Patients Underwent Emergency Repair Research Articles

Outcomes of elective and emergency surgical repair of incisional hernia: a comparative observational study.

Incisional hernia (IH) is a common complication following abdominal surgery. Surgical repair of IH is associated with the alleviation of symptoms and improvement of quality of life. Operative intervention can pose a significant burden to the patient and healthcare facilities. This study aims to describe and compare outcomes of elective and emergency surgical repair of IH. This study is a single-centre comparative retrospective study including patients who had repair of IH. Patients were divided into Group I (Emergency) and Group II (Elective), and a comparison was conducted between them. Two hundred sixty-two patients were identified with a mean age of 61.8 ± 14.2 years, of which 152 (58%) were females. The mean BMI was 31.6 ± 7.2 kg/m2. More than 58% had at least one comorbidity. 169 (64.5%) patients had an elective repair, and 93 (35.5%) had an emergency repair. Patients undergoing emergency repair were significantly older and had higher BMI, p = 0.031 and p = 0.002, respectively. The significant complication rate (Clavien-Dindo III and IV) was 9.54%. 30 and 90-day mortality rates were 2.3% (n = 6) and 2.68% (n = 7), respectively. In the emergency group, the overall complications, 30-day and 90-day mortality rates were significantly higher than in the elective group, p ≤ 0.001, 0.002 and 0.001, respectively. Overall, 42 (16.1%) developed wound complications, 25 (9.6%) experienced a recurrence, and 41 (15.71%) were readmitted within 90 days, without significant differences between the two groups. Patients who underwent emergency repair were significantly older and had a higher BMI than the elective cases. Emergency IH repair is associated with higher complication rates and mortality than elective repair.

SP7.11 Outcomes of Elective and Emergency Surgical Repair of Incisional Hernia - A Comparative Observational Study

Abstract Aims Incisional hernia (IH) is a common complication after abdominal surgery. This study aims to describe and compare the outcomes of IH's elective and emergency surgical repair. Methods A single-centre comparative retrospective study including all patients who had surgical repair of IH. The patients were divided into Group I (Emergency) and Group II (Elective). A comparison was made between the two groups. Results 262 patients were identified with a mean age of 61.8 SD±14.2 years, and 152 (58%) were females. More than 58% had at least one comorbidity. 169 (64.5%) had elective, and 93 (35.5%) had emergency repair. Patients undergoing emergency repair of IH were significantly older and had higher BM, p= 0.031 and 0.002, respectively. The overall complication rate in the full cohort was 46.2%, and the significant complication rate (Clavien-Dindo III and IV) was 9.54%. The 30-day and 90-day mortality rates were 6 (2.3%) and 7 (2.68%), respectively. In the emergency group, the complications, 30-day and 90-day mortality rates were significantly higher than in the elective group, p= <0.001, 0.002 and 0.001, respectively. The emergency group had a significantly longer hospital stay, and more of them needed a higher level of care, p= <0.001 each. Overall, 42 (16.1%) developed wound complications, 25 (9.6%) patients had a recurrence, and 41 (15.71%) had 90-day readmissions without significant differences between the two groups. Conclusions IH is associated with medical comorbidity and high BMI. Emergency repair of IH is associated with higher complication rates and mortality compared to elective repair.

Risk factors for decompensation and death following umbilical hernia repair in patients with end-stage liver disease.

Symptomatic umbilical hernias are a common cause of morbidity and mortality in patients with cirrhosis and end-stage liver disease (ESLD). This study set out to characterise the factors predicting outcome following repair of symptomatic umbilical hernias in ESLD at a single institution. A retrospective review was performed of all patients with ESLD who underwent repair of a symptomatic umbilical hernia between 1998 and 2020. Overall survival was predicted using the Kaplan-Meier method. Logistic regression was used to determine predictors of decompensation and 30-day, 90-day and 1-year mortality. One-hundred-and-eight patients with ESLD underwent umbilical hernia repair (emergency n = 78, 72.2%). Transjugular shunting was performed in 29 patients (26.9%). Decompensation occurred in 44 patients (40.7%) and was predicted by emergency surgery (OR, 13.29; P = 0.001). Length of stay was shorter in elective patients compared to emergency patients (3-days vs. 7-days; P = 0.003). Thirty-day, 90-day and 1-year survival was 95.2, 93.2 and 85.4%, respectively. Model for ESLD score >15 predicted 90-day mortality (OR, 18.48; P = 0.030) and hyponatraemia predicted 1-year mortality (OR, 5.31; P = 0.047). Transjugular shunting predicted survival at 1 year (OR, 0.15; P = 0.038). Repair of symptomatic umbilical hernias in patients with ESLD can be undertaken with acceptable outcomes in a specialist centre, however, this remains a high-risk intervention. Patients undergoing emergency repair are more likely to decompensate postoperatively, develop wound-related problems and have a longer length of stay. Transjugular shunting may confer a benefit to survival, but further prospective trials are warranted.

