Patients Requiring Emergency Surgery Research Articles

Idarucizumab, a Specific Reversal Agent for Dabigatran: Mode of Action, Pharmacokinetics and Pharmacodynamics, and Safety and Efficacy in Phase 1 Subjects

The direct oral anticoagulants (DOACs) provide a number of clinical advantages over vitamin K antagonists for the treatment of thromboembolism, including improved efficacy and safety, as well as no need for regular monitoring of anticoagulant effect. However, as with all anticoagulants, bleeding complications may occur, and anticoagulant reversal may be required in specific clinical situations, such as in patients experiencing spontaneous or traumatic bleeds, or in anticoagulated patients requiring emergency surgery or other invasive procedures. Therefore, several reversal agents for the DOACs are in development. This includes the specific reversal agent idarucizumab, which has been approved by the U.S. Food and Drug Administration and the European Medicines Agency for use in patients treated with dabigatran when urgent reversal of its anticoagulant effects is needed. Idarucizumab is a humanized monoclonal antibody fragment that binds with high affinity to free and thrombin-bound dabigatran, resulting in an almost irreversibly bound idarucizumab–dabigatran complex and thereby neutralizing dabigatran's anticoagulant activity. The reversal of the anticoagulant effects of dabigatran by idarucizumab has been demonstrated in animal bleeding models, in healthy volunteers with a range of ages and renal function, and in anticoagulated patients. In the phase 1 trials, at doses of 2 g or greater, idarucizumab resulted in immediate and complete reversal of the dabigatran anticoagulant effects and was well tolerated. In the absence of dabigatran, idarucizumab showed no effect on coagulation parameters or thrombin formation. These findings provide initial evidence that idarucizumab could provide a safe and effective means of reversing anticoagulant activity in patients treated with dabigatran in need of emergency surgery or in emergency bleeding situations.

Preoperative assessment of the risk for multiple complications after surgery

The association between preoperative patient characteristics and the number of major postoperative complications after a major operation is not well defined. In a retrospective, single-center cohort of 50,314 adult surgical patients, we used readily available preoperative clinical data to model the number of major postoperative complications from none to ≥3. We included acute kidney injury; prolonged stay (>48hours) in an intensive care unit; need for prolonged (>48hours) mechanical ventilation; severe sepsis; and cardiovascular, wound, and neurologic complications. Risk probability scores generated from the multinomial logistic models were used to develop an online calculator. We stratified patients based on their risk of having ≥3 postoperative complications. Patients older than 65years (odds ratio 1.5, 95% confidence interval, 1.4-1.6), males (odds ratio 1.2, 95% confidence interval, 1.2-1.3), patients with a greater Charlson comorbidity index (odds ratio 3.9, 95% confidence interval, 3.6-4.2), patients requiring emergency operation (odds ratio 3.5, 95% confidence interval, 3.3.-3.7), and patients admitted on a weekend (odds ratio 1.4, 95% confidence interval, 1.3-1.5) were more likely to have ≥3 postoperative complications than they were to have none. Patients in the medium- and high-risk categories were 3.7 and 6.3 times more likely to have ≥3 postoperative complications, respectively. High-risk patients were 5.8 and 4.4 times more likely to die within 30 and 90days of admission, respectively. Readily available, preoperative clinical and sociodemographic factors are associated with a greater number of postoperative complications and adverse surgical outcomes. We developed an online calculator that predicts probability of developing each number of complications after a major operation.

Diaphragmatic herniation following esophagogastric resectional surgery: an increasing problem with minimally invasive techniques? : Post-operative diaphragmatic hernias.

