Safety, Efficacy, and Cost-effectiveness of Outpatient Surgery for Uncomplicated Acute Appendicitis: The PENDI-CSI Randomized Clinical Trial.

OBJECTIVE: To evaluate the safety, efficacy, and cost-effectiveness of outpatient appendectomy in patients with uncomplicated acute appendicitis. BACKGROUND: Given that acute appendicitis is the most common cause of acute abdomen, the introduction of outpatient appendectomy protocols could significantly improve the effectiveness and sustainability of health care systems. METHODS: A total of 300 patients were enrolled from October 2018 to June 2021 in the PENDI-CSI randomized clinical trial: 149 were assigned to the outpatient surgery (OPS) group and 151 to the inpatient surgery (IPS) group, followed by 1 month postoperatively. All patients were aged older than 14 years and had uncomplicated acute appendicitis. Exclusion criteria were pregnancy, neoplasms, inflammatory bowel disease, and high anesthetic risk (ASA IV). The OPS group was discharged from the postanesthesia care unit while the IPS group was admitted. RESULTS: In total, 128 patients in the OPS group (85.9%) were discharged without admission. Predictors whether patients in the OPS group had to be admitted were aged over 31 years [relative risk (RR): 2.42 (1.04-5.65)], hypertension [RR: 6.21 (3.22-11.97)], anesthetic risk II-III [RR: 2.63 (1.17-5.94)], previous abdominal surgery [RR: 3.34 (1.55-7.20)], postoperative pain with visual analog scale >6 [RR: 4.28 (2.67-6.86)], and postoperative fear [RR: 2.2 (1.04-4.67)]. There were no differences in terms of complications, readmissions, and reinterventions, and the perceived quality was similar in both groups. The outpatient modality produced savings of €1 034.97 per patient ( P < 0.001). CONCLUSIONS: Outpatient appendectomy is safe and effective for uncomplicated acute appendicitis. Patient-perceived quality is similar to that of IPS, although it successfully reduces hospital costs compared with inpatient appendectomy.

Personalized additive manufacturing of devices for the management of enteroatmospheric fistulas.

Additive manufacturing techniques allow the customized design of medical devices according to the patient's requirements. Enteroatmospheric fistula is a pathology that benefits from this personalization due to its extensive clinical variability since the size and morphology of the wound differ extensively among patients. Standard prosthetics do not achieve proper isolation of the wound, leading to a higher risk of infections. Currently, no effective personalized technique to isolate it has been described. In this work, we present the workflow for the design and manufacture of customized devices adapted to the fistula characteristics as it evolves and changes during the treatment with Negative Pressure Wound Therapy (NPWT). For each case, a device was designed with dimensions and morphology depending on each patient's requirements using white light scanning, CAD design, and additive manufacturing. The design and manufacture of the devices were performed in 230.50 min (184.00-304.75). After the placement of the device, the wound was successfully isolated from the intestinal content for 48-72 h. The therapy was applied for 27.71 ± 13.74 days, and the device was redesigned to adapt to the wound when geometrical evolutionary changes occur during the therapy. It was observed a decrease in weekly cures from 23.63 ± 10.54 to 2.69 ± 0.65 (p = 0.001). The fistulose size was reduced longitudinal and transversally by 3.25 ± 2.56 cm and 6.06 ± 3.14 cm, respectively. The wound depth also decreased by 1.94 ± 1.08 cm. In conclusion, customization through additive manufacturing is feasible and offers promising results in the generation of personalized devices for the treatment of enteroatmospheric fistula.

Long-term influence of frailty in elderly patients after surgical emergencies.

PURPOSE: Frailty is known to increase vulnerability to stressful factors, and motivate a higher morbidity and mortality in several health conditions. However, long-term impact of frailty after surgical procedures remains unclear. The purpose of this study was to evaluate the relationship between frailty and long-term clinical outcomes after emergency surgery. METHODS: Prospective cohort study in patients older than 70 years undergoing emergency procedures. A total of 82 patients (mean age 78.5 years, 53.3% women) were consecutively enrolled. Data on demographics, surgical procedures, complications after 30 postoperative days, and frailty according to the clinical frailty scale, Triage Risk Screening Tool (TRST), and FRAIL scale were recorded. Readmission, mortality, and transition to frailty rates were analyzed at 6 and 18 months postoperatively. RESULTS: The prevalence of frailty ranged between 14.6 and 29.6% depending on the scale used. The overall mortality rate at 18 months was 19.5% (16 patients), and the survival curves demonstrated a significant difference in mortality between frail and non-frail patients assessed using the FRAIL scale and TRST (p = 0.049 and p = 0.033, respectively), with a hazard ratio of 2.28 (95% confidence interval 1.24-6.44). Logistic regression analysis showed that diabetes (p = 0.013) was an independent risk factor for transition to frailty, and antidepressant drug use was close to statistical significance (p = 0.08). CONCLUSION: Frailty is a predictive marker of long-term mortality in patients undergoing emergency procedures. Diabetes and depression may represent independent risk factors for transition to frailty over time.