FEASIBILITY OF ERAS (ENHANCED RECOVERY AFTER SURGERY) PROTOCOL IN PATIENTS UNDERGOING EMERGENCY REPAIR FOR PERFORATED PEPTIC ULCER DISEASE IN A TERTIARY CARE HOSPITAL

Introduction: The surgical treatment of perforated peptic ulcer disease has evolved in parallel to advances in medical treatment of Peptic Ulcer Disease. Objective: To investigate the feasibility of ERAS (Enhanced Recovery after Surgery) Pathways in patients undergoing emergency repair for Perforated peptic ulcer disease. Materials and methods: Institutional based prospective analytical study. Indoor patients in Dept. of General Surgery in Medical College and Hospital Kolkata. January 2019 to June 2020. Study was conducted for 18 months.14 months was provided for data collection. Next 2 months for statistical analysis and another 2 months for thesis writing and submission. Conclusion: ERAS pathway (with some modications) seems to be safe and feasible in a highly selected subset of patients undergoing emergency Omental grahams patch repair of Perforated Peptic Ulcer Disease

Increased risk of postoperative complications with retromuscular mesh placement in emergency incisional hernia repair: A nationwide register-based cohort study.

Incisional hernia is common after abdominal surgery. Watchful waiting carries the risk of incarceration and a need for emergency intervention. The aim of this study was to examine the risk of postoperative complications after emergency versus elective incisional hernia repair. Patients above 18 years of age undergoing open incisional hernia repair in Denmark in 2017-2018 were identified in the Danish Ventral Hernia Database. Patients were grouped according to elective or emergency hernia repair. The primary outcome was postoperative complications requiring operative intervention within 90 days, and the secondary outcome was postoperative length of stay. We included 1050 patients, of whom 882 were admitted for elective and 168 for emergency operation. Patients undergoing emergency repair were older (64.7 years vs 59.2 years, p < 0.001), more often smokers (25.8% vs 13.6%, p = 0.003), and more often had a Charlson comorbidity score ⩾2 (26.8% vs 19.2%, p = 0.005) compared to patients undergoing elective repair. In a multivariate regression analysis, emergency compared to elective operation (OR = 2.71, 95% CI = 1.4-5.25, p = 0.003) and retromuscular compared to onlay mesh placement (OR = 2.14, 95% CI = 1.08-4.24, p = 0.013) were factors significantly associated with increased risk of postoperative complications. In a subgroup analysis including only emergency repairs, risk of complications after retromuscular mesh placement was even higher (OR = 10.12, 95% CI = 1.81-56.68, p = 0.008). Emergency incisional hernia repair was associated with increased risk of postoperative complications and this risk was accentuated with retromuscular mesh placement. The use of retromuscular mesh in the emergency setting should be avoided, and the abdominal wall could either be closed by sutures or additional onlay mesh.

Abdominal Aortic Aneurysms in the Ageing: Outcomes of Aneurysm Surveillance in 85 Year Olds