Post-operative diaphragmatic hernias (PODHs) are serious complications following esophagectomy or total gastrectomy. The aim of this study was to describe and compare the incidence of PODHs at a high volume center over time and analyze the outcomes of patients who develop a PODH. A prospective database of all resectional esophagogastric operations performed for cancer between January 2001 and December 2015 was analyzed. Patients diagnosed with PODH were identified and data extracted regarding demographics, details of initial resection, pathology, PODH symptoms, diagnosis and treatment. Out of 631 patients who had hiatal dissection for malignancy, 35 patients developed of PODH (5.5% overall incidence). Median age was 66 (range 23-87) years. The incidence of PODH in each operation type was: 2% (4/221) following an open 2 or 3 stage esophagectomy, 10% (22/212) following laparoscopic hybrid esophagectomy, 7% (5/73) following MIO, and 3% (4/125) following total gastrectomy. The majority of patients had colon or small bowel in a left-sided hernia. Of the 35 patients who developed a PODH, 20 (57%) patients required emergency surgery, whereas 15 (43%) had non-urgent repair. The majority of the patients had had suture repair (n=24) or mesh repair (n=7) of the diaphragmatic defect. Four patients were treated non-operatively. In hospital post-operative mortality was 20% (4/20) in the emergency group and 0% (0/15) in the elective group. Further hernia recurrence affected seven patients (n=7/27, 26%) and 4 of these patients (15%) presented with multiple recurrences. PODH is a common complication following hybrid esophagectomy and MIO. Given the high mortality from emergency repair, careful thought is needed to identify surgical techniques to prevent PODH forming when minimal access esophagectomy are performed. Upper GI surgeons need to have a low index of suspicion to investigate and treat patients for this complication.

Abstract TP168: Risk of Stroke and Hemorrhage in Patients Treated With Warfarin Versus Dabigatran Requiring Surgery

Introduction: Patients with atrial fibrillation (AF) cease anticoagulants prior to surgery to minimize bleeding risk. Patients requiring emergency surgery may be particularly vulnerable to bleeding if anticoagulants remain in the blood. This may be especially problematic with dabigatran (DAB) use given its lack of reversal agent. Objective: This study compares stroke or bleeding risk in patients with AF taking DAB or warfarin (WARF) that undergo elective, urgent, or emergent inpatient surgery. Methods: Medicare inpatient claims were used to identify patients with AF who underwent elective (n=20,535) and urgent or emergent (n=24,665) surgery from 11/2010 -12/2012, and had received DAB or WARF within 90 days prior to admission. Outcomes included stroke and major bleeding within 30 days of surgery, and blood units used during the admission. Other patient characteristics included demographics, operation type, and comorbid conditions. Risk adjusted differences in outcomes between patients taking DAB or WARF were estimated within admission category using multivariable regression. Results: DAB was used by 5,495 (12%) of patients prior to admission. Overall, 1.0% of patients had stroke within 30 days of surgery, 1.2% had a major bleeding event, and patients received an average 0.12 units of blood. Stroke and bleeding rates did not differ for patients taking WARF or DAB, overall or within admission category. Among elective admissions, blood units used also did not differ between WARF or DAB patients. Among urgent and emergent admissions, patients taking DAB used significantly fewer blood units than patients taking WARF (0.09 vs 0.18, respectively; p<.001). Results were consistent after controlling for other patient factors in multivariable models. Conclusions: Stroke and bleeding risk in patients taking either DAB or WARF were comparable, while patients taking DAB required significantly fewer blood units than patients taking WARF when undergoing emergency surgery. The lack of a reversal agent for DAB does not appear to increase the risk of complications even for emergency surgery.

Surgical management of abdominal tuberculosis: a retrospective study from Central India

Background: Abdominal tuberculosis is a diagnostic and therapeutic challenge in resource limited countries. The vague clinical presentation is a barrier to early diagnosis. The study aims to highlight the role of surgery in the diagnosis and treatment of abdominal tuberculosis.Methods: This is a descriptive study of abdominal tuberculosis cases, which were operated in the Department of Surgery, Peoples College of Medical Sciences & Research Centre, Bhopal from August 2010 to July 2015. Cases were analyzed in terms of demography, clinical features, investigations, operative treatment, and outcome.Results: 72 cases of abdominal tuberculosis were operated during the study period. The median age was 30 years with male to female ratio of 3:2. Primary abdominal tuberculosis was 79.2%. Intestinal tuberculosis was the commonest with terminal ileum and ileo-caecal region being predominantly involved. 58% of the patients required emergency surgery. Surgical procedures performed were: resection of the diseased segment including right hemi-colectomy 32 (44.44%), release of band/adhesions 23 (31.9%), perforation repair 11 (15.3%), stricturoplasty 4(5.5%), etc. In the presence of gross peritonitis, temporary ileostomy was performed. Complication and mortality rates were 33.3% and 2.6% respectively. No patient had post-operative intestinal-leak.The median duration of hospital stay was 14 days.Conclusions: Early diagnosis is the key factor in avoiding systemic and local complications of intestinal tuberculosis. In emergency cases, prompt surgical exploration and vigilant care is met with good recovery. Resection-anastomosis in the form of right hemi-colectomy or segmental resection has largely been adopted instead of simple bypass of obstructive lesions with good results.

