Disease In Surgical Patients Research Articles

Cerebrovascular Disease in Surgical Patients

It is well established that patients with a personal history of a cerebrovascular accident (stroke or transient ischemic attack) are at increased risk for perioperative cardiovascular complications, including recurrent stroke. Although the individual patient risk for perioperative stroke is typically low, the overall prevalence is significant, appears to be increasing, and has the potential for devastating complications including death. The perioperative provider must not only be knowledgeable of the elevated risk for patients with a history of stroke undergoing surgery, but also be familiar with perioperative risk reduction strategies. This article provides a general overview of cerebrovascular disease in surgical patients with much of the content being presented at the 2023 Perioperative Medicine Summit in Orlando, Florida.

Алгоритм діагностики поєднаної хірургічної патології у пацієнтів із захворюваннями ендокринної системи

Актуальність. Кожні 2 роки частота випадків ендокринної патології зростає на 23–30 %. Під час діагностичного пошуку у 25–30 % пацієнтів з патологією ендокринних органів виявляється 2–4 поєднаних хірургічних захворювання. Кількість симультанних оперативних втручань у цієї групи пацієнтів залишається на рівні 1,5–6 %. Мета дослідження. Розробити діагностичний алгоритм для виявлення поєднаних хірургічних захворювань у хворих з патологією ендокринної системи. Матеріали та методи. Проведено аналіз 764 історій хвороби пацієнтів з ендокринною патологією, яким були виконані оперативні втручання в період з 2012 по 2016 рік на базі КЗ «Міська клінічна лікарня екстреної та швидкої медичної допомоги м. Запоріжжя» та Запорізької обласної клінічної лікарні. Результати. Проведений аналіз результатів лікування даної групи пацієнтів показав, що виконання симультанних операцій у хворих з поєднаною хірургічною патологією складає 5,5 %. Висновки. Незначна кількість виконаних симультанних оперативних втручань у хворих з ендокринною патологією обумовлена низьким виявленням поєднаних хірургічних захворювань, що пов’язано з недостатнім обстеженням пацієнтів в передопераційному періоді. Для своєчасної і повної діагностики поєднаної хірургічної патології у хворих із захворюваннями ендокринної системи необхідно розширити стандартні протоколи обстеження пацієнтів та впровадити широке застосування додаткових методів обстеження. Запропонований нами алгоритм обстеження хворих з патологією органів ендокринної системи дозволить своєчасно діагностувати поєднану хірургічну патологію.

SARS-CoV-2 infection is not associated with a higher rate of post-operative complications in adult appendectomy patients in Peru: Cross-sectional study

BackgroundWe present outcomes of patients with SARS-CoV-2 undergoing appendectomy in order to aid in clarification of current controversies regarding safety of therapeutic options for emergency surgical diseases in patients with SARS-CoV-2. Peru has the greatest number of per capita deaths due to SARS-CoV-2 of any country and is one of few with a COVID-dedicated hospital. Materials and methodsThis prospective observational study included all adult patients with acute appendicitis admitted to an urban, public, COVID-dedicated hospital over two months. Baseline characteristics and post-operative outcomes at 28 days are reported. Results58 patients, 35 male and 23 female, ages 15–73 years with SARS-CoV-2 as diagnosed by IgM (12%), IgG (19%) or both (69%) and acute appendicitis as diagnosed using the Alvarado Score and confirmed intraoperatively were enrolled. All patients presented with right lower quadrant pain, 86% with leukocytosis, 88% with nausea/emesis and no patients with respiratory complaints. All patients underwent open appendectomy, 90% under regional anesthesia. Average operative time was 54±25 min, length of stay 2.5±1.5 days. 14% of patients had a post-operative complication, all were minor, four (7%) incisional surgical site infections, one (2%) organ space, and three (5%) incisional seromas, no deaths or serious complications. ConclusionOpen surgical management of acute appendicitis with regional anesthesia in adults with pre-operative diagnosis of SARS-CoV-2 is feasible and not associated with an increased frequency or severity of post-operative complications, longer operative time, or extended hospitalization as compared to reports in similar patients without SARS-CoV-2.

