstein and laparoscopic transabdominal preperitoneal (TAPP) techniques were used. METHODS: A randomized clinical trial comparing open (Lichtenstein) versus laparoscopic (TAPP) hernia repair using polypropylene mesh was performed in 48 adult patients (20 to 60 years old) with primary bilateral inguinal hernia. Patients were evaluated preoperatively and 90 and 180 postoperative (PO) days. Sex hormones (Testosterone, FSH, LH and SHGB) analysis, testicular ultrasonography, semen quality sexual activity changes and quality of life (QoL) were performed. Postoperative pain was evaluated using the visual analog scale (VAS). RESULTS: Thirty-seven patients with aged of 44 ± 11 years were included, 19 operated on Lichtenstein and 18 operated on TAPP. The surgical time was similar between techniques. The pain was greater in the Lichtenstein group on the 7th PO day. The biochemical and hormonal analyses, testicular ultrasonography (Doppler, testicular volume, and morphological findings) and sperm quality were similar between groups. However, the sperm morphology was better in the Lichtenstein group after 180 days (p < 0.05 vs. preoperative) and two patients who underwent Lichtenstein hernia repair had oligospermia after 180 days. The QoL evaluation showed a significant improvement after surgery in the following domains: physical function, role emotional, bodily pain and general health (p < 0.05). On comparison of Lichtenstein vs. TAPP none of the domains showed statistically significant differences. No patient reported sexual changes. CONCLUSION: Bilateral inguinal hernia repair with polypropylene mesh, whether using Lichtenstein or TAPP, does not impair male fertility in terms of long-term outcomes. TRIAL REGISTRATION: Approved by the Ethics Committee for the Analysis of Research Projects (CAPPesq) of the HC/FMUSP, Number 2.974.457, in June 2015, Registered on Plataforma Brasil in October 2015 under Protocol 45535015.4.0000.0068. Registered on Clinicaltrials.gov, NCT05799742. Enrollment of the first subject in January 2016.

Association of antimicrobial use and incidence of hospital-acquired pneumonia in critically ill trauma patients with pulmonary contusion: an observational study.

BACKGROUND: Pneumonia occurs in about 20% of trauma patients with pulmonary contusions. This study aims to evaluate the association between empirical antibiotic therapy and nosocomial pneumonia in this population. METHODS: Retrospective cohort of adult patients admitted to a trauma-surgical ICU. The Antibiotic Therapy Group (ATG) was defined by intravenous antibiotic use for more than 48 h starting on hospital admission, while the Conservative Group (CG) was determined by antibiotic use no longer than 48 h. Primary outcome was microbiologically documented nosocomial pneumonia within 14 days after hospital admission. Logistic regression was used to estimate the association between group allocation and primary outcome. Exploratory analyses evaluating the association between resistant strains in pneumonia and antibiotic use were performed. RESULTS: The study included 177 patients with chest trauma and pulmonary contusion on CT scan. ATG were more severely ill than CG, as shown by higher Injury Severity Score, SAPS3, SOFA score, higher rates, and longer duration of mechanical ventilation. In the multivariate analysis, ATG was associated with a lower incidence of primary outcome (OR = 0.25, 95% CI 0.09-0.64; p < 0.01). Similar results were found in the sensitivity analysis with another set of variables. However, each day of antibiotic use was associated with an increased risk of pneumonia by resistant bacteria (OR = 1.18 per day, 95% CI 1.05-1.36; p < 0.01). CONCLUSIONS: Empiric antibiotic therapy was independently associated with lower incidence of nosocomial pneumonia in critically ill patients with pulmonary contusion. However, each day of antibiotic use was associated with increased resistant strains in infected patients.

Multivisceral resection for retroperitoneal liposarcoma-is it worth it? A 20-year single-center experience.

