Patients Requiring Emergency Surgery Research Articles

Our experience with emergency surgery in geriatric patients.

Aim: A significant portion of admissions to emergency departments are made up of elderly patients. We aim to determine the causes of acute abdomen in geriatric patients requiring emergency surgery, evaluate postoperative intensive care needs and mortality rates, and raise awareness about this patient group.
 Method: Patient files of individuals aged 65 and older who were consulted in our hospital's emergency department and subsequently admitted to the general surgery service between 2021 and 2023 were retrospectively reviewed. Data including age, gender, underlying diseases, additional illnesses, duration of stay in the intensive care unit, cause of mortality, and length of hospital stay were extracted from the patient's records. The collected data were analyzed statistically for comparisons.
 Results: Data of 27 patients were accessed.these patients, 40.7% (n=11) were female, and 59.3% (n=16) were male. The average age of the patients was determined to be 74.81 years (ranging from 65 to 88). Thirteen patients, comprising 5 males and 8 females, were monitored in the intensive care unit. 6 patients experienced mortality, and all of them were those admitted to the intensive care unit. When comparing mortality rates based on gender, it was 18.8% in male patients and 27.3% in female patients. All 27 patients had at least one comorbidity . Patients who experienced mortality had at least two comorbidities. Twelve patients did not undergo surgery. 
 Conclisions: In the emergency assessment of geriatric patients, a prompt diagnosis should be made, considering comorbidities after diagnosis, and follow-up and treatments should be adjusted multidisciplinary for patients requiring intensive care or those to be monitored in regular rooms.

Intestinal Helminths Infections as Infrequent Cause of Emergency Abdominal Surgery: A Retrospective Study in a University Hospital over 20 Years.

All organs of any organism can be affected by helminths. They can be seen in a broad spectrum, from simple infestations to extensive, life-threatening involvement. Symptomatology is usually of chronic latent course. However, sometimes the presentation is acute and requires urgent surgical intervention. We conducted a retrospective observational prospective recruitment study of patients undergoing emergency surgery for helminth infection from January 2000 to December 2019 at a university hospital. Sociodemographic and analytical variables, variables related to the clinical process, and the diagnostic test were analysed. Variables related to the surgical procedure and postoperative complications were also analysed. A total of 36 patients required emergency surgery for their helminth infection, which represented 0.26% of emergency abdominal surgeries. The mean age was 34.91 ± 21.5 years, with a predominance of men (69.4%). Most patients presented with pain in the right iliac fossa (69.4%), followed by symptoms compatible with intestinal obstruction (19.4%). The most frequent surgical interventions were appendectomy (38.9%) followed bowel resection (33.3%) and ileocecal resection (11.1%). Enterobious vermicularis and Anisakis simplex both together accounted for 75% of the sample. Statistically significant differences were identified in age (p < 0.001), diagnostic test performed (p = 0.032), intraoperative clinical diagnosis (p = 0.005) and surgical treatment received (p < 0.001). The frequency of emergency surgeries for intestinal helminth parasitism is decreasing. However, the majority of these are E. vermicularis and Anisakis simplex, which have distinctly different clinical presentations. Identification and recognition by physicians continue to be necessary for further postoperative management and possible complications.

WAITING TIME AMONG PATIENTS UNDERGOING EMERGENCY SURGERY IN A TERTIARY HOSPITAL OF NEPAL

Background: Managing emergency surgical services and availing prompt treatment on time is one the most important aspects in the delivering quality healthcare services. Prior the average time waiting for emergency surgery from this healthcare setting is unknow. Therefore, this study was delineated to evaluate average waiting time among patients undergoing emergency surgery. Methods: This descriptive observational study was conducted at Chitwan Medical College from 15 March 2023 to 15 July 2023. Self -structured proforma was developed to document waiting time in each phase of delivering healthcare services, including triage time, consultation time, investigation order and report time, shifting the client from ER to OT for emergency surgery. Data was analyzed using IBM SPSS 20, and were interpretated in terms of descriptive statistics. Results: Among 122 cases, the longest waiting time was seen in oral maxi facial surgery with the average time 8 hours 27 minutes. The major surgeries had longest waited hours on an average 6 hours 19 minutes, compared to minor and intermediate surgeries. Overall, the average waiting time form patient admitted to emergency department to start of the surgery was found to be 4 hours 43 minutes. Conclusions: In this study, the commonest delays were evidenced were, delay in transfer to pre-operative area, delay in second consultation, OT busy, and delay in providing consent and financial incapability. Further improvements can be done by analyzing root cause, modifying the system and formulating standard operating procedure and maintaining a tracking system of patients requiring emergency surgery.