Are Spanish surgeons prepared to treat trauma patients? Multicentre descriptive observational study.

PURPOSE: Specific training in the management of trauma patients is beneficial for surgeons. Training through specific courses in this area has a direct impact on the care of these patients. The aim of this work is to understand the participation and specific training in the care of trauma patients by Spanish surgeons. METHODS: A national survey was conducted and administered to all members of the Spanish Association of Surgeons. The survey assessed their degree of participation in emergency surgery, and therefore the probability of attending trauma patients, their assessment of the initial care of trauma patients in their centre, and their specific training in this field. RESULTS: The survey was completed by 510 surgeons from 47 Spanish provinces, with Catalonia and Andalusia being the most represented regions. In total, 456 (89.41%) of those surveyed work in the emergency department on a routine basis. Only 171 (33.53%) refer to having a registry of trauma patients in their hospital. While 79.02% of surgeons reported that general surgeons are not involved in care of severe trauma from the outset, only 66.47% have completed the ATLS course, 40.78% the DSTC course and 18.82% the MUSEC course. Despite this, 85.69% believe that the ATLS course should be compulsory during residency and 43.33% believe that severe trauma care in their hospital is poor or very poor. CONCLUSION: Only 40% have received specific training in definitive surgical management of severe trauma. Despite this, a large percentage of surgeons work in the emergency department on a routine basis and potentially face the challenge of managing these patients.

Is the use of endoloops safe and efficient for the closure of the appendicular stump in complicated and uncomplicated acute appendicitis?

INTRODUCTION: There is still controversy regarding the ideal technique to close the appendicular stump in laparoscopic appendectomy (LA). The objective of this study was to determine the safety and efficiency of the use of an endoloop (EL) and endostapler (ES) in complicated and uncomplicated acute appendicitis. METHODS: Retrospective cohort study of patients undergoing LA from February 2013 to December 2019. Acute uncomplicated and complicated appendicitis were analysed separately, establishing two groups according to the stump closure technique: EL or ES. Seven hundred-nine patients were included (535 uncomplicated and 174 complicated). In uncomplicated appendicitis, an EL was used in 447 of the patients (83.55%) and an ES was used in 88 patients (16.45%). In complicated appendicitis, an EL was used in 85 patients (48.85%) and an ES was used in 89 patients (51.15%). An analysis of effectiveness and a cost analysis of each technique were performed. RESULTS: In uncomplicated appendicitis, we found no differences with respect to global complications, although there were significant differences in the total mean hospital stay (EL group 1.55 (SD 1.48) days; ES group 2.21 (SD 1.69) days; p = 0.046). This meant a savings of 514.12€ per patient using the EL p < 0.001). In complicated appendicitis, the reoperations classified as Clavien-Dindo IIIB in the EL group (6.4%) were greater than in the ES group (0%) (p = 0.012), although the rate of postoperative abscesses (p = 0.788) and the mean volume of abscesses (p = 0.891) were similar. CONCLUSION: The systematic use of an EL could reduce costs in uncomplicated appendicitis, while in complicated cases, both options are valid. Prospective studies with a greater number of patients are needed to observe differences in postoperative complications.

Análisis de los resultados en seguridad de pacientes y profesionales durante la pandemia COVID-19 en el contexto de la cirugía urgente / Analysis of the safety of patients and professionals during the COVID-19 pandemic in the context of emergency surgery

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Using a bio-scanner and 3D printing to create an innovative custom made approach for the management of complex entero-atmospheric fistulas.