Introduction - By 2036 it is estimated that the number of people over the age of 85 years will double from present levels.1 This will have a profound impact on the management of complex vascular pathologies, such as abdominal aortic aneurysms (AAA). Despite this, the evidence relating to AAA surveillance was performed on patients aged less than 80 years and subsequently there is a paucity of evidence relating to the continued surveillance of this cohort.2 We aim to assess the outcomes of patients of 85 year olds who are under surveillance for small AAAs (3.0-5.5cm). Methods - A single-centre, retrospective analysis of all patients, aged 85 or over, undergoing active surveillance of small AAAs between January 2007-January 2018. Patients were stratified into four groups according to AAA diameter (<4.0, 4.0-4.5, 4.6-5.0, >5.0cm) at the age of 85 years (index scan), or older if first scan after this age. A comparison between the groups was performed to identify the rates of patients reaching threshold (>5.5cm), subsequent management and mortality (ruptured AAA and other cause mortality). Follow-up was continued from index scan to death or 01/01/2018 (whichever sooner). Results - 101 patients were identified (male=88) with a mean AAA diameter of 4.5cm (SD=0.92) at index scan. Mean follow-up was 1078 days (SD=739). 28 patients (27.7%) reached threshold size for repair, of which 8 (28.6%) underwent elective surgical repair. Of patients undergoing repair, 6(75%) had an AAA of >5cm at index scan. In patients with an AAA of <4.0cm at index, only 1 (3.4%) reached threshold and none underwent repair. Standard endovascular aneurysm repair was the modality of choice (62.5%). No patients underwent emergency repair. Comparison of outcomes between groups is shown in table 1. Overall mortality in the cohort was 26 (25.7%). Acute lower respiratory tract infection (42.3%) and cerebral vascular accident (23.1%) were the leading causes of death. Only 2 deaths occurred from ruptured AAAs (7.7%), both having an AAA of >5cm at index. No 30-day post-operative mortality was recorded.Table 1Comparison of patients reaching threshold and undergoing repairAneurysm diameter at aged 85 (cm)TotalTotal reaching threshold (% total)Surgical repair (% threshold)Mortality - ruptured aneurysm (% total)<4.0291 (3.4)0 (0.0)0 (0.0)4.0-4.5264 (15.4)1 (25.0)0 (0.0)4.6-5.0171 (5.9)1 (100)0 (0.0)>5.02922 (75.9)6 (27.3)2 (6.9) Open table in a new tab Conclusion - At the age of 85 years, it is very unlikely that patients with AAAs of <4cm will reach a threshold size for repair and discontinuation of surveillance can be considered. In our experience, the risk of death for a rupture in patients with AAAs 3.0-5.5cm at the age of 85 years remains relatively low and occurred only in patients with AAAs >5cm at index scan.

Dissection Thoracic Aneurysm After Type A Surgical Repair: “Kick-Off registry”

Introduction - The success of aortic dissection surgery depends upon complete resection of the primary intimal tear with attempted obliteration of the false lumen; in this concept the major goal for acute type A aortic dissection (AAAD) after surgical aortic replacement is to have a living patient.” This motto is always the directive for the cardiac-surgeon. However, the extent of the “A” dissection and surgical management could lead to “chronic dissection B”; which may eventually require additional treatments during follow-up. The traditional approach of open distal anastomosis is associated with high rates of persistent false lumen patency which exposes the patient to the formation of complex thoraco-abdominal dissection aneurysms. Kick-Off is a registry which evaluates the results of “cardiac-surgery” performed on patients with AAAD, in acute phase as well as during follow-up (the need of intervention surgery or endovascular aortic repair for dissection thoracic aneurysm > 55 mm). Methods - Between January 2010 and December 2017, in Santa Maria Hospital - Terni data concerning acute type A aortic dissection was collected in a registry: “Kick-Off Registry”. Urgent admissions with the diagnosis of acute A dissection were selected. Surgical outcomes were evaluated in terms of operative mortality and morbidity. Furthermore the development of thoracic dissection aneurysm was analysed, during follow-up. The following anatomic conditions like entry tear (patent / non patent); entry tear localization (inner or external), diameter of entry tear (major or minor 10 mm); initial aortic diameter (major or minor 40 mm), false lumen thrombosis (yes or not), shape of true lumen (elliptical or circular) and type of dissecton (linear or spiral) were taken into consideration. Moreover the type of surgical approach was evaluated. Statistical analyses were carried out using SPSS statistics version 22. Results - 196 patients underwent emergency repair for AAAD using a standard approach. 66% patients required replacement of the dissected ascending aorta, 27% required an emiarch replacement and 7% required total aortic root replacement. The mean age was 65.7 (146 male – 50 female). Median-follow-up was 29 months. Overall operative mortality was 21%. Multivariate analysis revealed that older age, stroke and malperfusion increased the risk of operative death. During follow-up the overall need for any kind of intervention (surgery, TEVAR or Hybrid intervention) was 19%. In multivariate analysis (Cox regression) a patent primary entry tear (P<0.05), initial diameter (superior to 40 mm - P<0.05)were predictors of thoraco-abdominal dissection aneurysm superior to 55 mm. Multivariate analysis showed that the type of required repair (emiarch replacement) was the primary factor associated with the development of dissection aneurysm (P<0.001). Conclusion - The anatomic conditions of AAAD and an unsuitable surgical strategy could bring about the development of thoraco-abdominal dissection aneurysm. The “Kick-Off” registry is helpful to understand the mechanisms that lead to dissection aneurysm; in the future we hope to categorization the risk patients for aneurysm disease. Furthermore, treatment options in acute phase and suggest preventive strategies to reduce the occurrence of this dissection aneurysm to a minimum would be define.