Diabetes Mellitus in Patients Presenting with Adhesive Small Bowel Obstruction: Delaying Surgical Intervention Results in Worse Outcomes.

The impact of diabetes mellitus (DM) on outcomes in patients undergoing emergency laparotomy for adhesive small bowel obstruction (ASBO) remains unknown. Low-risk (ASA class of I and II) patients requiring emergency operation for ASBO were identified using the ACS NSQIP database. Propensity score matching was used to match patients with DM to those without DM in a ratio of 1:3. Mortality, infectious complications, acute renal failure (ARF), and myocardial infarction (MI) were compared between the two groups. The impact of delaying OR ≥ 24 h was also analyzed in the two groups. A total of 1,608 patients were matched, 402 with DM and 1,204 without DM. Overall, patients with DM were significantly more likely to develop infections, ARF and MI. Diabetes had no negative impact on outcomes if the operation was performed within 24 h of admission. However, delaying surgery >24, significantly increased infections, ARF and MI. DM in low-risk patients has no negative impact on outcomes in patients undergoing surgery for ASBO within 24 h. However, delaying surgery >24 h resulted in worse outcomes.

P0035 Palliative chemotherapy compared with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for patients with colorectal peritoneal carcinomatosis

Background Cytoreductive surgery (CRS) and hyperthermic intra-peritoneal chemotherapy (HIPEC) prolong survival in selected patients with colorectal peritoneal carcinomatosis. However, this modality of treatment is not standard therapy, and many patients are offered palliative chemotherapy (PC) instead. We hypothesise that PC is suboptimal as complications from the peritoneal disease often disrupts or prevents the PC. We compared overall survival between patients treated with PC and patients undergoing CRS and HIPEC, and we analysed morbidity in those receiving PC. Methods We performed a retrospective review of a prospectively maintained database at the National Cancer Centre Singapore from January 2008, to December 2013. 34 patients underwent CRS and HIPEC, 21 patients were treated with PC. Secondary outcomes were frequency of disruption of chemotherapy, need for surgery or invasive interventions, and duration of hospitalisation for complications of peritoneal disease. Findings Median overall survival for patients receiving PC was 1.7 years (95% confidence interval (CI) 0.7–2.1), but that of CRS and HIPEC was not reached. This was in spite of a longer median follow-up time for patients undergoing CRS and HIPEC of 2.2 years (0.2–7.2) compared with 1.1 years (0.0–3.8) with PC. The hazard of death for a patient treated with PC was 5.5 times that of a patient who underwent CRS and HIPEC (p < 0.05). Of the PC group, 71.4% had chemotherapy disruptions; 60.0% due to complications of peritoneal disease. 14.3% of patients required emergency surgery with stoma creation for intestinal obstruction, and 23.8% of patients required abdominal cope loop and ureteric stent insertion. Median total duration of unforeseen hospitalisation post-CRS and HIPEC was 11 days (0–149), compared with 21 days (0–85) in the PC group. Interpretation CRS and HIPEC prolonged survival compared with PC in selected patients with CLR peritoneal carcinomatosis. Patients treated with PC have significant morbidity from disease progression, which disrupts planned chemotherapy and results in significantly longer hospitalisation compared with CRS and HIPEC. Cytoreductive surgery (CRS) and hyperthermic intra-peritoneal chemotherapy (HIPEC) prolong survival in selected patients with colorectal peritoneal carcinomatosis. However, this modality of treatment is not standard therapy, and many patients are offered palliative chemotherapy (PC) instead. We hypothesise that PC is suboptimal as complications from the peritoneal disease often disrupts or prevents the PC. We compared overall survival between patients treated with PC and patients undergoing CRS and HIPEC, and we analysed morbidity in those receiving PC. We performed a retrospective review of a prospectively maintained database at the National Cancer Centre Singapore from January 2008, to December 2013. 34 patients underwent CRS and HIPEC, 21 patients were treated with PC. Secondary outcomes were frequency of disruption of chemotherapy, need for surgery or invasive interventions, and duration of hospitalisation for complications of peritoneal disease. Median overall survival for patients receiving PC was 1.7 years (95% confidence interval (CI) 0.7–2.1), but that of CRS and HIPEC was not reached. This was in spite of a longer median follow-up time for patients undergoing CRS and HIPEC of 2.2 years (0.2–7.2) compared with 1.1 years (0.0–3.8) with PC. The hazard of death for a patient treated with PC was 5.5 times that of a patient who underwent CRS and HIPEC (p < 0.05). Of the PC group, 71.4% had chemotherapy disruptions; 60.0% due to complications of peritoneal disease. 14.3% of patients required emergency surgery with stoma creation for intestinal obstruction, and 23.8% of patients required abdominal cope loop and ureteric stent insertion. Median total duration of unforeseen hospitalisation post-CRS and HIPEC was 11 days (0–149), compared with 21 days (0–85) in the PC group. CRS and HIPEC prolonged survival compared with PC in selected patients with CLR peritoneal carcinomatosis. Patients treated with PC have significant morbidity from disease progression, which disrupts planned chemotherapy and results in significantly longer hospitalisation compared with CRS and HIPEC.