Enteroatmospheric fistulae are challenging clinical conditions that require surgical expertise and that can result in chronic debilitating conditions placing the patient in a vicious cycle characterized by non healing wounds and malnutrition. They are a complex entity that presents great variability depending on the number, shape, and size of the fistulous orifices, their debit, and the dimensions of the wound. This means that, at present, there is no device that adapts to the anatomical characteristics of each patient and manages to control the spillage of intestinal effluvium from the wound. The aim of this study is to describe the manufacturing technique and to assess the preliminary results of a custom device designed through bioscanner imaging and manufactured using 3D printing for use with negative pressure wound therapy (NPWT) in the management of enteroatmospheric fistula. A proof of concept is given, and the design of the device is presented for the first time. After obtaining images of each fistula with a bioscanner, a personalised device was designed for each patient by 3D printing shape of a prism and a hollow base, taking into account the dimensions of the fistulous area in order to perform a floating ostomy to isolate the wound from the debit enteric. The polycaprolactone (PCL) device was placed including inside the fistulous surface and surrounding it with the NPWT system in order to accelerate wound healing.

Atención de la urgencia quirúrgica durante la pandemia COVID-19. Recomendaciones de la Asociación Española de Cirujanos / Emergency Surgery and Trauma Care During COVID-19 Pandemic. Recommendations of the Spanish Association of Surgeons

La infección por el nuevo coronavirus SARS-CoV-2 (enfermedad por coronavirus 2019 [COVID-19]) ha determinado la necesidad de la reorganización de muchos centros hospitalarios en el mundo. España, como uno de los epicentros de la enfermedad, ha debido asumir cambios en la práctica totalidad de su territorio. Sin embargo, y desde el inicio de la pandemia, en todos los centros que atienden urgencias quirúrgicas ha sido necesario el mantenimiento de su cobertura, aunque igualmente ha sido inevitable introducir directrices especiales de ajuste al nuevo escenario que permitan el mantenimiento de la excelencia en la calidad asistencial. Este documento desarrolla una serie de indicaciones generales para la cirugía de urgencias y la atención al politraumatizado desarrolladas desde la literatura disponible y consensuadas por un subgrupo de profesionales desde el grupo general Cirugía-AEC-COVID-19. Estas medidas van encaminadas a contemplar un riguroso control de la exposición en pacientes y profesionales, a tener en cuenta las implicaciones de la pandemia sobre diferentes escenarios perioperatorios relacionados con la urgencia y a una adaptación ajustada a la situación del centro en relación con la atención a pacientes infectados

New coronavirus SARS-CoV-2 infection (coronavirus disease 2019 [COVID-19]) has determined the necessity of reorganization in many centers all over the world. Spain, as an epicenter of the disease, has been forced to assume health policy changes in all the territory. However, and from the beginning of the pandemic, every center attending surgical urgencies had to guarantee the continuous coverage adopting correct measures to maintain the excellence of quality of care. This document resumes general guidelines for emergency surgery and trauma care, obtained from the available bibliography and evaluated by a subgroup of professionals designated from the general group of investigators Cirugía-AEC-COVID-19 from the Spanish Association of Surgeons, directed to minimize professional exposure, to contemplate pandemic implications over different urgent perioperative scenarios and to adjust decision making to the occupational pressure caused by COVID-19 patients

Respuesta a «Resultados en el tratamiento de traumatismos esplénicos utilizando un protocolo multidisciplinar en 110 pacientes consecutivos en un hospital de nivel II» / Response to «Management of splenic injuries utilizing a multidisciplinary protocol in 110 consecutive patients at a level II hospital»

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Emergency surgery and trauma care during COVID-19 pandemic. Recommendations of the Spanish Association of Surgeons / Atención de la urgencia quirúrgica durante la pandemia COVID-19. Recomendaciones de la Asociación Española de Cirujanos

New coronavirus SARS-CoV-2 infection (coronavirus disease 2019 [COVID-19]) has determined the necessity of reorganization in many centers all over the world. Spain, as an epicenter of the disease, has been forced to assume health policy changes in all the territory. However, and from the beginning of the pandemic, every center attending surgical urgencies had to guarantee the continuous coverage adopting correct measures to maintain the excellence of quality of care. This document resumes general guidelines for emergency surgery and trauma care, obtained from the available bibliography and evaluated by a subgroup of professionals designated from the general group of investigators Cirugía-AEC-COVID-19 from the Spanish Association of Surgeons, directed to minimize professional exposure, to contemplate pandemic implications over different urgent perioperative scenarios and to adjust decision making to the occupational pressure caused by COVID-19 patients