Laparoscopic versus open repair of perforated peptic ulcer: Improving outcomes utilizing a standardized technique

The objective of this study was to compare the outcomes of patients who underwent laparoscopic and open repair of perforated peptic ulcers (PPUs) at our institution. This is a retrospective review of a prospectively collected database of patients who underwent emergency laparoscopic or open repair for PPU between December 2010 and February 2014. A total of 131 patients underwent emergency repair for PPU (laparoscopic repair, n=63, 48.1% vs. open repair, n=68, 51.9%). There were no significant differences in baseline characteristics between both groups in terms of age (p=0.434), gender (p=0.305), body mass index (p=0.180), and presence of comorbidities (p=0.214). Both groups were also comparable in their American Society of Anesthesiologists (ASA) scores (p=0.769), Boey scores 0/1 (p=0.311), Mannheim Peritonitis Index > 27 (p=0.528), shock on admission (p<0.99), and the duration of symptoms > 24 hours (p=0.857). There was no significant difference in the operating time between the two groups (p=0.618). Overall, the laparoscopic group had fewer complications compared with the open group (14.3% vs. 36.8%, p=0.005). When reviewing specific complications, only the incidence of surgical site infection was statistically significant (laparoscopic 0.0% vs. open 13.2%, p=0.003). The other parameters were not statistically significant. The laparoscopic group did have a significantly shorter mean postoperative stay (p=0.008) and lower pain scores in the immediate postoperative period (p<0.05). Mortality was similar in both groups (open, 1.6% vs. laparoscopic, 2.9%, p < 0.99). Laparoscopic repair resulted in reduced wound infection rates, shorter hospitalization, and reduced postoperative pain. Our single institution series and standardized technique demonstrated lower morbidity rates in the laparoscopic group.

The decreasing incidence of ruptured abdominal aortic aneurysm in Wales.

AimsPrior to the introduction of the NHS Abdominal Aortic Aneurysm (AAA) Screening Programme some authors have reported a decline in incidence of clinically-relevant AAAs. The aim of this study was to identify the changing pattern of, and mortality from, ruptured AAA (rAAA) in patients reaching hospital alive in Wales.MethodsData was obtained from the Public Health Wales Observatory retrieved Patient Episode Database submitted by all seven Welsh Health Boards of patients admitted alive with a rAAA over a five year period from 2007 - 2012. This data was compared to an historic publication of similar data (Basnyat et al.) for Wales in 1997.ResultsFor 1996-1997 233 patients (158 males) presented to Welsh hospitals with a rAAA, in comparison to 115 (78 male) in 2012-13. Furthermore in 1996-1997 133 patients underwent emergency surgery with 48 (36%) surviving compared to 66 (51%) operated and 21 (19%) surviving in 2012-13. ConclusionsOver a 16 year period prior to the introduction of a national screening program the number of patients presenting with a rAAA has more than halved in Wales. Unfortunately, outcomes for patients undergoing emergency repair of a rAAA remains poor.

Coronary atherosclerotic lesions in patients with a ruptured abdominal aortic aneurysm

In this study, the coronary findings in 185 autopsy cases with a ruptured abdominal aortic aneurysm (AAA) from the Tokyo Medical Examiner's Office were examined and compared with those in 1,056 patients undergoing AAA repair at the University of Tokyo Hospital or Sakakibara Heart Institute (Tokyo, Japan). The number of cases with any significant coronary stenosis was significantly greater in the autopsy cases with a ruptured AAA than in the patients undergoing emergency repair of a ruptured AAA, suggesting that the low prevalence of CAD observed in patients undergoing emergency repair of a ruptured AAA was due to the survival bias before reaching hospital. In addition, we also found that significant coronary left main trunk stenosis was more frequent in CAD cases with a ruptured AAA than in those with an unruptured AAA, findings that suggest novel clinical implications. Large-scale prospective studies are warranted to confirm our findings and to clarify the pathophysiological relationship between coronary atherosclerosis and AAA status.