Faux anévrisme de l’artère iliaque interne au cours de l’évolution d’une maladie de Behçet

This case illustrates a very rare localization of false aneurysm in Behçet's disease and demonstrates the importance of monitoring treated patients. The diagnosis of severe Behçet's disease was established in a young man after discovery of a cerebral venous thrombosis. One year later, the patient required emergency surgery for a symptomatic pseudoaneurysm of the internal iliac artery. Performed after a 3-day regimen of corticosteroid boluses, the pseudoaneurysm was treated by ligation of the hypogastric artery. Corticosteroids were then given for immunosuppression. Arterial involvement in Behçet's disease can be at the forefront of the clinical features and can cause potentially fatal complications. False aneurysm of the internal iliac artery is exceptional with only two cases reported in the literature. These false aneurysms occur on a fragile artery wall. Treatment requires the administration of immunosuppressive drugs. This rare clinical presentation highlights the importance of clinical and radiological monitoring in young patients with Behçet's disease.

Cardiac tamponade after pulmonary valvuloplasty for presumed pulmonary valvular stenosis in a patient with double-chambered right ventricle: An unexpected diagnosis during emergency surgery

Corresponding author: Sahin Bozok, M.D. Recep Tayyip Erdogan Universitesi Tip Fakultesi Kalp ve Damar Cerrahisi Anabilim Dali, 53200 Rize, Turkey. Tel: +90 464 217 03 65 e-mail: sahinboz@yahoo.com Double-chambered right ventricle (DCRV) is a rare cardiac congenital anomaly characterized by an obstruction of subinfundibular region by abnormal muscle bands. Herein, we report a case with DCRV and cardiac tamponade requiring urgent surgery following pulmonary valvuloplasty due to presumed pulmonary valvular stenosis. A 42-year-old female patient was admitted to cardiology department with a complaint of dyspnea. The patient was diagnosed with pulmonary valvular stenosis by echocardiography and cardiac catheterization. A maximum hemodynamic gradient of 110 mmHg was detected in the right ventricular outf low tract (RVOT). The patient required emergency surgery due to the right atrial laceration and cardiac tamponade following an attempt for pulmonary valvuloplasty. Right atrial injury was repaired by primary suturing and a longitudinal incision was made to the RVOT. A fibrotic, circular muscular ring in the subinfundibular region was resected. Pressure tracings from the right ventricle and pulmonary arteries revealed resolution of pressure gradient. Preoperative correct diagnosis of DCRV and associated pathologies increase the success of surgical procedures and may prevent unexpected complications for both the surgeon and the patient.