Postoperative complications for complicated malignant tumours of the stomach

Objective — to determine the frequency and structure of postoperative complications for malignant tumours of the stomach accompanied by gastrointestinal bleeding. Materials and methods. The study analysed the treatment outcomes of 101 patients with a malignant tumour of the stomach complicated by bleeding (84 cases), perforation (6 cases), or stenosis (19 cases, with 8 of them having both stenosis and bleeding). These patients underwent inpatient treatment at the Kyiv City Centre for Gastrointestinal Bleeding and the Kyiv City Clinical Hospital of Emergency Medical Help between 2015 and 2020. Out of the patients, 78 (77.2%) had histologically confirmed cancer, 11 (10.9%) had GIST, and 12 (11.9%) had malignant lymphoma. Results. During the peak period of ongoing and recurrent bleeding, 5 (6%) patients required emergency surgery, including 2 (40%) radical and 3 (60%) non‑radical procedures. After proper preoperative preparation and a comprehensive follow‑up assessment, 58 (57.4%) patients underwent radical surgical interventions for stomach cancer complicated by acute gastrointestinal bleeding in the early delayed period. In the early postoperative period, 4 (15.4%) patients experienced complications after 26 radical gastrectomies combined with jejunogastroplasty. In the delayed period, early postoperative complications occurred in 9 (28.1%) patients after 32 radical gastric resections. The total postoperative mortality after emergency surgical interventions was 20.0%. The total postoperative mortality in the early‑term period was 5.7% (5 patients out of 88), which is 3.5% less compared to emergency operations (the difference is statistically significant, p ≤0.05). Conclusions. When urgent surgical interventions are carried out at the peak of ongoing and recurrent bleeding, the mortality rate from postoperative complications is 3.5 times higher than when operations are performed in the early delayed period after adequate preparation and comprehensive patient monitoring. The death rate after radical operations is 2.1 times lower than that after palliative and symptomatic operations. As the operations conducted during the peak bleeding period are associated with high postoperative mortality, we believe that they pose a high risk to patients with malignant tumours of the stomach.

Factors Associated with Newly Developed Postoperative Neurological Complications in Patients with Emergency Surgery for Acute Type A Aortic Dissection.

Background and Objectives: Postoperative neurological complications (NCs) are an important cause of mortality in patients with acute type A aortic dissection (ATAAD). The aim of the study was to determine the association between intraoperative risk factors and newly developed postoperative NCs in patients after emergency surgery for ATAAD. Materials and Methods: A total of 203 patients requiring emergency surgery were included in the study. Patients with preoperative neurological dysfunction, deceased on the operating table or within the first 48 h after intensive care admission, with uncertain postoperative neurologic status or with incomplete records were excluded. Results: Mean age was 57.61 ± 12.27 years. Hyperlipidemia was the most frequent comorbidity (69%). A bicuspid aortic valve was present in 12.8% of cases, severe acute aortic regurgitation was present in 29.1% of patients, and cardiac tamponade was present in 27.1% of cases. The innominate artery was the most frequently dissected supra-aortic artery in 27.1% of cases. In 65% of cases, the primary entry tear was at the level of the ascending aorta. The incidence of newly developed postoperative NCs was 39.4%. The most common surgical technique performed was supra-coronary ascending aorta and hemiarch replacement, in 53.2% of patients. Using logistic regression, cardiopulmonary bypass time (OR = 1.01; 95% CI = 1.01-1.02; p < 0.001), aortic cross-clamp time over 3 h (OR = 2.71, 95% CI = 1.43-5.14, p = 0.002) and cerebral perfusion time (OR = 1.02; 95% CI = 1.002-1.03; p = 0.027) were independently associated with newly developed postoperative NCs. Conclusions: Based on the results of the study, all efforts should be made to reduce operative times. Using a simple surgical technique, like the supra-coronary ascending aorta and hemiarch technique, whenever possible, and using a simpler technique for cerebral perfusion like unilateral cerebral perfusion via the right axillary artery, could reduce operating times.

Cardiac magnetic resonance imaging for myocardial viability assessment: Optimizing surgical revascularization in ischemic heart disease.