Performance of a Four-Antigen Staphylococcus aureus Vaccine in Preclinical Models of Invasive S. aureus Disease.

A Staphylococcus aureus four-antigen vaccine (SA4Ag) was designed for the prevention of invasive disease in surgical patients. The vaccine is composed of capsular polysaccharide type 5 and type 8 CRM197 conjugates, a clumping factor A mutant (Y338A-ClfA) and manganese transporter subunit C (MntC). S. aureus pathogenicity is characterized by an ability to rapidly adapt to the host environment during infection, which can progress from a local infection to sepsis and invasion of distant organs. To test the protective capacity of the SA4Ag vaccine against progressive disease stages of an invasive S. aureus infection, a deep tissue infection mouse model, a bacteremia mouse model, a pyelonephritis model, and a rat model of infectious endocarditis were utilized. SA4Ag vaccination significantly reduced the bacterial burden in deep tissue infection, in bacteremia, and in the pyelonephritis model. Complete prevention of infection was demonstrated in a clinically relevant endocarditis model. Unfortunately, these positive preclinical findings with SA4Ag did not prove the clinical utility of SA4Ag in the prevention of surgery-associated invasive S. aureus infection.

Incidence, features, outcome and impact on health system of de-novo abdominal surgical diseases in patients admitted with COVID-19

Objectiveto assess the epidemiology and features of de novo surgical diseases in patients admitted with COVID-19, and their impact on patients and healthcare system. Summary background dataGastrointestinal involvement has been described in COVID-19; however, no clear figures of incidence, epidemiology and economic impact exist for de-novo surgical diseases in hospitalized patients. MethodsThis is a prospective study including all patients admitted with confirmed SARS-CoV-2 rT-PCR, between 1 March and 15 May 2020 at two Tertiary Hospitals. Patients with known surgical disease at admission were excluded. Sub-analyses were performed with a consecutive group of COVID-19 patients admitted during the study period, who did not require surgical consultation. ResultsTen out of 3089 COVID-19 positive patients (0.32%) required surgical consultation. Among those admitted in intensive care unit (ICU) incidence was 1.9%. Mortality was 40% in patients requiring immediate surgery and 20% in those suitable for conservative management. The overall median length of stay (LOS) of patients admitted to ICU was longer in those requiring surgical consultation compared with those who did not (51.5 vs 25 days, p = 0.0042). Patients requiring surgical consultation and treatment for de-novo surgical disease had longer median ICU-LOS (31.5 vs 12 days, p = 0.0004). A median of two post-surgical complications were registered for each patient undergoing surgery. Complication-associated costs were as high as 38,962 USD per patient. ConclusionsIncidence of de-novo surgical diseases is low in COVID-19, but it is associated with significant morbidity and mortality. Future studies should elucidate the mechanism underlying the condition and identify strategies to prevent the need for surgery.

Diagnosis and treatment of acute surgical diseases in patients with COVID-19

Экстренная хирургическая помощь в условиях инфекционного стационара — актуальная проблема во время пандемии новой коронавирусной инфекции COVID-19. Городская клиническая больница № 15 имени О. М. Филатова оказывает экстренную хирургическую помощь в условиях перепрофилирования с 27 марта 2020 г. по настоящее время. Специалистами больницы накоплен большой практический опыт: в апреле 2020 г. выполнено 194, а в мае — 289 оперативных пособий. В статье представлен опыт работы экстренной хирургической службы на этапе перепрофилирования в инфекционный стационар. Среди всех госпитализированных пациентов 482 (5,29%) имели острую хирургическую патологию, потребовавшую экстренного оперативного вмешательства. У 472 (98%) экстренно прооперированных пациентов присутствовала вызванная COVID-19 внебольничная пневмония разной степени тяжести. В статье рассмотрены некоторые особенности острой хирургической патологии и осложнения, встречающиеся у пациентов с COVID-19. Особенности хирургической помощи в перепрофилированном стационаре — это строгое соблюдение эпидемиологического режима, минимизация численности персонала в операционной, возможная минимизация числа оперативных пособий и сокращение их длительности. Наиболее важной задачей в условиях пандемии COVID-19 является безопасность персонала.