Increased health services use by severely obese patients undergoing emergency surgery: a retrospective cohort study.

The aim of this study was to assess perioperative outcomes in obese patients undergoing emergency surgery. We retrospectively reviewed the charts of all adult (> 17 yr) patients admitted to the acute care emergency surgery service at the University of Alberta Hospital between January 2009 and December 2011 who had a body mass index (BMI) of 35 or higher. Patients were divided into subgroups for analysis based on "severe" (BMI 35-39.9) and "morbid" obesity (BMI ≥ 40). Multivariate logistic regression was performed to identify predictors of in-hospital mortality after controlling for confounding factors. Data on 111 patients (55% women, median BMI 39) were included in the final analysis. Intensive care unit (ICU) support was required for 40% of patients. Postoperative complications occurred in 42% of patients, and 31% required reoperation. Overall in-hospital mortality was 17%. Morbidly obese patients had increased rates of reoperation (40% v. 23%, p = 0.05) and increased lengths of stay compared with severely obese patients (14.5 v. 6.0 d, p = 0.09). Age (odds ratio [OR] 1.08 per increment) and preoperative ICU stay (OR 12) were significantly associated with in-hospital mortality after controlling for confounding, but BMI was not. Obese patients requiring emergency surgery represent a complex patient population at high risk for perioperative morbidity and mortality. Greater resources are required for their care, including ICU support, repeat surgery and prolonged ICU stay. Future studies could help identify predictors of reoperation and strategies to optimize nutrition, rehabilitation and resource allocation.

Iatrogenic Aortic Dissection Complicating Percutaneous Coronary Intervention for Chronic Total Occlusion

BackgroundWe aimed to determine the prevalence of iatrogenic aortic dissection in chronic total occlusion (CTO) recanalization procedures, and to assess the management strategy and outcome of such a complication. MethodsThis study was a retrospective analysis of CTO percutaneous coronary intervention (PCI) cases performed by a single CTO experienced operator. Iatrogenic aortic dissection was defined as persistent contrast staining in the aortic cusp or root. ResultsAmong 956 CTO PCI cases, iatrogenic aortic dissection occurred in 8 patients for an overall frequency of 0.83%. The right coronary artery was the CTO involved vessel in all cases with ostial location and severe calcifications in 37.5% and 62.5% of cases, respectively. Four patients underwent the antegrade approach and a retrograde strategy was adopted in the remaining 4 patients. The iatrogenic aortic dissection started from the right sinus of Valsalva in 87.5% of cases and catheter trauma was the presumed mechanism of dissection in most cases. Stenting of the entry point was performed in all cases, and dissection was limited (< 40 mm) in all patients. No patients required emergency surgery. One cardiac death was observed 12 days after the index procedure (12.5%), and a mean follow-up of 31.5 months was uneventful in the remaining 7 patients. ConclusionsCTO recanalization procedures might be associated with a greater incidence of iatrogenic aortic dissection than non-CTO PCI. The therapeutic strategy and outcome depend on the rapidity of the entry point sealing and the degree of extension of the dissection into the aorta in serial imaging assessment.

Laparoscopic peritoneal lavage for Hinchey III diverticulitis: is it as effective as it is applicable?