Patients with poor ejection fraction undergoing coronary artery bypass grafting carry higher operative risk and have poor long-term survival. Cardiac magnetic resonance is a useful modality to assess viability which can identify patients likely to benefit most from revascularization. In this study, we aimed to assess the outcome in patients selected for surgical revascularization by cardiac magnetic resonance imaging and identify predictors associated with poor outcomes. The study included patients with severely impaired left ventricular function but with at least six viable segments. Patients requiring emergency surgery, undergoing combined procedures, or where cardiopulmonary bypass was required were excluded. Cardiac magnetic resonance was carried out both preoperatively and at six months postoperatively by the same radiologist in all cases. Late gadolinium enhancement was used for the evaluation of myocardial viability. Amongst a total of 493 segments studied, there were 89 (18.1%) non-viable, 117 (23.7%) hibernating and 287 (58.2%) viable segments. At six months, the number of non-viable segments changed from 89 (18.1%) to 97 (19.7%), with an increase in viable segments from 287 (58.2%) to 374 (75.8%) and a corresponding reduction of hibernating segments from 117 (23.7%) to 22 (4.5%). There was improvement in ejection fraction from 28 ± 5.54 to 37 ± 5.86 (p < 0.0001) in the entire cohort at six months. Overall mortality was 1 (3.2%). Preoperative left ventricular end-systolic volume had the strongest negative correlation with post-operative ejection fraction. Cardiac magnetic resonance aided revascularization is associated with low mortality. Preoperative left ventricular end-systolic volume is an important determinant of postoperative ejection fraction.

A Modern Series of Secondary Aortoenteric Fistula - A 19-Year Experience.

Secondary aortoenteric fistula is a rare and life-threatening condition. Clear evidence on the ideal therapeutic approach is largely missing. This study aims to analyze symptoms, etiology, risk factors, and outcomes based on procedural details. All patients with secondary aortoenteric fistula admitted between 2003 and 2021 were included. Patient characteristics, surgical procedure details, and postoperative outcomes were analyzed. Outcomes were stratified and compared according to the urgency of operation and the procedure performed. Descriptive statistics were used. The primary endpoint was in-hospital mortality. A total of twentytwo patients (68% male, median age 70years) were identified. Main symptoms were gastrointestinal bleeding, pain, and fever. From the twentytwo patients ten patients required emergency surgery and ten urgent surgery. Emergency patients were older on average (74 vs 63years, P = .015) and had a higher risk of postoperative respiratory complications (80% vs 10%, P = .005). Primary open surgery with direct replacement of the aorta or an extra-anatomic bypass with an additional direct suture or resection of the involved bowel was performed in sixteen patients. In four patients underwent endovascular bridging treatment with the definitive approach as a second step. Other two patients died without operation (1x refusal; 1x palliative cancer history). In-hospital mortality was 27%, respectively. Compared to patients undergoing urgent surgery, those treated emergently showed significantly higher in-hospital (50% vs 0%, P = .0033) mortalities. Despite rapid diagnosis and treatment, secondary aortoenteric fistula remains a life-threatening condition with 27% in-hospital mortality, significantly increased upon emergency presentation.

SP1.11 Hospitals offering emergency laparoscopic surgery have improved outcomes

Abstract Aims Only 20% of patients requiring emergency surgery in the UK are offered laparoscopic surgery; there is wide variability in uptake of laparoscopic emergency surgery between hospitals, ranging from 0% to over 80% of cases. This study investigated whether hospitals with an advanced laparoscopic culture had improved outcomes. Methods The national NELA database was interrogated to identify patients requiring surgery for adhesional small bowel obstruction; this was selected because it is common (around 25% of cases in NELA) and often amenable to laparoscopic surgery. Hospitals were grouped into quintiles, according to the number of cases attempted by the laparoscopic approach; each group was assessed for length of stay and mortality. Results In 176 acute hospitals, 20597 operations were performed for adhesional SBO. Overall mortality was 6.2%. In the quintile with the lowest rate of laparoscopy, 4% of cases were started laparoscopically, compared with 44% in the highest quintile. In the lowest quintile, 4.8% of patients were discharged within 3 days, compared to 13.8% in the highest quintile; discharge at 7 days was 26% versus 37%. Overall, 30-day mortality in the group with the lowest rate of laparoscopy was 6.9%, compared with 5.4% in hospitals with the highest rate of laparoscopy (p&amp;lt;0.001). Conclusions Hospitals where patients with adhesional SBO are offered laparoscopic emergency surgery demonstrate shorter lengths of stay and a significantly reduced mortality. This may be due to the benefits of the laparoscopic approach; it could also be a surrogate marker for an advanced culture of emergency surgery.