Diagnosis and treatment of acute surgical diseases in patients with COVID-19

Emergency surgery in the infectious diseases hospital is an urgent problem during the COVID-19 pandemic. Municipal Clinical Hospital No.15 named after O. M. Filatov has been providing emergency surgical care after conversion, from March 27, 2020 until now. The hospital’s medical staff has built up extensive experience: 194 surgical procedures were carried out in April, and 289 surgical procedures were carried out in May 2020. The paper reports the experience of emergency surgery at the stage of conversion to an infectious diseases hospital. Among all hospitalized patients, 482 (5.29%) people had acute surgical pathology requiring emergency surgery. Among patients who underwent urgent surgery, 472 (98%) people had the caused by COVID-19 community-acquired pneumonia of various degrees of severity. The paper discusses some features of acute surgical pathology and complications identified in patients with COVID-19. The surgical care features in the hospital after conversion are proper epidemiological regime implementation, minimization of the number of staff in the operating room, possible minimization of the number and reduction of the duration of surgical procedures. The most important challenge during the COVID-19 pandemic is medical staff safety.

Determination of Treatment Policy for Acute Surgical Disease of the Abdominal Cavity and Retroperitoneal Space in Patients with Late-Stage HIV Infection According to Multislice Computed Tomography and Magnetic Resonance Imaging Data

Objective: to determine treatment policy for an acute surgical disease in patients with late-stage HIV infection diagnosed using the data of the highly informative imaging techniques multislice computed tomography (MSCT) and magnetic resonance imaging (MRI). Material and methods. In 2008 and 2016, the authors examined 425 patients (320 men and 105 women) with acquired immunodeficiency syndrome (AIDS) who were treated at the surgical units of the Surgut Regional Clinical Hospital, by using the data of MSCT (Toshiba Aquilion 64, Japan) and MRI (Siemens 1,5T Magnetom Essenza, Germany) in identifying both local surgical and general mixed diseases.Results. Analysis of acute surgical diseases of the abdominal cavity and retroperitoneal space in patients with late-stage HIV infection determined that the treatment policy in this category of patients depended on clinical diagnostic data.Conclusions. 1. MSCT and MRI are highly informative techniques in diagnosing acute surgical diseases in patients with late-stage HIV infection. 2. The course of an acute surgical disease in patients with late-stage HIV infection in the presence of generalized opportunistic infection makes it preferable to perform minimally invasive surgical interventions.

Detecting Invasive Fungal Disease in Surgical Patients: Utility of the (13)- β-d-Glucan Assay.

Background: The specificity and sensitivity of the (13)-β-d-glucan (BDG) assay in surgical patients needs further investigation. We hypothesized that the BDG assay would have lower sensitivity/specificity compared with that of medical patients. Methods: We reviewed patients who had undergone laparotomy, gastrectomy, hepatectomy, or colectomy and had a BDG assay post-operatively. Results: A total of 71 patients met study criteria. There were 29 (40.8%) who had proven/probable invasive fungal infection. Sensitivity for BDG level ≥80 diagnosed within one week of the assay draw was 77.3% (95% confidence interval [CI], 54.6-92.2%), and specificity was 44.9% (95% CI, 30.7-59.8). The positive predictive value was 38.6% (95% CI, 31.0-46.9%), and negative predictive value was 82.5% (95% CI, 65.7-91.0%). A BDG assay result of 149 pg/mL had a classification rate of 63.4%. Therefore, a BDG assay result ≥150 pg/mL has a sensitivity of 78.6% and a specificity of 41.4%. Conclusion: A BDG assay can be useful for ruling out invasive fungemia in post-operative patients.

Laparoscopic cholecystectomy in a patient with situs inversus totalis

Situs inversus totalis (SIT) is a rare congenital anomaly, in which both the thoracic and the abdominal viscera are transposed to the opposite side of the body. The diagnosis of surgical diseases in patients with SIT is often delayed, leading to complications. Surgery in these patients has been reported to be more challenging for right-handed surgeons. We herein present a case of a 30-year-old woman, not known to have SIT, with a history of intermittent left upper quadrant pain related to food for more than a year. After clinical examination, chest X-ray, and abdominal ultrasound, she was diagnosed with SIT and chronic cholecystitis, and underwent laparoscopic cholecystectomy performed by a right-handed surgeon. We believe that this case report will be informative for surgeons in managing chronic cholecystitis in patients with SIT, and for physicians to always look for clues for SIT in patients presenting with abdominal pain.

