Life-threatening Surgical Condition Research Articles

Necrotising soft tissue infection of chest wall secondary to rib fractures

Necrotising soft tissue infection (NSTI) is a surgical emergency. We hereby present a rare case with NSTI of the chest wall secondary to rib fractures without any intra pulmonary pathology leading to a life-threatening surgical condition.

The Role of the Mannheim Peritonitis Index for Predicting Outcomes in Patients With Perforation Peritonitis in a Rural Hospital in India.

Introduction Acute secondary peritonitis due to hollow viscus perforation is a life-threatening surgical condition with significant morbidity and mortality, depending on the severity with outcomes that differ in the Western and developing world. Various scoring systems have been developed to assess the severity and its relation to morbidity and mortality. We conducted this study to evaluate the role of the Mannheim peritonitis index (MPI) in predicting outcomes in perforation peritonitis patients in a rural hospital in India. Materials and methods A prospective study of 50 patients with hollow viscus perforation with secondary peritonitispresented to the emergency department, Acharya Vinoba Bhave Rural Hospital, Sawangi (Meghe), Wardha, from 2016 to 2020. Each operated patient was scored according to the MPI to predictmortality. Results The majority of the patients were discharged uneventfully and about 16% (8/50) of the patients expired. The patients with an MPI score of more than 29 had maximum mortality of 62.5%. Mortality was seen in 37.5% of the patients with MPI scores between 21 and 29, whereas no mortality was recorded in patients with an MPI score of 21. Higher mortality was associated with age greater than 50 years (p=0.007), the presence of malignancy (p=0.013), colonic perforation (p=0.014), and fecal contamination (p=0.004). There was no significant correlation with gender (p=0.81), the presence of organ failure (p=1.6), delayed presentation, i.e., preoperative duration >24 hours (p=0.17), and the presence of diffuse peritonitis (p=0.25). Conclusion MPI is a specific, easily reproducible, and less cumbersome scoring method for predicting mortality in patients with hollow viscus perforation (secondary) peritonitis with minimal laboratory investigations. Higher scores correlate with a poorer prognosis and need intensive management, making use of MPI in clinical practice relevant and beneficial, especially in resource-poor settings.

INFLAMMATORY MARKERS IN THE DIAGNOSIS OF COMPLICATED APPENDICITIS IN CHILDHOOD

Acute abdominal pain is challenging because of the nonspecific nature of symptoms and difficulties in physical examination in children. In most of them, it is a manifestation of an urgent surgical or medical condition, where the biggest challenge is a timely diagnosis to start appropriate treatment without any diagnostic delays. There are many conditions that present with abdominal pain in all age groups, ranging from a common viral illness to a life-threatening surgical condition. History, physical examination, laboratory tests, and imaging are initially used to differentiate surgical illnesses categorized as urgent. Their characteristics, age, and physical examination of the patient direct appropriate tests in the context of these differences.

Thoracoscopic surgery for congenital diaphragmatic hernia in neonates: Should it be the first choice?

Congenital diaphragmatic hernia (CDH) is an uncommon but potentially life-threatening surgical condition in neonates. Surgery can be performed by either open or thoracoscopic techniques. In this study, we compared the clinical efficacy, safety, and effectiveness of thoracoscopic and open CDH repair. A retrospective review of neonates with CDH who underwent operations at our hospital from 2013 to 2021 was performed. The various perioperative parameters were compared between neonates undergoing thoracoscopic and open surgery. There were 50 neonates in this study (37 in the thoracoscopic group and 13 in the open group). Thoracoscopic surgery was associated with significantly shorter hospital stay (13.32 vs. 18.77 days, p < 0.001); shorter duration of postoperative mechanical ventilation (3.70 vs. 5.98 days, p < 0.001); early feeding (4.34 vs. 7.46 days, p < 0.001); and shorter time to reach optimal feeding (8.21 vs. 13.38 days, p < 0.001). There was one postoperative death in the open group and no death in the thoracoscopic group. The median follow-up time of the two groups was 23.8 months (20.5 months in open group and 25.0 months in thoracoscopic group). Thoracoscopic surgery was associated with lower recurrence rates, but the difference was not statistically significant (2.7% vs. 7.7%, p = 0.456). Thoracoscopy CDH repair, a safe and effective surgical technique for neonates, has better cosmesis, faster postoperative recovery, and a lower recurrence rate than other procedures. It can be considered the first choice for CDH treatment for neonates among experienced surgeons.