Sutureless technique combined with vertical vein incision and pulmonary veins unroofed for correction of infracardiac total anomalous pulmonary venous connection.

We report a surgical method (sutureless technique), combined with vertical vein incision and pulmonary veins unroofed (semisutureless technique), to correct infracardiac total anomalous pulmonary venous connection (TAPVC). The clinical characteristics of 21 patients, who were diagnosed with infracardiac TAPVS between February 2017 and March 2022, were retrospectively analyzed. These patients were divided into three groups according to different surgical methods: conventional surgery group, sutureless technique group, and semisutureless technique group. The conventional surgery group enrolled five patients with a median age of 16 days (interquartile range, 9-27 days) and a median weight of 3.25 kg (interquartile range, 3.1-3.42 kg). In this group, no preoperative pulmonary vein obstruction (PVO), preoperative ventilator support, or emergency surgery were reported. The sutureless technique group enrolled seven patients with a median age of 12 days (interquartile range, 5-16 days) and a median weight of 3.04 kg (interquartile range, 2.76-3.20 kg). In this group, two patients with preoperative PVO, four patients with preoperative ventilator support, and seven patients requiring emergency operation were found. The semisutureless technique group enrolled nine patients with a median age of 14 days (interquartile range, 7-24 days) and a median weight of 3.22 kg (interquartile range, 3.15-3.50 kg). In this group, four patients with preoperative PVO, two patients with preoperative ventilator support, and seven patients requiring emergency operation were noted. In the conventional surgery group, two patients with postoperative supraventricular tachycardia, one patient with postoperative low cardiac output syndrome, one patient with PVO, and no case of postoperative death were reported. In the sutureless technique group, two patients with postoperative low cardiac output syndrome, one patient with postoperative supraventricular tachycardia, one patient with postoperative PVO, and no postoperative deaths were determined. In the semisutureless technique group, three patients had low cardiac output syndrome, two patients had supraventricular tachycardia after the operation, and one patient, who had been admitted to the hospital after cardiopulmonary resuscitation in the emergency room, died early after the operation. No case of death or PVO was noted after the operation. The semisutureless technique has positive effects. This surgery method can enlarge the anastomotic stoma, increase the volume of the left atrium, reduce the tension of the anastomotic stoma, fix the pulmonary vein to avoid distortion, and prevent postoperative hemorrhage.

Extracorporeal hemoadsorption therapy as a potential therapeutic option for rapid removal of Apixaban in high risk-surgical patients: a case report

BackgroundApixaban is a non-vitamin K antagonist oral anticoagulant (NOACs) recently emerged as an effective alternative to conventional vitamin K antagonists (VKAs) in the treatment of several thromboembolic disorders. However, in case of overdose or in patients requiring emergency surgery there is a high bleeding rate and severe adverse side effects due to the absence of an antidote. There is promising data from in vitro and clinical studies, that certain antithrombotic agents (that is Rivaroxaban and Ticagrelor) have been successfully removed by the extracorporeal hemoadsorption therapy CytoSorb. Here, we present the case of a patient successfully treated with CytoSorb as a kind of antidote to enable emergency surgery for bilateral nephrostomy.Case presentationA 82-year-old Caucasian man was admitted to the Emergency Room with acute kidney injury (AKI) in the context of severe bilateral hydroureteronephrosis. The patient’s medical history included chronic obstructive pulmonary disease, arterial hypertension, atrial fibrillation (anticoagulated with Apixaban) and a locally advanced prostate adenocarcinoma treated with trans-ureteral resection of the bladder and radiotherapy in the previous months. The indication for a bilateral nephrostomy could not be considered immediately given the major bleeding risk due to Apixaban, which was discontinued and replaced with calciparin. After 36 hours of continuous renal replacement therapy (CRRT), the Apixaban blood level was still elevated and it was decided to install CytoSorb into the running CRRT to accelerate the drug clearance. After 2 hours 30 minutes, there was good reduction of Apixaban from 139 to 72 ng/ml (reduction rate of 48.2%) registered, and this allowed for an easy placement of bilateral nephrostomies without complications. Four days after surgery renal function parameters further normalized, the patient did not require additional dialysis treatments and Apixaban therapy was prescribed again once the patient returned home.ConclusionsIn this case we report the findings of a patient with post-renal AKI requiring emergency nephrostomy placement while on chronic anticoagulation with Apixaban therapy. Combined treatment with CRRT and CytoSorb was associated with the rapid and effective removal of Apixaban allowing for prompt and urgent surgery while simultaneously ensuring the low risk of bleeding as well as an uneventful post-operative course.