Combined quantification of procalcitonin and HLA-DR improves sepsis detection in surgical patients

Early recognition of sepsis is a key factor to improve survival to this disease in surgical patients, since it allows prompt control of the infectious source. Combining pro-inflammatory and immunosupression biomarkers could represent a good strategy to improve sepsis detection. Here we evaluated the combination of procalcitonin (PCT) with gene expression levels of HLA-DRA to detect sepsis in a cohort of 154 surgical patients (101 with sepsis and 53 with no infection). HLA-DRA expression was quantified using droplet digital PCR, a next-generation PCR technology. Area under the receiver operating curve analysis (AUROC) showed that the PCT/HLA-DRA ratio outperformed PCT to detect sepsis (AUROC [CI95%], p): PCT: 0.80 [0.73–0.88], <0.001; PCT/HLA-DRA: 0.85 [0.78–0.91], <0.001. In the multivariate analysis, the ratio showed a superior ability to predict sepsis compared to that of PCT (OR [CI 95%], p): PCT/HLA-DRA: 7.66 [1.82–32.29], 0.006; PCT: 4.21 [1.15–15.43] 0.030. Multivariate analysis was confirmed using a new surgical cohort with 74 sepsis patients and 21 controls: PCT/HLA-DRA: 34.86 [1.22–995.08], 0.038; PCT: 5.52 [0.40–75.78], 0.201. In conclusion, the combination of PCT with HLA-DRA is a promising strategy for improving sepsis detection in surgical patients.

Preoperative Gastroesophageal Reflux Disorder Is Associated With Increased Morbidity in Patients Undergoing Abdominal Surgery

BackgroundIn North America, the prevalence of gastroesophageal reflux disorder ranges from 18.1% to 27.8%. We measured the risk posed by preoperative esophageal disease for patients undergoing abdominal operations. MethodAmerican College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP; 2005-2015) data were merged with institutional clinical data repository records to identify esophageal disease in surgical patients undergoing intra-abdominal procedures. Patients with esophageal disease were classified as gastroesophageal reflux disorder (GERD) or other, which included patients with esophageal stricture, spasm, ulcer, or diverticuli, achalasia, esophagitis, reflux esophagitis, Barrett's esophagus, and multiple esophageal diagnoses, excluding GERD. ACS NSQIP–targeted procedure groups included were colectomy, proctectomy, ventral hernia repair, bariatric surgery, hepatectomy, appendectomy, abdominal aortic aneurysm repair, open aortoiliac repair, hysterectomy, myomectomy, and oophorectomy. Multivariable logistic regression was used to model postoperative complication rates, adjusting for ACS NSQIP risk of morbidity, demographic factors, ACS NSQIP–targeted procedure groups, and open versus laparoscopic surgery. ResultsOf 9172 intra-abdominal cases, 21.3% had preoperative esophageal disease (19.6% GERD and 1.7% other). After adjustment, patients with GERD were at higher risk for experiencing a number of complications, including all-cause 30-d complication (odds ratio [OR] = 1.21, 95% confidence interval [CI] 1.05-1.41, P = 0.044), renal complication (OR = 1.43, 95% CI 1.09-1.87, P = 0.036), wound complication (OR = 1.40, 95% CI 1.10-1.79, P = 0.028), and readmission within 30 d (OR = 1.66, 95% CI 1.35-2.04, P < 0.001). ConclusionsPreoperative GERD is associated with increased postoperative complication rate. Surgeons should consider assessing GERD in patients undergoing abdominal operations.

