Required Emergency Surgery Research Articles

The impact of primary tumor resection for asymptomatic colorectal cancer patients with unresectable metastases: a systematic review and meta-analysis.

Whether patients with asymptomatic primary tumors and unresectable metastases of colorectal cancer (CRC) should undergo primary tumor resection (PTR) remains controversial. This study aims to determine the appropriateness of PTR for these individuals by evaluating a number of outcome measures. A systematic literature search was performed. Outcome measures included overall survival, emergency surgery rates, incidence of postoperative complications, time to initiate chemotherapy, conversion rates, and chemotherapy-related toxicities. Patients who received PTR in addition to chemotherapy had a better overall survival rate than those who only received chemotherapy (HR = 0.62, 95%CI, 0.50-0.78, I2 = 84%, p < 0.00001). In the RCT subgroup, there were no significant differences with a HR of 0.72 (95%CI, 0.45-1.13, I2 = 17%, p = 0.15). More patients in the chemotherapy alone group could be converted to resectable status (OR = 0.47, 95%CI, 0.27-0.82, I2 = 0%, p = 0.008), but the incidence of emergency surgery was 23% (95%CI, 17-29%, I2 = 14%). The risk of chemotherapy-related toxicity was not significantly higher in the PTR group (OR = 1.5, 95%CI, 0.94-2.43, p = 0.09, I2 = 0%), with a 7% incidence of postoperative complications (95%CI, 0-14%, p = 0.05, I2 = 0%). The time to initiate chemotherapy after PTR was approximately 33.06days (95%CI, 25.55-40.58, I2 = 0%). PTR plus chemotherapy may be associated with improved survival in asymptomatic CRC patients with unresectable metastases. However, PTR did not provide a significant survival benefit in the subgroup of RCTs. Additionally, PTR did not result in a significantly increased risk of chemotherapy-related toxicity, with a postoperative complication rate of approximately 7%, and chemotherapy could be initiated at approximately 33.06days after PTR. Compared with the PTR plus chemotherapy, chemotherapy alone could result in a significantly higher conversion rate. However, about 23% of patients receiving chemotherapy alone required emergency surgery for primary tumor-related symptoms. The above results needed to be validated in future larger prospective randomized trials.

Study of factors associated with waiting time for patients undergoing emergency surgery

Background: Emergency surgeries throughout the world are demanding earlier surgical times. In a developing country like this cannot be possible because of lot of factors. So we planned to study such factors that could interplay and increase the waiting time for emergency surgeries. Methods: A prospective observational study was conducted in Department of Anaesthesiology, Gonoshasthaya Samaj Vittik Medical College, Savar, Dhaka, Bangladesh from January to June 2021. Out of 102 required emergency surgery. All patients diagnosed with general surgical and orthopedic emergencies were followed till they were operated. Results: Out of 102 required emergency surgery. The mean age was 29.72 year and 76.5% of the patients were male. The mean time from presentation to the emergency department to the first surgical consultation was 170 minutes, from surgical consultation to decision of surgery was 28 minutes, from decision of surgery to transfer to operating room was 426 minutes, from arrival in operating room to anesthesia consultation was 18 minutes, and from anesthesia consultation to start of surgical incision was 75 minutes. The total average waiting time from arrival at emergency department to the start of surgery was 717 minutes. The factors were, viz., pre-occupancy of theatre (59.8%), special procedures/intervention required prior to surgery (23.5%), arrangement of logistics/finances by patient family (13.7%), arrangement of blood products (10.5%), consultations (9.8%), delay in giving consent by patients/family (5.9%), delay in arrangement of supplies (9.8%), and shift change of nursing staff (3.9%). Conclusion: This study shows that various preventable factors increases waiting times for emergency surgeries that should be minimized so that waiting times can be reduced.