Diverticulitis with abscess formation: Outcomes of non-operative management and nomogram for predicting emergency surgery: The Diplicab Study Collaborative Group

BackgroundTo assess short- and long-term outcomes from non-surgical management of diverticulitis with abscess formation and to develop a nomogram to predict emergency surgery. MethodsThis nationwide retrospective cohort study was performed in 29 Spanish referral centers, including patients with a first episode of a diverticular abscess (modified Hinchey Ib–II) from 2015 to 2019. Emergency surgery, complications, and recurrent episodes were analyzed. Regression analysis was used to assess risk factors, and a nomogram for emergency surgery was designed. ResultsOverall, 1,395 patients were included (1,078 Hinchey Ib and 317 Hinchey II). Most (1,184, 84.9%) patients were treated with antibiotics without percutaneous drainage, and 194 (13.90%) patients required emergency surgery during admission. Percutaneous drainage (208 patients) was associated with a lower risk of emergency surgery in patients with abscesses of ≥5 cm (19.9% vs 29.3%, P = .035; odds ratio 0.59 [0.37–0.96]). The multivariate analysis showed that immunosuppression treatment, C-reactive protein (odds ratio: 1.003; 1.001–1.005), free pneumoperitoneum (odds ratio: 3.01; 2.04–4.44), Hinchey II (odds ratio: 2.15; 1.42–3.26), abscess size 3 to 4.9 cm (odds ratio: 1.87; 1.06–3.29), abscess size ≥5 cm (odds ratio: 3.62; 2.08–6.32), and use of morphine (odds ratio: 3.68; 2.29–5.92) were associated with emergency surgery. A nomogram was developed with an area under the receiver operating characteristic curve of 0.81 (95% confidence interval: 0.77–0.85). ConclusionPercutaneous drainage must be considered in abscesses ≥5 cm to reduce emergency surgery rates; however, there are insufficient data to recommend it in smaller abscesses. The use of the nomogram could help the surgeon develop a targeted approach.

Degenerative spinal conditions requiring emergency surgery: an evolving crisis in a publicly funded health care system.

Surgery for degenerative spine pathologies is typically performed on a scheduled basis; however, worsening symptoms may warrant emergency surgery. An increasing number of patients requiring emergency surgery has been observed (22.6% in 2006 to 34.8% in 2019). We sought to compare the outcomes of patients who received scheduled surgery and those who required emergency surgery. All patients treated between Jan. 1, 2006, and Dec. 31, 2019, were included. Retrospective comparisons were made between patients who were scheduled (elective) for surgery and those requiring emergency surgery, patients who were scheduled for surgery and those who decompensated while on the surgical waitlist and patients who presented as de novo emergencies and those who decompensated while on the surgical waitlist. Among the 6217 patients with degenerative pathologies, 4654 (74.9%) patients were scheduled (elective) for surgery and 1563 (25.1%) were patients requiring emergency surgery. Compared with patients who were scheduled, patients requiring emergency surgery had a longer length of stay (LOS) in hospital (5.1 d, interquartile range [IQR] 2.7-11.2 v. 3.6 d, IQR 1.3-6.4, p < 0.001) and lower rate of home discharge (78.6% v. 94.2%, p < 0.001). Patients requiring emergency surgery were 1.34 times more likely to have any adverse events (95% confidence interval [CI] 1.06-1.68, p = 0.01). When compared with patients who were scheduled for surgery, those who decompensated while on the surgical waitlist had longer LOS (7.0 d, IQR 3.3-15.0 v. 3.6 d, IQR 1.3-6.4, p < 0.001), less home discharge (77.6% v. 94.2%, p < 0.001) and were 2.5 times more likely to have any adverse events (95% CI 1.5-4.1, p < 0.001). Patients who decompensated had a 2.1 times higher risk of having any adverse events than patients who presented as de novo emergencies (95% CI 1.2-3.6, p < 0.001). We observed worse perioperative outcomes for patients requiring emergency surgery for degenerative spinal conditions than for patients who were scheduled for surgery. Patients who decompensated while on the surgical waitlist had the worst outcomes.