Academic Pediatric Surgery Capacity Building in Vietnam Through PASS, a Pediatric Acute Surgical Support Course.

Neonatal and pediatric surgical emergencies in Low and Low Middle Income countries remain a significant challenge in combatting the burden and inequities of global health. IPSAC-Vietnam is a small Non-Governmental Organization that has been engaged in a 12-year multi-pronged partnership with several children’s hospitals in Vietnam VN to enhance pediatric surgery capacity. We describe the health care, medical training and emergency system in VN as the background for IPSAC activities and development of Pediatric Acute Surgical Support (PASS) course. The course goal is to prepare health care personnel in the immediate management of neonatal/pediatric life-threatening surgical conditions and road injuries at their first point of entry into Vietnam hospitals. PASS is a horizontal outreach initiative that adopts an interprofessional, multidisciplinary, team-training, train-the-trainers, and outcome-based training approach. PASS can be used as a tool for sustainable horizontal capacity-building by champion leaders at the teaching children’s hospitals and medical universities in developing countries, to strengthen training for pediatric surgical emergencies, to integrate pediatric and pediatric surgical care and to advocate for a comprehensive approach to emergency care of the critically ill child.

The analysis of the predictive factors of mortality in patients with acute mesenteric ischemia

Abstract Background: The acute mesenteric ischemia is a rare life-threatening surgical condition, followed by high mortality and morbidity rate. Disparate etiologies and nonspecific symptoms make the diagnosis and the surgery delayed, which leads to a higher mortality rate (60-80%). Methods: This research was designed as a retrospective study, including a total of 86 patients operated for acute mesenteric ischemia between 2014 and 2020 at the 2nd Department of Surgery in Mureș County Emergency Clinical Hospital. We recorded and analyzed the demographic, clinical, pre-operative radiological and laboratory, and surgical findings of the patients. Results: We analyzed the findings of 86 patients (59,3% men, 40,7% women), the mortality rate was 77,9% (77% in women, 78% in men), and the average age was 76,81 years. The youngest patient was 39 years old and the oldest was 96 in the moment of the diagnosis. The mortality rate was higher (93%) in patients, who suffered just an explorative laparotomy surgery (in 50% of the cases, p=0,001, Chi-squared test). The presence of the peritonitis (12 cases) had a negative impact on the survival rate, every patient who had peritonitis described on the computed tomography died after the surgical intervention (p=0,047, Chi-square test). Statistically, there was not a positive relationship between the time spent in the Emergency Room and the mortality rate, but this time was much longer in the group of patients who died after the surgery, 408,22 minutes, compared to the group of the patients who survived, 352,47 minutes (p=0,431, T-test). The survival rate was higher in patients who had abdominal surgery in the personal history (p=0,021, Chi-square test). Conclusions: The symptoms and the paraclinical findings of patients with acute mesenteric ischemia are not specific, so the fast radiological examinations and the optimal time for the surgical intervention represent the key of the improvement of the survival rate.

Transhiatal esophagectomy in Boerhaave syndrome - Case report and literature review.

IntroductionBoerhaave syndrome or spontaneous rupture of the esophagus wall is a rare life-threatening condition. It is more common in male gender and is due to a very swift rise in intraluminal pressure during vomiting. The patient usually presents with chest pain after vomiting. In some cases, there is subcutaneous emphysema in the neck or upper chest. Due to its rarity, the diagnosis is often not straightforward. Chest radiography can reveal pneumothorax, pleural effusion or pneumomediastinum, but diagnosis is more likely possible with an oral contrast X-ray study.Case presentationThis paper reports a clinical case with surgical approach, in a 68-years old patient with a 48 h period between onset of symptoms and diagnosis of a Boerhaave syndrome. Firstly, the patient was admitted with a presumptive diagnosis of pneumonia. The patient was with chest pain, fever and vomiting. An emergent transhiatal esophagectomy was performed with primary anastomosis with no significant post-operative morbidity and allowing for the patient to return to previous daily routine with a good quality of life.Discussion and conclusionBoerhaave syndrome is a rare life-threatening surgical condition. Surgery is the most effective treatment. It is necessary to have a high index of suspicion. Treatment should promptly start because prognosis is related with time from diagnosis, with increasing mortality rate if no treatment is performed.