PURPOSE: Soft tissue sarcomas are rare malignant tumors. Liposarcoma constitutes the most frequent histological subtype of retroperitoneal sarcoma. The prognosis of soft tissue sarcomas depends on clinical and histologic characteristics. OBJECTIVE: Evaluate variables that may be related to the overall and local recurrence-free survival in patients with retroperitoneal liposarcoma and discuss the need for visceral resection en-bloc for tumors. METHODS: A retrospective analysis was conducted of the medical records of 60 patients seen between 1997 and 2017 who underwent surgical resection of retroperitoneal liposarcoma. RESULTS: The overall survival rate at 5 years of follow-up was 75.22% (95% confidence interval [CI] 0.58-0.86). The probability of a local recurrence-free survival at 5 years of follow-up was 26.04% (95% CI 0.11-0.44). The multivariate analysis showed that dedifferentiated or pleomorphic tumors and R2/fragmented resection were associated with a shorter time to recurrence. No other characteristics markedly influenced the overall survival (P > 0.05). CONCLUSION: Patients with dedifferentiated or pleomorphic tumors and incomplete resection were associated with higher local recurrence rates than others. This study reinforces the need for complete and en-bloc resection with organs when there is clear involvement or technical surgical difficulty to maintain the tumor integrity.

Could trauma laparoscopy be the standard of care for hemodynamically stable patients? A retrospective analysis of 165 cases.

BACKGROUND: Trauma laparoscopy may provide a less invasive alternative to laparotomy by providing accurate diagnosis and minimally invasive management of selected trauma patients. The risk of missing injuries during the laparoscopic evaluation still refrains surgeons from using this approach. Our aim was to evaluate feasibility and safety of trauma laparoscopy in selected patients. METHODS: We performed a retrospective review of hemodynamically trauma patients who underwent laparoscopic management in a tertiary center in Brazil due to abdominal trauma. Patients were identified by searching through the institutional database. We collected demographic and clinical data, focusing on avoidance of exploratory laparotomy, and missed injury rate, morbidity, and length of stay. Categorical data were analyzed using Chi-square, while numerical comparisons were performed using Mann-Whitney and Kruskal-Wallis test. RESULTS: We evaluated 165 cases, of which 9.7% needed conversion to an exploratory laparotomy. One-hundred and twenty-one patients (73%) had at least one intrabdominal injury. Two missed injuries to retroperitoneal organs were identified (1.2%), of which only one was clinically relevant. Three patients died (1.8%), one of which was due to complications from an intestinal injury after conversion. No deaths were related to the laparoscopic approach. CONCLUSION: In selected hemodynamically stable trauma patients, the laparoscopic approach is feasible and safe, and reduces the need for exploratory laparotomy and its associated complications.

Challenges to implement laparoscopic appendectomy as the first-line treatment for acute appendicitis: a fifteen-year experience in a tertiary hospital in Brazil.

BACKGROUND: the barriers to implement emergency laparoscopy in public teaching hospitals involve issues such as resident learning curves and resource costs and availability. This study was designed to describe the issues facing the implementation of laparoscopic approach for acute appendicitis over 15 years in a single academic center in Brazil. MATERIALS AND METHODS: retrospective study of patients undergoing emergency appendectomy from 2004 to 2018. Clinical data were compared to four major actions implemented in the emergency surgical service: minimally invasive surgery training for residents (2007), laparoscopic stump closure using metal clips (2008), 24/7 availability of laparoscopic instruments for emergency surgeries (2010), and third-party contract for maintenance of the laparoscopic instruments and implementation of polymeric clips for stump closure (2013). We evaluated the increase in laparoscopic appendectomy after the implementation of those major changes. RESULTS: we identified 1168 appendectomies during the study period, of which 691 (59%), 465 (40%), and 12 (1%) were open, laparoscopic, and converted, respectively. The implementation of the major changes since 2004 resulted in an increase of laparoscopic appendectomies from 11% in 2007 to 80% in 2016. These actions were decisive in the widespread use of laparoscopy for acute appendicitis (p<0.001). The standardization of the hem-o-lok clip in the treatment of the appendiceal stump made the procedure more feasible, reducing the surgical time using laparoscopic access and increasing the team's adherence, so that this became the route of choice in about 85% of cases in the period from 2014 to 2018, 80% performed by 3rd year resident physicians. No intraoperative complications were noted related to laparoscopic access, even in more complicated appendicitis. There was no mortality reported, no reoperations or readmissions to hospital during a 30-day postoperative period. CONCLUSION: the development of a feasible, reproducible, and safe technical standardization, associated with continuous cost optimization, are the cornerstones for a consistent and viable change in the current practice for appendectomies in middle and lower-income countries.