Usefulness of Intravenous Regional Anesthesia for Upper Extremity Arterial Injury Emergencies in Patients with COVID-19: A Case Series and Literature Review

The medical field has undergone many changes since the start of the coronavirus disease 19 (COVID-19) pandemic. In small- and medium-sized hospitals that lack negative pressure facilities for operating rooms, it is impossible to operate on patients infected with COVID-19. As a result, many patients requiring emergency surgery experience serious complications or die. The authors performed intravenous regional anesthesia (IVRA) and emergency surgery in an isolation room on three patients who needed prompt surgical management for upper extremity arterial injuries but could not enter the operating room due to COVID-19 infection. Anesthesia was successful in all cases. A minor anesthetic complication occurred in one patient, who recovered spontaneously. IVRA is a relatively safe and easy method for anesthesia. Moreover, since the tourniquet is inflated before anesthesia, it is well-suited for patients with arterial injury. The method is simple and therefore easy to perform in an isolation room where space and manpower are limited. IVRA can be a good option in emergency surgery for upper extremity artery injury.

P639 Percutaneous drainage vs surgery as definitive treatment for anastomotic leak after intestinal resection in patients with Crohn’s disease.

Abstract Background Anastomotic leak remains one of the most relevant complications after intestinal resection for Crohn’s disease (CD). While surgery has always been considered the standard treatment for perianastomotic abscess or collection, percutaneous drainage (PD) has been proposed as a potential alternative. The aim of this study was therefore to compare the success rate of percutaneous drainage with that of surgery for the management of anastomotic leak in CD patients. Methods Retrospective, single-centre study including all consecutive patients who were diagnosed with an anastomotic leak as a complication of intestinal resection for CD between 2004 and 2022. Patients requiring emergency surgery due to generalised peritonitis or clinical instability were excluded. Anastomotic leak was defined as a perianastomotic fluid collection confirmed by radiological findings within 30 days from surgery. Patients underwent either PD or surgery as a primary treatment for the complication. The success after PD was defined as the removal of the drainage with clinical and radiological resolution of the complication. The need for further surgical treatment was considered as a failure in both groups. Primary aim: to compare the success rate of PD vs surgery. Secondary aims: to compare the outcomes at 90 days after the procedures; to identify the variables associated with the indication to PD. Results Among the 47 patients included, 25 (53%) underwent PD and 22 (47%) surgery. Table 1 shows the outcomes by the procedure. Success rate was 84% in PD and 95% in surgery group (p=0.20). The median time to success was 14 days after PD (drainage removal) and 12.5 days after surgery (discharge) (p=0.92). Similar rates of post-procedure medical (12% vs 18%, p=0.55) and surgical (24% vs 36%, p=0.62) complications were shown. An ileostomy was required in 91% of surgery cases. At 90 days, similar rates of discharges (100% vs 95%, p=0.28), readmissions (8% vs 0%, p=0.18) and reoperations (16% vs 9%, p=0.48) were observed between PD and surgery cases, respectively. In the multivariate analysis (Table 2), PD was more likely to be performed in patients whose anastomotic leak was diagnosed later after surgery (OR 1.25, 95%CI 1.03-1.53, p=0.027), in those who underwent an ileo-colic anastomosis alone (OR 3.72, 95%CI 2.29-12.45, p=0.034) and in those who were treated after 2016 (OR 6.36, 95%CI 1.04-39.03, p=0.046). Conclusion The present study confirms that PD is a safe and effective procedure to treat anastomotic leak and perianastomotic abscess in CD patients. Surgery, in particular, is associated with a high risk of stoma formation, which would require a subsequent operation. PD should be indicated in all eligible patients as an effective alternative to surgery.

Intussusception After Roux-en-Y Gastric Bypass: Correlation Between Radiological and Operative Findings

IntroductionIntussusceptions diagnosed on computed tomography (CT) scans in Roux-en-Y gastric bypass (RYGB) patients could cause serious small bowel obstruction (SBO) or be an incidental finding. The objective of this study was to correlate radiological findings with clinical outcomes to differentiate intussusceptions requiring emergent surgery for SBO.MethodsA search for acute abdominal CT scans reporting intussusceptions in RYGB patients between 2012 and 2019 at Skåne University Hospital, Malmö, Sweden, retrieved 35 scans. These were independently reevaluated by two radiologists for the length and location of the intussusception, whether oral contrast passed through, proximal bowel dilatation, and signs of internal herniation. Clinical outcome in terms of emergency surgery and the diagnosis was determined through chart review.ResultsOut of 35 acute patients, 9 patients required emergency surgery within 24 h. Intussusception caused SBO in five patients, and one patient had an internal herniation, while three patients had unremarkable findings. Eight patients were evaluated for intermittent pain with five unremarkable laparoscopies, while 18 patients had intussusceptions as incidental findings. Intussusception length on CT as measured by radiologists O.E. and D.L. predicted acute bowel obstruction (p = .014 and p < .001). A 100 mm threshold predicted bowel obstruction with a sensitivity of 80% and 100% and a specificity of 93% and 86% by radiologists O.E. and D.L., respectively. Proximal bowel dilatation predicted SBOs of any cause as well as SBO caused by an intussusception (all p < .05).ConclusionIntussusception length > 100 mm on CT in RYGB patients is an easy and valuable sign indicating SBO that may require emergent surgery.Graphical