Risk Factors for Serum Bilirubin Rebound After Stopping Phototherapy in Neonatal Hyperbilirubinemia

Objective: To identify the factors affecting rebound increase in bilirubin levels after stopping phototherapy in neonatal hyperbilirubinemia. Setting: Tertiary-level neonatal unit. Patients: This was a hospital-based cross-sectional observational study. The study was conducted in neonatal division of rural tertiary care hospital. All neonates who were admitted for hyperbilirubinemia treatment and fulfilled the inclusion criteria were included in the study. Inclusion Criteria: All neonates 1.5 kg and above and treated in newborn intensive care unit for hyperbilirubinemia. Exclusion Criteria: (a) Critically ill patients requiring respiratory support any time after delivery, (b) neonates presenting with life-threatening surgical conditions, (c) patient with congenital malformation, (d) conjugated bilirubin elevation, (e) patients with birth asphyxia. Statistical Analysis: All the data were entered into a Microsoft Excel sheet. Appropriate tests of significance were applied. The various variables were sorted and presented as a number or percentage. The categorical variables used in the analysis were evaluated using the chi-square test (Yates’s correction and Fischer exact test were employed where applicable). The continuous data were analyzed by “t” test. The P value of less than 0.05 was taken to be level of statistical significance. Results: One hundred and fifty patients of neonatal hyperbilirubinemia were included in this study. In this study, 81 newborns (54.0%) were male and 78 (52%) of them were born by normal vaginal delivery. One hundred and nine babies (72.6%) were term babies. Fifty babies (33.3%) were low birth weight. Out of 150 neonates, 18(12%) had ABO incompatibility, 13(8.7%) Rh incompatibility, 23(15.7%) neonatal sepsis, and 4 (2.6%) had polycythemia. Out of 150 patients, 15(10%) babies had rebound hyperbilirubinemia at 24 h of life requiring phototherapy prematurity (particularly &lt;34 weeks) ( P value: .03), low birth weight (particularly &lt;2.0 kg) ( P value:.009), onset of jaundice requiring phototherapy before 72 h of life ( P value .04), blood group (both Rh and ABO) incompatibility ( P values: .001 and .002), neonatal sepsis ( P value: .004) were significantly associated with rebound hyperbilirubinemia. Glucose 6 phosphate dehydrogenase (G6PD) deficiency, polycythemia, maturity, mode of feeding, and gender did not show any statistical significant relationship with rebound hyperbilirubinemia. Conclusions: Rebound level of bilirubin need not be checked in all babies. Babies with risk factors like born preterm, low birth weight, having sepsis, requirement of phototherapy before 72 h of life, Rh and ABO group incompatibility, only need to be checked for serum bilirubin rebound. We recommend more studies with larger sample size to evaluate all these factors including polycythemia and G6PD deficiency.

Acute intestinal intussusception among children under five years of age admitted in an Ouagadougou hospital, Burkina Faso, 2008-2013: epidemiological, clinical and therapeutic aspects.

Introductionacute intestinal intussusception is a life-threatening surgical condition. In some settings, rotavirus vaccines have been associated with a low-level increased risk of intussusception. We describe the epidemiology, clinical manifestations and management of intussusception in a tertiary referral hospital in Burkina Faso prior to the introduction of rotavirus vaccine in October 2013.Methodswe retrospectively reviewed medical records of all children under 5 years of age treated at the Charles de Gaulle Pediatric Hospital for intussusception meeting the Brighton level 1 diagnostic criteria, from October 31st, 2008 to October 30th, 2013. We report the incidence of intussusception as well as descriptive characteristics of these cases.Resultsa total of 107 Brighton level 1 intussusception cases were identified, representing a hospital incidence of 21.4 cases / year. There were 69 males and 38 females (sex ratio of 1.8), with a median age of 8 months (range 2 months to 4 years). Sixty-two percent of intussusception cases occurred among infants (n = 67 cases). The average time from symptom onset to seeking medical consultation was 3.8 days +/- 2.7 (range 0 to 14 days). Treatment was mainly surgical (105 patients, 98.1%) with 35 patients (32.7%) undergoing intestinal resection. Thirty-seven patients (35.5%) experienced post-operative complications. The mortality rate was 9.3%. Intestinal resection was a risk factor for death from intussusception.Conclusionin this review of intussusception hospitalizations prior to rotavirus vaccine introduction in Burkina Faso, delays in seeking care were common and were associated with mortality.