Over the past few years, the laparoscopic peritoneal lavage has emerged as a therapeutic alternative to standard resection procedures. However, its effectiveness and applicability remain debatable. The aim of this study was to assess laparoscopic lavage in controlling abdominal sepsis secondary to purulent peritonitis. This study was conducted as a retrospective analysis of prospectively collected data. This study was conducted at a single tertiary care institution. Patients requiring emergency surgery for perforated diverticulitis and generalized peritonitis between June 2006 and June 2013 were identified from a prospective database. Laparoscopic assessment was considered in all of the hemodynamically stable patients, and laparoscopic lavage was performed according to intraoperative strict criteria. Primary outcomes were the effectiveness and applicability of laparoscopic lavage. Secondarily, feasibility, morbidity, and mortality were also assessed. Seventy-five patients required emergency surgery for generalized peritonitis secondary to perforated diverticulitis. Forty-six patients who underwent laparoscopy presented a purulent generalized (Hinchey III) peritonitis and were examined under the intention-to-treat basis to perform a laparoscopic lavage. Thirty-two patients (70.0%; 95% CI 56.2-82.7) had no previous episodes of diverticulitis. Thirty-six patients (78.0%; 95% CI 66.3-90.1) had free air on a CT scan. The conversion rate was 4% (95% CI 0-10). The feasibility of the method was 96.0% (95% CI 90.4-100), and its applicability was 59.0% (95% CI 44.8-73.2). Median operative time was 89 minutes (range, 40-200 minutes). Postoperative morbidity was 24.0% (95% CI 11.7-36.3), and the mortality rate was 0%. We registered 5 failures, and all of them underwent reoperation. The effectiveness of the procedure was 85% (95% CI 76-93). This was a single-institution retrospective study. The effectiveness of laparoscopic lavage seems to be high. Although its applicability is lower, it could be applied in more than half of patients requiring emergency surgery. This alternative strategy should be considered when laparoscopic assessment reveals Hinchey III diverticulitis.

Diabetes mellitus in patients presenting with adhesive small bowel obstruction: delaying surgical intervention results in worse outcomes

The impact of diabetes mellitus (DM) on outcomes in patients undergoing emergency laparotomy for adhesive small bowel obstruction (ASBO) remains unknown. Low-risk (ASA class of I and II) patients requiring emergency operation for ASBO were identified using the ACS NSQIP database. Propensity score matching was used to match patients with DM to those without DM in a ratio of 1:3. Mortality, infectious complications, acute renal failure (ARF), and myocardial infarction (MI) were compared between the two groups. The impact of delaying OR ≥24 h was also analyzed in the two groups. A total of 1,608 patients were matched, 402 with DM and 1,204 without DM. Overall, patients with DM were significantly more likely to develop infections, ARF and MI. Diabetes had no negative impact on outcomes if the operation was performed within 24 h of admission. However, delaying surgery >24, significantly increased infections, ARF and MI. DM in low-risk patients has no negative impact on outcomes in patients undergoing surgery for ASBO within 24 h. However, delaying surgery >24 h resulted in worse outcomes.

Vagotomy/Drainage Is Superior to Local Oversew in Patients Who Require Emergency Surgery for Bleeding Peptic Ulcers

To compare early postoperative outcomes of patients undergoing different types of emergency procedures for bleeding or perforated gastroduodenal ulcers. Although definitive acid-reducing procedures are being used less frequently during emergency ulcer surgery, there is little published data to support this change in practice. A retrospective analysis of data for patients from the 2005-2011 American College of Surgeons National Surgical Quality Improvement Program database who underwent emergency operation for bleeding or perforated peptic ulcer disease was performed to determine the association between surgical approach (local procedure alone, vagotomy/drainage, or vagotomy/gastric resection) and 30-day postoperative outcomes. Multivariable regression analysis was used to adjust for a number of patient-related factors. A total of 3611 patients undergoing emergency ulcer surgery (775 for bleeding, 2374 for perforation) were included for data analysis. Compared with patients undergoing local procedures alone, vagotomy/gastric resection was associated with significantly greater postoperative morbidity when performed for either ulcer perforation or bleeding. For patients with perforated ulcers, vagotomy/drainage produced similar outcomes as local procedures but required a significantly greater length of postoperative hospitalization. Conversely, vagotomy/drainage was associated with a significantly lower postoperative mortality rate than local ulcer oversew when performed for bleeding ulcers. Simple repair is the procedure of choice for patients requiring emergency surgery for perforated peptic ulcer disease. For patients requiring emergency operation for intractable ulcer bleeding, vagotomy/drainage is associated with lower postoperative mortality than with simple ulcer oversew.