National Outcomes in Acute Aortic Dissection: Influence of Surgeon and Institutional Volume on Operative Mortality

Despite clinical and technical advances, acute aortic dissection carries high operative mortality. This study was designed to establish whether this is influenced by institution and surgeon volume. Outcomes of 5,184 patients (mean age, 60.3 years; 65.9% male) diagnosed with acute aortic dissection from the Nationwide Inpatient Sample from 2003 to 2008 were analyzed with risk-adjustment for preoperative comorbidity using multivariate logistic regression analysis. Overall operative mortality was 21.6%, with similar preoperative patient risk profile across institutions and individual surgeons. A strong inverse relationship was observed between operative mortality and both institution and surgeon volume: surgeons who averaged less than 1 aortic dissection repair annually had a mean operative mortality of 27.5%, compared with 17.0% for those averaging 5 or more annually (odds ratio, 1.78; 95% confidence interval, 1.39 to 2.29; p < 0.001). This was similar to therelationship seen between institution volume and mortality: operative mortality was 27.4% in institutions performing 3 or fewer acute aortic dissections a year, compared with 16.4% in those performing more than 13 annually (p<0.001). Nationally, operative mortality decreased steadily from 23% in 1998-2000 to 19% in 2005-2008, with no significant decrease in patient risk profile. Patients undergoing emergency repair of acute aortic dissection by lower-volume surgeons and centers have approximately double the risk-adjusted mortality of patients undergoing repair by the highest volume care providers. Routine involvement, whenever feasible, of teams experienced in acute aortic dissection repair may be a strategy to reduce operative mortality and major morbidity.

Predictors of mortality after emergency or elective repair of abdominal aortic aneurysm in a Japanese population

In Japan, there has been virtually no study in a population large enough to definitively demonstrate a relationship between the preoperative clinical features and postoperative outcomes in patients undergoing abdominal aortic aneurysm (AAA) repair. The aim of this study was to determine the preoperative variables that significantly predict postoperative mortality after emergency or elective repair in Japanese patients with infrarenal AAA. In this retrospective cohort study, we assessed significant predictors of postoperative mortality in 1055 consecutive patients undergoing emergency (n = 186) or elective repair (n = 869) of an infrarenal AAA at the University of Tokyo Hospital or Sakakibara Heart Institute (Tokyo, Japan). Using logistic regression analysis, anemia (hemoglobin <9 g/dl), shock (systolic blood pressure <80 mmHg), and hypocholesterolemia (total cholesterol <120 mg/dl) were found to be independent preoperative predictors of 30-day mortality after emergency repair for ruptured AAA. The hazard ratio (HR) (95 % confidence interval) for these three predictors was 5.96 (1.70-20.84), 8.48 (1.47-49.02), and 7.31 (1.96-27.35), respectively. In the elective repair cases, no significant preoperative predictor of postoperative mortality could be identified either within or beyond 30 days of surgery. Hypocholesterolemia, anemia, and shock were found to be independent preoperative predictors of a postoperative high mortality rate in Japanese patients undergoing emergency repair for ruptured infrarenal AAA.

Long-term outcome following repair of acute type A aortic dissection after previous cardiac surgery

We evaluated the outcome after repair for acute spontaneous type A aortic dissection in patients with previous cardiac surgery. From January 2000 to December 2009, 114 patients underwent emergency repair for acute spontaneous type A dissection at Southampton University Hospital. Eleven (median age 64years; range 36-83years; two females) patients (9.8%) had undergone previous cardiac surgery and were included in this study. Aortic root replacement was performed in three patients (27%), aortic arch replacement in four patients (36%) and two patients (18%) required aortic valve re-suspension. The elephant trunk operation was performed in two patients (18%). There were two hospital deaths (18%). Two patients (18%) suffered a stroke, two needed re-opening for bleeding (18%) and two patients (18%) required haemofiltration postoperatively. Median length of hospital stay was 16days (range 6-34days). Actuarial survival at five and eight years for redo compared to first-time surgery was 68±3.63% vs. 81±5.34% and 51±3.8% vs. 61±5.4%, respectively (P=0.365). In conclusion, acute type A aortic dissection repair in patients with previous cardiac surgery has an acceptable mortality and comparable long-term outcome to first-time surgery.