Clinical Outcome and Predictors of Intestinal Obstruction Surgery in Ethiopia: A Cross-Sectional Study.

Background Despite the advancement in the healthcare system, the impact of surgical interventions on public health systems will continue to grow. But predicting the outcome is challenging. Concerns related to unexpected outcomes and delays in the diagnosis of postoperative complications are the major issue. Intestinal obstruction is a common life-threatening surgical condition followed by fatal and nonfatal postoperative complications. This study was aimed at assessing results after surgery for intestinal obstruction in a hospital of Ethiopia. Methodology. An institutional-based cross-sectional study was conducted among 254 postoperative patients admitted with intestinal obstruction from January 1, 2014, to December 31, 2017. Data were coded and entered into EpiData 4.2.0.0 software and exported to the Statistical Package for the Social Sciences version 22 for analysis. A binary logistic regression model was used for analysis. All variables with a p value < 0.25 during bivariable analysis were considered for multivariable logistic regression analysis. Results The magnitude of poor surgical outcome of intestinal obstruction was 21.3% for patients enrolled into this investigation. The age group of ≥55 years (adjusted odds ratio (AOR) = 2.9, 95% CI: 1.03, 8.4), duration of illness of ≥24 hrs (AOR = 3.1, 95% CI: 1.03, 9.4), preoperative diagnosis of a gangrenous large bowel (AOR = 3.6, 95% CI: 1.3, 9.8), and a gangrenous small bowel (AOR = 4.2, 95% CI: 1.3, 13.7) were significantly associated with poor surgical outcome. Conclusions The magnitude of poor surgical outcome was high. Age, late presentation of illness, and gangrenous bowel obstructions were significantly associated with poor outcomes. So, concern should be given in early detection and follow-up of patients who came late and older patients.

A 3 years’ Experience of Operated Surgical Neonates Outcome in a Tertiary Hospital of Ain Shams University (Neonatal Intensive Care Unit)

Background: Surgery on a newborn has been one of the most challenging subjects in medical science. A neonate is born with its unique physiological features of very narrow normal ranges, beyond which it is helpless to cope with the adverse situations. Added to this, it has to be able to respond to life-threatening surgical conditions for its survival. Objectives: We aimed in this piece of work to assess the outcome of different neonatal surgical conditions and factors responsible for mortality in surgical neonates. Patients and Methods: The present retrospective study was conducted in the NICU of Ain Shams University Children’s Hospital using the records from the beginning of year 2011 till the end of year 2013. The recorded data included gestational age, postnatal age at admission, sex of neonates, maternal age, mode of delivery, surgical diagnosis, surgery outcome, risk factors for occurrence of sepsis, classification of type of sepsis if present (Early-onset sepsis, Late-onset, or nosocomial) , blood culture results, antimicrobials used, length of hospital stay, need for ventilation, risk factors for occurrence of sepsis, cause of death. Results: The study included 69 patients with surgical problems who were admitted to the NICU. They were 45 males (65.22%) and 24 females (34.78%) with a male to female ratio of 1.8: 1. They were 10 preterms (14.49%) and 59 full-terms (85.51%); with mean gestational age range from 32-40 weeks, mean ± SD: 36.91±1.98 weeks. 37 (53.62%) were delivered by LSCS and 32 (46.38%) by SVD. 33.33% of neonates were admitted between 1 and 2 days postnatal, 42.9% were more than 1 week old, with mean age of admission 9.49 ±10.37 days. The most common surgical problems were Tracheo-oesophageal fistula (9 cases), followed by imperforate anus low anomaly 5 cases, imperforate anus high anomaly 5 cases, then Hirshsprung disease 4 cases. Also hydrocephalus and Arnold Chiari malformation each 4 cases. Diaphragmatic hernia 4 cases. 61 cases had sepsis, 50 cases were discharged, 19 died and 8 had no complications. The most common causes of death were; sepsis (16 cases), heart failure (9 cases), respiratory failure (5 cases), cardio –pulmonary failure (3 cases) and pneumonia and pulmonary hypertension each one case. Conclusion: Most of cases were full term babies and had late presentation to our hospital which led to delayed operations. Most common surgical problem was trachea-oesophageal fistula.