Impact of withholding early antibiotic therapy in nonseptic surgical patients with suspected nosocomial infection: a retrospective cohort analysis.

BACKGROUND: Systemic inflammatory responses mimicking infectious complications are often present in surgical patients. METHODS: The objective was to assess the association between withholding early antimicrobial therapy while investigating alternative diagnoses and worse outcomes in nonseptic patients with suspected nosocomial infection in a retrospective cohort of critically ill surgical patients. The initiation of antibiotic therapy within 24 h of the suspicion of infection was defined as the Early Empirical Antibiotic strategy (EEA) group and the initiation after 24 h of suspicion or not prescribed was defined as the Conservative Antibiotic strategy (CA) group. Primary outcome was composite: death, sepsis, or septic shock within 14 days. Main exclusion criteria were sepsis or an evident source of infection at inclusion. RESULTS: Three hundred and forty patients were eligible for inclusion (74% trauma patients). Age, sex, reason for hospital admission, SAPS3 score, SOFA score, and use of vasopressors or mechanical ventilation were not different between the groups. Within 14 days of inclusion, 100% (130/130) of EEA patients received antibiotics compared to 57% (120/210) of CA patients. After adjusting for confounding variables, there was no association between primary outcome and the groups. In a post hoc subgroup analysis including only patients with a posteriori confirmed infection (by microbiological cultures), delay in initiation of adequate antimicrobial therapy was independently associated with the primary outcome (Odds Ratio = 1.19 per day of delay; 95% CI 1.05-1.37). CONCLUSIONS: Withholding early empiric antibiotic therapy was not associated with progression of organ dysfunction within 14 days in nonseptic surgical patients with suspected nosocomial infection without an obvious source.

Symptomatic uterine leiomyomatosis with intracaval and intracardiac invasion: Video case report.

Background: Fibroid is the most prevalent benign tumor of the female genital tract. Intravenous and intracardiac leiomyomatosis (IVL and ICLM, respectively) are rare complications that present with symptoms of pulmonary thromboembolism and heart failure and whose etiology, despite controversial, is a direct vascular invasion by a primary uterine leiomyoma. Case presentation: We present the case of a 31-year-old female patient with a previous history of pelvic pain and dysmenorrhea, whose ultrasound showed an enlarged and heterogeneous uterus. Complete hysterectomy was performed, and the anatomopathological examination showed leiomyomas without evidence of malignancy. One month later, the patient manifested dyspnea and chest pain. A neoplastic thrombus was identified, extending from the inferior vena cava to the right atrium, for which we proceeded with cavo-atrial thrombectomy under Normothermic Cardiopulmonary Bypass (CPB) with Warm Blood Cardioplegia (WBC). A metastatic lung injury of non-malignant histology was also detected. Discussion: Uterine leiomyoma is a very common benign tumor of the female genital tract. IVL with ICLM are rare and difficult-to-treat complications, whose etiology is a direct vascular invasion by a primary uterine leiomyoma, although it is still controversial. The incidence of ICLM is 10 to 30% of IVL cases. The main symptoms of ICLM are dyspnea, syncope, edema of the lower extremities and palpitations. Treatment is based on complete surgical removal of the tumor thrombus. Studies demonstrated that the one-stage procedure is safer from the patient's perspective and that CPB with WBC reduced intraoperative blood loss and total operative time, ensuring a less traumatic postoperative. Conclusions: Most patients with uterine leiomyoma are asymptomatic and acute complications are rare. In ICLM clinical manifestations are related to heart failure and flow obstruction. Because of the severity of the condition and the curative potential of treatment, surgery is morbid but highly recommended. The use of CPB with WBC improved the postoperative period and increased the patient's quality of life.