The Other Fungi: It's Not Just Candida albicans Anymore

Candida albicans continues to be the fungus most often causing disease in surgical patients, but with the treatment of an increasing number of critically ill and immunosuppressed patients, other candidal and non-candidal fungal pathogens are becoming more common. Review of current practice and guidelines. The presentation and management of non-C. albicans fungal infections differs depending on the genus and species. The availability of newer anti-fungal agents has in many cases improved outcomes or decreased toxicities associated with these diseases. Although such infections are still relatively uncommon, a working knowledge of infections with non-C. albicans fungi may be beneficial for surgeons, who are likely to encounter such patients both primarily and in consultation. Prompt recognition and treatment of these diseases should improve outcomes.

Surgical experience in patients with cystic fibrosis: a 25-year perspective.

The spectrum of surgical diseases in patients with cystic fibrosis (CF) has not been comprehensively studied. A retrospective review of 792 consecutive patients with CF presenting over a 25 year period (1970-1994) was made to determine the incidence of operations, procedures performed, complications encountered, and impact on physical development and pulmonary function tests (PFTs). A total of 191 operations were performed on 130 (16%) of the 792 patients; 98 operations (51%) were abdominal, 58 (30%) thoracic, and 31 (16%) hernias; 64 were male, and 66 female; average age was 14 +/- 10 years. Complications occurred in 12 (16%); 9 deaths were from progressive respiratory failure, 2 from superficial wound infections, and 1 from an episode of line sepsis. In the first 15 years, 9 complications occurred in 126 operations vs. 3 in 73 operations during the last 10 years. Operations were classified as emergent, urgent, or elective. Of the 9 deaths, 8 occurred after emergent or urgent operations (4 abdominal and 4 thoracic), while 1 death occurred following elective herniorrhaphy. For each subgroup, (abdominal, thoracic, and hernia), there was no difference in height/weight indicies, peak flow, forced vital capacity (FVC), forced expired volume in 1 sec (FEV(1)), or FEV(1)/FVC ratio when comparing 1 year preoperation and 1 year postoperation. In conclusion, patients in this high-risk population were operated on with few complications, but when a complication occurred it tended to be pulmonary and fatal (4.7% of all operations). Furthermore, operations did not cause significant deteriorations in PFTs and they did not cause these children to fall off their expected age-adjusted growth curves.

Seroprevalence of Helicobacter pylori in Patients With Surgical Peptic Ulcer

Helicobacter pylori is known as a major cofactor in ulcerogenesis. However, the role of H pylori in surgical patients with peptic ulcer and its possible influence on surgical treatment is unclear. To determine the prevalence of H pylori infection in surgical patients with complicated peptic ulcer diseases and analyze its clinical significance. A prospective, controlled study. University-affiliated hospital and tertiary care center. Two study groups: surgical group (n = 66), i.e., patients who received surgical treatment for their peptic ulcer disease), and control group (n = 377) comprising 3 subgroups: normal volunteers (NV subgroup, n = 136) and patients who required only medical treatment for duodenal ulcer (DU subgroup, n = 119) or gastric ulcer (GU subgroup, n = 122) from January 1, 1994 to June 30, 1995. Preoperative or overnight fasting serum samples were collected, and H pylori state was assessed by serum anti-H pylori IgG. Seropositivity was similar between the surgical group (60.6%) and NV control subgroup (58.8%), but it was highest in the DU control subgroup (87.4%) (P < .001 compared with NV control subgroup), followed by GU control subgroup (76.2%) (P < .01 compared NV). The patients with surgical peptic ulcer who had both seropositive and seronegative results for H pylori were similar for sex, age, social status, ulcer history, associated major medical problems, use of nonsteroid anti-inflammatory drugs, ulcer location, type of surgery, and ulceration recurrence rate. Although patients who underwent elective surgery had a higher seroprevalence rate (88.9%) than those requiring emergency surgery (56.4%) and patients who were seronegative for H pylori seemed to be associated with a higher major morbidity, these results were not statistically significant. No significant association of H pylori infection and peptic ulcer was noted between patients who required surgical treatment compared with those who required only medical treatment; H pylori played only a limited role in the cause of disease in surgical patients, perhaps only in the cases complicated with stenosis or intractable ulcers. This suggests that presently adequate acid reduction procedure will still be the main objective of surgical treatment and prevention of the ulcer recurrence.

Coronary artery disease in surgical patients. Perioperative management.