Managing acute abdominal pain in pediatric patients: current perspectives.

Acute abdominal pain in pediatric patients has been a challenge for providers because of the nonspecific nature of symptoms and difficulty in the assessment and physical examination in children. Although most children with acute abdominal pain have self-limited benign conditions, pain may be a manifestation of an urgent surgical or medical condition where the biggest challenge is making a timely diagnosis so that appropriate treatment can be initiated without any diagnostic delays that increase morbidity. This is weighed against the need to decrease radiation exposure and avoid unnecessary operations. Across all age groups, there are numerous conditions that present with abdominal pain ranging from a very simple viral illness to a life-threatening surgical condition. It is proposed that the history, physical examination, laboratory tests, and imaging studies should initially be directed at differentiating surgical versus nonsurgical conditions both categorized as urgent versus nonurgent. The features of the history including patient’s age, physical examination focused toward serious conditions, and appropriate tests are highlighted in the context of making these differentiations. Initial testing and management is also discussed with an emphasis on making use of surgeon and radiologist consultation and the need for adequate follow-up and reevaluation of the patient.

Surgical Neonatal Sepsis in Developing Countries.

Surgery on a newborn has been one of the most challenging subjects in medical science. A neonate is born with its unique physiological features of very narrow range of normalcy, beyond which it is helpless to cope with the adverse situations. Added to this burden, it has to be able to respond to life-threatening surgical conditions for its survival when these are present or do arise. Among several other factors, infections and sepsis remain as persistent and significant cause of mortality and morbidity among neonates. Newborns suffering from sepsis have a prohibitive mortality and persistent high mortality from sepsis remains as a challenge to neonatal surgical care. Survival following neonatal surgery has made a significant improvement in the developed countries because of better understanding of neonatal physiology, introduction of sophisticated devices, and availability of trained personnel and of course antibiotics treating infections effectively. But the situation still remains gloomy in the developing countries and sepsis remains as the predominant cause for high morbidity and mortality. Limitations in the developing countries are aplenty including dearth of skilled man power, scarcity of resources and facilities, unhygienic health delivery system including maternal and neonatal health, poverty, illiteracy and ignorance etc. [1-6]. Sepsis and other complications among surgical neonates have to be taken seriously into the main childhood health programs of the developing countries to be able to overcome the huge load on the overall economy of these countries.

Cost‐effectiveness of Dental Surgery Procedures: A Call for Strengthening the Evidence: Reply

We thank Benzian and Neiderman [1] for their comments regarding the lack of evidence for the cost-effectiveness of dental surgery in the literature in their response to our article [2]. Indeed, neglect of cases requiring immediate dental extraction is an important cause of sepsis in lowand middleincome countries (LMICs) which can ultimately be life threatening. As part of the International Collaboration of Essential Surgery, we believe that essential surgical procedures, defined as simple interventions that save lives and prevent disability, should be available and accessible to all, and that includes dental extraction for neglected caries. We agree with their call for more cost-effectiveness studies to be done on tooth extraction to dispel the myths that surgical interventions are costly. We also call again for more studies to be done on the cost-effectiveness of other neglected simple surgical interventions for common disabling and life-threatening surgical conditions. We note an increasing interest in atraumatic restorative treatment for dental caries, which removes the need for drills, electricity, or running water and which has been specifically developed for LMICs [3]. Studies on comparative costs and benefits of this technique are also apposite. We join with Benzian and Neiderman in calling for the inclusion of basic oral surgery in the armamentarium of Essential Surgeons.

Ruptured corpus luteum with hemoperitoneum: A study of 173 surgical cases

Ovarian hemorrhage from the corpus luteum of menstruation or pregnancy can be a life-threatening surgical condition which occurs at all stages of a woman's reproductive life. A corpus luteum cyst predisposes to rupture. There may be a delay of menses. Pregnancy increases the risk of rupture, and there is an increased risk of abortion and ectopic pregnancy. Most ruptures occur in the right ovary and can be misdiagnosed as appendicitis. Culdocentesis is positive for hemoperitoneum, and if the hematocrit is over 12%, surgical intervention is indicated for hemostasis. A tissue diagnosis should be made by cystectomy, luteectomy, or wedge excision.