Prognostic factors associated with mortality in patients undergoing emergency surgery for abdominal aortic aneurysms

Surgical mortality rates following emergency surgery for ruptured abdominal aortic aneurysms (AAAs) remain high. This study investigated the mortality rate and identified prognostic factors affecting mortality in patients undergoing emergency repair of AAAs in our hospital. Between January 2005 and June 2010, a total of 42 patients underwent emergency surgery for AAAs and were included in this retrospective study. The following variables concerning each patient were collected by chart review and compared between survivors and nonsurvivors: age; gender; preoperative levels of hemoglobin (Hb), hematocrit (Ht), platelets (Plts), base excess (BE), and serum glucose and lactate; presence of preoperative shock defined as hypotension (systolic blood pressure of less than 80mmHg); incidence of blood transfusion, whether AAA was ruptured or impending; interval from admission to the hospital or arrival in the operating room until aortic cross-clamping; surgical duration; and volume of intraoperative blood loss and transfusion, total fluid infusion, and urine output. Nine patients died within 30days postoperatively, a 30-day mortality rate of 21.4%. Among these nine nonsurvivors, eight had shown persistent preoperative shock (P=0.0004 vs. survivors). Compared with the survivors, nonsurvivors were significantly older (P=0.0052) and had lower preoperative levels of Hb/Ht (P<0.0001), Plts (P=0.0003), and BE (P<0.0001), an elevated lactate level (P=0.0048), shorter interval from admission (P=0.0459) or arrival in the operating room (P=0.0288) until aortic clamping, and intraoperatively more hemorrhage (P=0.0038) associated with larger amounts of blood transfusion (P=0.0083) and less urine output (P=0.0004). The authors clarified that certain features such as age, persistent preoperative shock, and greater amounts of transfusion associated with greater blood loss and anemia were factors affecting the mortality in patients undergoing emergency surgery for AAAs. It might be of great importance to correct preoperative shock and anemia caused by massive bleeding before the onset of hemodynamic deterioration.

Complications of axial lumbar interbody fusion

Axial lumbar interbody fusion (AxiaLIF) is a novel minimally invasive approach for fusion of L4-5 and L5-S1. This technique uses the presacral space for percutaneous access to the anterior sacrum. The AxiaLIF procedure has the potential to decrease patient recovery time, length of hospital stay, and overall occurrence of surgical complications. It can be used alone or in combination with minimally invasive or traditional open fusion procedures. The purpose of this study was to evaluate complications of the AxiaLIF procedure at the authors' institutions. Patients who underwent AxiaLIF surgery between October 2005 and June 2009 at the authors' institutions were identified. The authors retrospectively reviewed these patients' charts, including operative reports and postoperative medical records, to determine what complications were encountered. A total of 68 patients underwent AxiaLIF surgery, with an average follow-up time of 34 months. Sixteen patients (23.5%) experienced a total of 18 complications (26.5%); this group included 8 men and 8 women (mean age 52.1 years). These complications included pseudarthrosis (8.8%), superficial infection (5.9%), sacral fracture (2.9%), pelvic hematoma (2.9%), failure of wound closure (1.5%), transient nerve root irritation (1.5%), and rectal perforation (2.9%). The complication rate associated with AxiaLIF in the present study was relatively low (26.5%). The most common complications were superficial infection and pseudarthrosis. There were 2 cases of rectal perforation associated with AxiaLIF; one case was found intraoperatively and the other presented 4 days postoperatively. Both patients underwent emergency repair by a general surgeon and had no long-term sequelae as a result of the rectal injuries. It is important for surgeons to be aware of the potential for these complications. Many of these complications can probably be avoided with proper patient selection and operative planning. Preoperative MR imaging, a detailed patient physical examination and history, full bowel preparation, and the use of live fluoroscopy can all help to prevent complications with AxiaLIF surgery.