Clinical Analysis and Proper Management of the Patients Visited ER Due to Ingested Foreign Body: Single Center Experience

Purpose: The conventional treatment for ingested foreign bodies (IFB) is removal, which is successful in most cases. However, it can be associated with severe complications, such as gastrointestinal tract perforation, and require emergency surgery. The aim of this study is to analyze clinical data relating to IFB and to develop a proper management plan to reduce the incidence of severe complications. Methods: Between September 2001 and September 2009, 117 patients visited the emergency room complaining of IFB. Among these patients, 29 were diagnosed with bezoar and were excluded from the study. Medical data for the remaining 88 patients was reviewed retrospectively. For statistical analysis, the foreign bodies (FB) were classified into three subgroups according to their shape (round, sharp, and amorphous). Results: The median age of patients with IFB was seven years, and the male-to-female ratio was 1.3:1. Many of these patients were preschool children under the age of seven who had accidentally swallowed FB (56 cases, 63.6%). The most common symptom presented among the patients was FB sensation (18 cases, 21%). The results of subgroup analysis showed no significant relation between the shape of the FB and the treatment modality. Spontaneous passage was observed in 21 cases (23.9%). Otherwise, endoscopic removal was performed successfully in 61.4% of cases, and 13 patients required emergency operations (14.8%). Conclusion: Early diagnosis and a prompt approach are significant in the successful treatment of IFB. Endoscopic or surgical procedures are sometimes required, particularly in cases where complications are suspected.

Recent advances in gastric cancer.

Recent advances in gastric cancer.

Transcatheter embolisation of iatrogenic renal vascular injuries

The aim of our study was to review our experience and long-term follow-up in the treatment of iatrogenic renal vascular injuries using transcatheter embolisation. Our retrospective analysis of cases collected in two interventional centres consists of a total of 21 patients who underwent renal arterial embolisation (RAE) for iatrogenic arterial kidney bleeding. Biopsy (n = 4), percutaneous nephrolithotomy (n = 4), nephron-sparing surgery (n = 4), guidewire-induced arterial perforation during coronary angiography or renal stenting (n = 3), percutaneous nephrostomy (n = 3), renal endopyelotomy/pyeloplasty (n = 2) and surgical nephrectomy were the iatrogenic causes. Seven patients presented with haemodynamic instability requiring blood transfusion (33.3%), the remaining were haemodynamically stable (66.7%). Diagnostic renal angiography revealed 9 actively bleeding vessels, 6 pseudoaneurysms, 4 arteriovenous fistulas and 1 arterio-calyceal fistula. In one patient selective renal arteriography was negative probably because the bleeding observed at CT angiography was self-limited. Twenty-one embolisation procedures were performed in 20 patients; one patient required a second embolisation 3 h after the first one. Embolisation was performed with microcoils, polyvinyl alcohol particles, embospheres, spongostan emulsion and vascular plug. The technical success rate was 100%. The overall clinical success rate was 95%. Apart from a patient who died due to disseminated intravascular coagulation, no major complications requiring intensive care treatment were encountered during or after the procedures. No patient required emergency surgery or subsequent surgical treatment. No statistically significant differences in eGFR or renal function stage appeared after RAE. Percutaneous treatment can be proposed as a first-line treatment in iatrogenic renal arterial injuries, resulting in a safe and effective procedure.

Is preoperative period associated with severity and unexpected death of injured patients needing emergency trauma surgery?

Early operative control of hemorrhage is the key to saving the lives of severe trauma patients. We investigated whether emergency room (ER) stay time [time from the ER to the operating room (OR)] is associated with trauma severity and unexpected trauma death [Trauma and Injury Severity Score (TRISS) method-based probability of survival (Ps) ≥0.5 but died] of injured patients needing emergency trauma surgery. We performed a retrospective review of all trauma patients requiring emergency surgery and all patients with pelvic fractures requiring transcatheter arterial embolization at our hospital from January 2002 to December 2012. We analyzed the relationships among injury severity on ER admission [Injury Severity Score (ISS); Revised Trauma Score (RTS); Ps; Shock Index (SI); American Society of Anesthesiologists Physical Status (ASA-PS)]; mortality rate; unexpected trauma death rate; and ER stay time. ER stay times were significantly shorter for patients with life-threatening conditions [RTS <6.0 (p<0.01), Ps <0.5 (p<0.001), SI ≥1.0 (p<0.01), and ASA-PS ≥4E (p<0.001)]. In particular, ER stay time was inversely related to injury severity up to 120min. The risk of unexpected trauma death significantly increased as ER stay time increased over 90min (p<0.01). Our results suggest that all medical staff should work together effectively on high-risk patients in the ER, bringing them immediately to the OR according to their level of risk. If injured patients need emergency trauma surgery, ER stay times should be kept as short as possible to reduce unexpected trauma death.