La infección por el nuevo coronavirus SARS-COV-2 (enfermedad por coronavirus 2019 [COVID-19]) ha determinado la necesidad de la reorganización de muchos centros hospitalarios en el mundo. España, como uno de los epicentros de la enfermedad, ha debido asumir cambios en la práctica totalidad de su territorio. Sin embargo, y desde el inicio de la pandemia, en todos los centros que atienden urgencias quirúrgicas ha sido necesario el mantenimiento de su cobertura, aunque igualmente ha sido inevitable introducir directrices especiales de ajuste al nuevo escenario que permitan el mantenimiento de la excelencia en la calidad asistencial. Este documento desarrolla una serie de indicaciones generales para la cirugía de urgencias y la atención al politraumatizado desarrolladas desde la literatura disponible y consensuadas por un subgrupo de profesionales desde el grupo general Cirugía-AEC-COVID-19. Estas medidas van encaminadas a contemplar un riguroso control de la exposición en pacientes y profesionales, a tener en cuenta las implicaciones de la pandemia sobre diferentes escenarios perioperatorios relacionados con la urgencia y a una adaptación ajustada a la situación del centro en relación con la atención a pacientes infectados

Early implementation of protective measures defines surgical outcomes in the COVID-19 pandemic.

Quick implementation of specific protocols and protective measures in a tertiary hospital in Spain allowed for the early diagnosis and optimal management of patients with SARS-CoV-2 infection and proper protection of staff and inpatients. From the COVID-19 outbreak in this country until the time of writing, 14 patients in our hospital underwent surgery with COVID-19, or COVID-19 developed postoperatively. Their postoperative outcomes did not differ from those in our routine clinical practice, with a 0% respiratory failure rate and a 7.14% mortality rate, in contrast with other published series. COVID-19 did not develop in any of the healthcare workers present in the operating room during these procedures or in those who cared for these patients on the ward.

[Emergency Surgery and Trauma Care During COVID-19 Pandemic. Recommendations of the Spanish Association of Surgeons]. / Atención de la urgencia quirúrgica durante la pandemia COVID-19. Recomendaciones de la Asociación Española de Cirujanos.

New coronavirus SARS-CoV-2 infection (coronavirus disease 2019 [COVID-19]) has determined the necessity of reorganization in many centers all over the world. Spain, as an epicenter of the disease, has been forced to assume health policy changes in all the territory. However, and from the beginning of the pandemic, every center attending surgical urgencies had to guarantee the continuous coverage adopting correct measures to maintain the excellence of quality of care. This document resumes general guidelines for emergency surgery and trauma care, obtained from the available bibliography and evaluated by a subgroup of professionals designated from the general group of investigators Cirugía-AEC-COVID-19 from the Spanish Association of Surgeons, directed to minimize professional exposure, to contemplate pandemic implications over different urgent perioperative scenarios and to adjust decision making to the occupational pressure caused by COVID-19 patients.

El modelo Acute Care Surgery en el mundo y la necesidad e implantación de unidades de trauma y cirugía de urgencia en España / The Acute Care Surgery model in the world, and the need for and implementation of trauma and emergency surgery units in Spain

El modelo Acute Care Surgery agrupa bajo una misma disciplina el trauma, la cirugía de urgencias y los cuidados intensivos posquirúrgicos. Concebido y extendido durante las 2 últimas décadas por territorio norteamericano, la magnitud e idiosincrasia clínica de la urgencia quirúrgica han hecho que este modelo se haya asumido en muchos otros puntos de la geografía mundial. En nuestro país, el reflejo ha sido la creación e implantación de las denominadas unidades de trauma y cirugía de urgencias, cuyos objetivos son comunes a las publicadas para el modelo original: evitar la nocturnidad en las urgencias quirúrgicas, liberar a los profesionales vinculados a la cirugía electiva en horario laboral y convertirse en el eslabón y referente perfectos de la continuidad asistencial. En el presente artículo se resumen el nacimiento y la expansión del modelo original, la evidencia aportada en cuanto a resultados y la situación actual en nuestro país

The Acute Care Surgery model groups trauma and emergency surgery with surgical critical care. Conceived and extended during the last 2 decades throughout North America, the magnitude and clinical idiosyncrasy of emergency general surgery have determined that this model has been expanded to other parts of the world. In our country, this has led to the introduction and implementation of the so-called trauma and emergency surgery units, with common objectives as those previously published for the original model: to decrease the rates of emergency surgery at night, to allow surgeons linked to elective surgery to develop their activity in their own disciplines during the daily schedule, and to become the perfect link and reference for the continuity of care. This review summarizes how the original model was born and how it expanded throughout the world, providing evidence in terms of results and a description of the current situation in our country