Brachial artery transection caused by closed elbow dislocation in a mature in-line skater: a case report with review of the literature

Regarding skating injuries, isolated cases of closed elbow dislocations are reported only for children or teenage patients. Due to the anatomic proximity of neurovascular structures, elbow dislocations run the risk of concomitant injury, but its occurrence remains very rare. We describe the case of an advanced mature in-line skater with a complete disruption of the brachial artery caused by a closed elbow dislocation. The patient underwent emergency repair of the arterial injury with an autologous saphenous vein bypass. One year after surgery, the patient recovered without any complaints and has returned to all activities of daily living as well as sporting activities. This case should sensitize the readers for concomitant vascular lesions when confronted with elbow dislocations. The mechanism of closed elbow dislocation in relation to skating sports is discussed with the current literature. We hold the view that accurate clinical assessment by orthopedic and vascular surgeons is absolutely necessary and immediate operative approach is the only acceptable treatment.

Lack of Association between Angiotensin-converting Enzyme Gene Polymorphism and Type I Aortic Dissection

The relationship between angiotensin-converting enzyme (ACE) gene polymorphism and type I aortic dissection was examined in 205 unrelated hypertensives. A total of 94 patients underwent emergency repair due to type I aortic dissection, confirmed by computed tomography, and the remaining 111 were controls. Polymerase chain reaction was used to confirm that ACE gene polymorphism was due to insertion (I) or deletion (D) of a 287 base pair (bp) DNA sequence within intron 16. The genotype distribution and allele frequency of ACE I/D polymorphism between patients and controls were not statistically significant. When the frequency of at least one D allele carrier (DD or ID genotype) was compared with the II homozygous genotype, there was also no significant difference between the study groups. The findings revealed no association between ACE I/D polymorphism and aortic dissection. We conclude that I/D mutation of the ACE gene does not seem to be a risk factor for aortic dissection.

Emergency ultrasound of the abdominal aorta by UK emergency physicians: a prospective cohort study

Objective: To establish whether UK emergency physicians could reliably perform focused ultrasound of the abdominal aorta in patients with suspected abdominal aortic aneurysm (AAA). Methods: A prospective cohort study was...

Massive retroperitoneal hemorrhage post bone marrow biopsy mimicking ruptured abdominal aortic aneurysm

We present the case of a 74-year-old man who presented with acute abdominal pain and shock a few hours following a bone marrow biopsy. He had a history of cardiovascular disease and a known abdominal aortic aneurysm (AAA). Emergency CT abdomen revealed a large retroperitoneal hematoma and a 6 cm AAA. The patient underwent emergency repair of aortic aneurysm which was found not to be ruptured. The hematoma was secondary to vascular injury during bone marrow biopsy. We review the complications of bone marrow biopsy and the imaging findings of ruptured AAA.

Outcome after emergency repair of symptomatic, unruptured abdominal aortic aneurysm: Results in 42 patients and review of the literature

ObjectiveTo evaluate the results of our experience in the management of patients with symptomatic, unruptured abdominal aortic aneurysm (AAA), to identify the predictors of immediate outcome and to define the worldwide postoperative mortality rate through a review of previous studies on this condition.Patients and methodsForty-two patients underwent emergency repair for symptomatic, unruptured AAA.ResultsFour patients (9.5%) died during the in-hospital stay, three of myocardial infarction and one of multiorgan failure. Only preoperative creatinine was predictive of postoperative death (p=0.04, OR 1.31). The Glasgow Aneurysm Score tended to be predictive of postoperative death (p=0.06), survivors having had a median score of 76.0 (IQR, 75.5–82.1) and patients who died of 87.1 (78.9–89.9). The receiver operating characteristic (ROC) curve analysis showed that the Glasgow Aneurysm Score had an area under the curve of 0.789 (95% CI: 0.596–0.983, SE: 0.099, p=0.06). Its best cut-off value in predicting postoperative death was 85 (specificity 86.8%, sensitivity 75.0%). The postoperative mortality rate among patients with a Glasgow Aneurysm Score <85 was 2.9%, whereas it was 37.5% among those with a score >85 (p=0.003). A review of the results of previous studies on this condition, including also the present series, showed that 207 out of 1312 patients (15.8%) died after emergency operation for symptomatic, unruptured AAA.ConclusionEmergency open repair of symptomatic, unruptured AAA is associated with a high risk of postoperative death. The results of this study suggest that a rather good postoperative survival rate can be expected in patients with a Glasgow Aneurysm Score <85. A watchful waiting policy or, alternatively, emergency endovascular repair should be advocated in patients with a higher score.