Ovarian tumor cases that were preoperatively diagnosed as benign but postoperatively confirmed as borderline or malignant after laparoscopic surgery

Abstract Objective Laparoscopic surgery is the gold standard for benign ovarian tumors because of its overall improved quality of life (QOL). However, some tumors diagnosed preoperatively as benign may be proven to be malignant by postoperative studies. The standard approach for the removal of a malignant ovarian tumor in our hospital is via laparotomy; however, there is no referential prognostic data on malignancies that are excised laparoscopically. To evaluate clinical and histological factors and prognosis, this study retrospectively reviewed patients who underwent surgery in our hospital, based on a preoperative diagnosis of benignancy, but later postoperative testing proved their tumors to be borderline or malignant. Participants and methods The study group comprised 1322 women who underwent a laparoscopic procedure in our hospital on the basis of a preoperative diagnosis of a benign ovarian tumor. The procedures were performed between 1995 and 2011. The rate of borderline and malignant cases, histology, and postoperative treatment were investigated. Results Of the 1322 patients, 15 (1.1%) patients were postoperatively diagnosed as having a borderline malignancy with various histological types and all of these patients had a good prognosis; four (0.3%) patients were postoperatively diagnosed as having a malignant tumor with various histological types; of these patients, two patients required emergency surgery. All four patients underwent additional surgery and chemotherapy with no recurrence to date. Conclusion Some tumors diagnosed preoperatively as benign proved postoperatively to be malignant. Appropriate postoperative treatment effectively improved the prognosis. Particular attention should be paid to a possible occult malignancy that may manifest postoperatively, especially in patients who underwent emergency surgery. We recommend preoperative magnetic resonance imaging, even for emergency cases, to improve preoperative diagnosis.

Emergency surgery for acute diverticulitis

The optimal surgical management of acute diverticulitis is still a controversial and unresolved issue. While the Hartmann's procedure (`) is the most commonly performed operation, primary anastomosis (PA), with or without proximal diversion, has also been used with increasing frequency. This is a National Surgical Quality Improvement Program database study including all patients requiring emergency surgery for acute diverticulitis. Three operative approaches were analyzed: HP, colectomy with PA, and colectomy with PA with proximal diversion (PAPD). Mortality and postoperative outcomes were compared between the three groups using a logistical regression model. There were 1,314 patients who required emergent operation for acute diverticulitis, 75.4% underwent HP, 21.7% underwent PA, and 2.9% underwent PAPD. Thirty-day mortality was 7.3%, 4.6%, and 1.6% for HP, PA, and PAPD respectively (p = 0.163), while surgical site infections occurred in 19.7%, 17.9%, and 13.2%, respectively (p = 0.59). After multivariable analysis adjusting for age, alcohol consumption, comorbidities, steroid use, preoperative laboratory values, hemorrhage at admission and laparoscopic surgery, the adjusted odds ratio for 30-day mortality comparing PA with HP was 0.77 (95% confidence interval [CI], 0.38-1.56; p = 0.465), 0.47 (95% CI, 0.06-3.74; p = 0.479) comparing PAPD with HP, and 1.62 (95% CI, 0.19-13.78; p = 0.658) comparing PA with PAPD. In addition, the three groups did not have significantly different adjusted odds ratio for the development of surgical infectious complications, acute kidney injury, cardiovascular incidents, or venous thromboembolism after surgery. Resection and PA in patients undergoing an emergency operation for acute diverticulitis is a safe alternative to the HP, with no significant difference in mortality or postoperative surgical site infections. Therapeutic study, level IV.