With effective communication, optimal use of perioperative therapeutic techniques, and postoperative follow-up, the medical, surgical, and anesthetic teams can prevent or minimize cardiac complications that occur during the postoperative period. Up to 50% of postoperative myocardial infarctions may be silent, or they may present as congestive heart failure, hypotension, or arrhythmia. Dyspnea is a common finding. All high-risk patients should be monitored in the intensive care unit during the first 7 days after surgery, when adverse cardiac events are most common.

Coronary artery disease in surgical patients. Preoperative evaluation.

Primary care physicians play a major role in the risk stratification of patients with coronary artery disease (CAD) preparing for noncardiac surgery. Preoperative risk assessment takes into account the type and urgency of surgery and the extent of underlying CAD. With this approach, patients can be categorized as being at high, intermediate, or low risk for postoperative cardiac complications. Judicious use of preoperative noninvasive cardiac testing may help identify those patients at particularly high risk for such complications.

Hepatobiliary complications associated with TPN: an enigma.

Despite the fact that the clinical experience with TPN has been gathered from patients of all age groups suffering from a variety of underlying diseases running very different clinical courses and often complicated by a number of septic metabolic and therapeutic problems, certain points can be made with regard to predisposing factors. 1) Prematures and neonates are particularly at risk. 2) Cholestasis occurs earlier and has a greater chance of leading to chronic liver disease in surgical patients. 3) Hepatobiliary abnormalities are more likely to develop after a prolonged period of TPN and are less frequent in patients who are also receiving oral feedings. Definition of the mechanism of hepatobiliary complications remains a problem. Although calcium bilirubinate appears to be responsible for sludge and stones, there is as yet no explanation for the presence of large amounts of indirect-reacting bilirubin in gallbladder and hepatic bile in patients on TPN. The pathogenesis of cholestatic liver disease remains an enigma; the lack of normal gastrointestinal stimuli for bile formation, abnormalities of bile acid metabolism, and sepsis might play roles, but attention has recently been attracted to amino acid toxicity and this possibility deserves further study.

Increased incorporation of an infused labelled amino acid into plasma proteins as a means of assessing the severity of injury or activity of disease in surgical patients.

Following injury there is increased synthesis of several plasma proteins. During a constant rate infusion of 1-(1-14C) leucine some of the labeled amino acid became incorporated into plasma proteins, the amount being readily determined after precipitation with perchloric acid. This value was correlated with the clinical state of the patient to see if an index of severity of injury could be derived. Before operation 6.7 +/- 0.5% (mean +/- SD, n = 16) of the infused labeled amino acid was incorporated in asymptomatic patients, irrespective of their dietary intakes, while in the presence of symptomatology this value rose, correlating with tumor staging in patients with colorectal neoplasia (r = 0.988, p = 0.001). It returned to normal following tumor resection, but was elevated in the presence of recurrence or residual disease. After operation it also rose, being maximal in the early postoperative period and following the more major surgical procedures, the increase correlating with the change in cortisol level in patients following cholecystectomy (r = 0.84, p less than 0.01; n = 8). The pattern of distribution of the label among the plasma proteins did not change with increased incorporation. The increase in incorporation of 1-(1-14C) leucine into plasma proteins would appear to offer a good index for severity of injury of activity of a disease state.

Incidence of concurrent systemic disease in the surgical population of a tertiary care hospital

A retrospective analysis was made of the case records of 1568 surgical patients admitted in 1975 to a tertiary care hospital in the Province of Newfoundland, to determine and classify the incidence of concurrent systemic disease. Almost 60 percent of patients had symptoms or signs of concurrent disease, the numbers increasing progressively from below 30 per cent at 21-30 years, to 90 per cent at ages 71-80. The predominant abnormalities were cardiovascular (60 per cent), followed by respiratory and metabolic conditions (41 and 40 per cent respectively). Detailed findings are presented, including those relating to the incidence of ischaemic heart disease and hypertension, to the coexistence of several diseases, to smoking and chronic obstructive lung disease, to obesity, to diabetes, and to alcoholism. This review documents the high incidence of concurrent disease in surgical patients and has implications for the training of anaesthetists and the organization of their work.