Psoas attenuation and cross-sectional area improve performance of traditional sarcopenia measurements in predicting one-year mortality among elderly patients undergoing emergency abdominal surgery: a pilot study of five computed tomography techniques.

Risk stratification is challenging in the growing population of geriatric patients requiring emergency surgery. Sarcopenia, which assesses muscle bulk, is a surrogate for frailty and predicts 1-year mortality, but does not incorporate potentially valuable additional information about muscle quality. To describe five different CT methods of measuring sarcopenia and muscle quality and to determine which method has the greatest sensitivity for predicting 1-year mortality following emergency abdominal surgery in elderly patients. This retrospective study includes 297 patients 70years and older who underwent "urgent" or "emergent" laparotomy or laparoscopy for acute abdominal disease between 2006 and 2011 at a single quaternary academic medical center. All patients received a CT abdomen and pelvis with intravenous contrast within 1month of surgery. Five different methods were applied to the psoas muscles on CT: method 1 (total psoas index TPI, which is total psoas area TPA normalized by height), method 2 ("pseudoarea" = anterior-posterior × transverse dimensions), method 3 (average HU), method 4 (TPA × HU), and method 5 ("pseudoarea" × HU). For all five CT measures, mortality was greatest for the lowest quartile by univariate and adjusted Cox proportional hazard analyses at all time points up to 1-year. The C-statistic was highest for Method 4, using a composite index of TPA and Hounsfield Units, indicating the greatest predictive ability to estimate mortality at all time points. Muscle quality and muscle size can be used in tandem to refine risk assessment of older patients undergoing emergency abdominal surgery. Routine calculation of the composite score of psoas cross-sectional area and HU in the emergency room setting may provide surgeons and patients valuable insight on the risk of 1-year mortality to guide preoperative decision-making and counseling. Muscle quality and size, both strong independent predictors of surgical outcomes in older patients undergoing emergency abdominal surgery, may be used in tandem to refine risk assessment. A composite score of psoas muscle cross-sectional area and Hounsfield units on CT may provide insight on 1-year mortality in this patient population.

644. PREDICTORS OF ADVERSE CLINICAL EVENTS FOR CAUSTIC INGESTION IN ADULTS: A 20-YEAR CROSS-SECTIONAL STUDY

Abstract Caustic ingestion is an uncommon but potentially life-threatening condition. It can lead to various complications. There are limited epidemiological studies on caustic ingestion, especially in the Asian population. This study aims to review the clinical characteristics of corrosive ingestion in Hong Kong adults and look for predictors of adverse clinical events. Patients admitted for caustic ingestion at a tertiary referral center in Hong Kong between January 2001 and December 2021 were studied. Patients’ demographic and clinical characteristics, types of caustic substances ingested, Zargar endoscopic grading and clinical outcomes were obtained. Adverse clinical events are defined as the presence of any of the following outcomes: intensive-care-unit (ICU) admission, gastrointestinal (GI) complications (including stricture, ischemia, gangrene, perforation and fistulation), need for surgical or endoscopic intervention, in-hospital mortality, or length of hospital stay (LOS) more than 14 days. Relationships between patients’ factors and different outcomes were then evaluated. Among 69 patients, 45 (65.2%) were suicidal intent. Eight (11.6%) patients required emergency surgery (7 gastrectomies, and 1 esophagectomy). The most common GI complication was esophageal stricture (n=12, 17.4%). Eleven patients underwent endoscopic dilatation; 4 required elective esophagectomy. Patients with diabetes mellitus had a higher Zargar grading (OR=4.259, p=0.040). Adverse clinical events were associated with acid ingestion (OR=4.110, p=0.015) and suicidal intent (OR=3.635, p=0.027). Subgroup analysis showed that diabetes (OR=4.062, p=0.040), acid ingestion (OR=4.222, p=0.016) and suicidal intent (OR=15.932, p=0.009) had higher risks for ICU admission. The morbidity and mortality rates were 29.0% and 7.2% respectively. Caustic ingestion remains an important clinical problem in daily practice, with potential risks of developing severe complications. Suicidal attempt, acid ingestions and history of diabetes are predictors of adverse clinical events.

502 Emergency Giant Hiatus Hernia Surgery: Experiences with Post-Operative Complications

Abstract Aim Patients with giant hiatus hernias can present acutely with volvulus or strangulation. Early emergency surgical intervention with reduction of the hernia and hiatal repair is shown to reduce the mortality rate. However, surgery is not without risk or complications. This study assessed the rate of complications and length of hospital stay in patients requiring emergency surgery. Method A retrospective study was done looking at all patients who underwent emergency hiatal hernia surgery at a tertiary oesophagogastric centre. Over an eight-year period, 80 patients were identified. Their clinical course was evaluated from medical records, collecting data on their length of stay, complications, and mortality. Results Of the 80 patients, 30 patients (37.5%) had no documented complications from the surgery. 62.5% did have complications, of which respiratory complications were the most frequent (43%). 10% of patients had symptomatic recurrence of the hiatus hernia that required operative correction either during index admission or a subsequent admission. Median length of hospital stay was 8 days (IQR 5–16). There was a positive correlation between number of complications and length of stay. Post-operative mortality was 9%. Conclusions Emergency surgery for hiatus hernias has a high morbidity rate, as expected for an emergency procedure in acutely unwell patients. Despite the high rate of post-operative complications, the length of hospital stay was relatively short with low mortality, showing emergency surgery to be an effective lifesaving treatment.

SP2.1.6 A Systematic Review of the Incidence and Predictors of Incisional Hernias in Robotic Prostatectomy

Abstract Aims To conduct a systematic review of the literature to identify the incidence and predictors of incisional hernia (IH) following robotic prostatectomy; and to provide recommendations to reduce the risk factors for IH development post-operatively. Methods The review was performed adhering to PRISMA guidelines, using search terms pertaining to robotic prostatectomy and incidence of IH via electronic databases (MEDLINE, EMBASE and Cochrane database). All original peer-reviewed articles in English were assessed for inclusion and quality by two independent reviewers. A quantitative analysis was conducted to evaluate methodologies, patient demographics, and the incidence of IH following robotic prostatectomy. Results We included 18 studies with a total of 17,965 patients. Average age of patients was 61.83 years and with an average BMI of 27.35. A transperitoneal, 6 port technique was the commonest robotic approach. Main sites of herniation included supraumbilical and lateral ports. The estimated incidence of IH was 1.49% (95% CI 1.28 to 4.25). Studies examining risk factors found age, high BMI, previous hernia repair and wound infections to be contributory to IH development. Only 6 studies reported surgical repair of IH with 3 patients requiring emergency operations. 5 studies reported reduction in IH following modifications in surgical technique. Conclusions Incisional hernias following robotic prostatectomy are a rare complication which can result in high patient morbidity. Our review demonstrated a variable incidence rate with increasing age and high BMI as common potential risk factors. Prevention strategies can result in reduction of IH; however, the studies were heterogenous with inconsistent data quality.

TU8.9 Emergency Giant Hiatus hernia repair, Single Centre Experience

Abstract Aim Patients with giant hiatus hernias can present acutely with volvulus or strangulation. Early emergency surgical intervention with reduction of the hernia and hiatal repair reduces the mortality rate. However, surgery is not without risk or complications. This study assessed the rate of complications and length of hospital stay in patients requiring emergency surgery. Method A retrospective study looked at all patients who underwent emergency hiatal hernia surgery at a tertiary oesophagogastric centre. Over an eight-year period, 80 patients were identified. Their clinical course was evaluated from medical records, collecting data on their length of stay, complications and mortality. Results Of the 80 patients, 30 patients (37.5%) had no documented complications from the surgery. 62.5% did have complications, of which respiratory complications were the most frequent (43%). 10% of patients had a symptomatic recurrence of the hiatus hernia that required operative correction during index admission or subsequent admission. The median length of hospital stay was eight days (IQR 5–16). There was a positive correlation between the number of complications and length of stay. Post-operative mortality was 9%. Conclusion Emergency surgery for hiatus hernias has a high morbidity rate, as expected for an emergency procedure in acutely unwell patients. Despite the high rate of post-operative complications, the length of hospital stay was relatively short with low mortality, showing emergency surgery to be an effective lifesaving treatment.