Laparoscopic treatment of small bowel incarceration and perforated appendix within right-sided spigelian hernia: case report and review of the literature

Spigelian hernia is a rare disease and a quarter of the patients present with incarceration or strangulation of the hernia content and require emergency surgery. We report a case of an elderly obese woman with comorbidity presented with abdominal pain and right flank palpable mass. The contrast enhanced computer tomography showed bowel incarceration within right side spigelian hernia. Only at laparoscopic exploration a diagnosis of appendicitis within spigelian hernia was made and the patient underwent laparoscopic appendicectomy and open debridement of the abscess with primary closure of the defect. The postoperative stay was uneventful. Few cases of appendicitis within spigelian hernia have been reported in literature and, as in our case, the diagnosis is usually difficult and laparoscopy has a key role in the diagnosis and treatment of those patients also in emergency setting. Early repair decreases the rate of morbidity related to this condition.

Surgical Treatment in Ulcerative Colitis, Still Topical: A Narrative Review.

In this paper, different studies were integrated to conclude the impact of ulcerative colitis (UC) on the patient's vital prognosis, specifically highlighting the association with colorectal cancer (CRC). These severe complications have led us to consider studying the role of preventive surgery in managing UC. This study reviewed total preventive colectomy in UC patients for preventing the onset of CRC, the role of surgery in UC management, and its potential as a definitive treatment for the condition. The study also emphasized the effectiveness of annual colonoscopic monitoring and preventive colectomy in reducing the incidence of colorectal cancer (CRC). It discussed the role of laparoscopic surgery in minimizing postoperative complications and highlighted that partial surgical resection of the colon can be a viable option, offering improved bowel function without increasing the risk of CRC-related mortality. Elective surgery has an important place in UC management by preventing the development of forms requiring emergency surgery. Although surgery can cure UC, it can lead to significant postoperative complications and adverse effects.

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.

Preoperative Risk Factors for Adverse Events in Adults Undergoing Bowel Resection for Inflammatory Bowel Disease: 15-Year Assessment of the American College of Surgeons National Surgical Quality Improvement Program.

Older adults with inflammatory bowel disease (IBD) are at higher risk for postoperative complications as compared to their younger counterparts; however, factors contributing to this are unknown. We assessed risk factors associated with adverse IBD-related surgical outcomes, evaluated trends in emergency surgery, and explored differential risks by age. Using the American College of Surgeons National Surgical Quality Improvement Program database, we identified adults ≥18 years of age who underwent an IBD-related intestinal resection from 2005 to 2019. Our primary outcome included a 30-day composite of mortality, readmission, reoperation, and/or major postoperative complication. Overall, 49,746 intestinal resections were performed with 9,390 (18.8%) occurring among older adults with IBD. Nearly 37% of older adults experienced an adverse outcome as compared to 28.1% among younger adults with IBD ( P < 0.01). Among all adults with IBD, the presence of preoperative sepsis (adjusted odds ratio [aOR], 2.08; 95% confidence interval [CI] 1.94-2.24), malnutrition (aOR, 1.22; 95% CI 1.14-1.31), dependent functional status (aOR, 6.92; 95% CI 4.36-11.57), and requiring emergency surgery (aOR, 1.50; 95% CI 1.38-1.64) increased the odds of an adverse postoperative outcome, with similar results observed when stratifying by age. Furthermore, 8.8% of surgeries among older adults were emergent, with no change observed over time ( P = 0.16). Preoperative factors contributing to the risk of an adverse surgical outcome are similar between younger and older individuals with IBD, and include elements such as malnutrition and functional status. Incorporating these measures into surgical decision-making can reduce surgical delays in older individuals at low risk and help target interventions in those at high risk, transforming care for thousands of older adults with IBD.

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.

How to recognize a dying patient? Acute traumatic coagulopathy: experience in a level I trauma center

Background: It is possible to detect abnormal clotting parameters in 25-35% of injured patients at their arrival to the hospital, which are proportional to the severity of the injuries and associate with higher morbimortality rates. Objectives: Therefore, it arises the question whether the results of conventional laboratory tests carried out while monitoring the injured patient may be used as early available predictors. Methods: We conducted a prospective, descriptive and observational multivariable study at the Central Hospital of the Mexican Red Cross to determine the correlation between the alterations in the results of clotting tests obtained at the time of hospital admission of the patient and the likelihood of emergency surgery necessity or death within the first 48 hours of hospital stay. Results: We included 327 patients, between 1-92 years old, 20.79% patients were admitted with ATC criteria, 40.36% required emergency surgery (54.41% in the context of ATC) and 18.65% died (10.39% of them during or after the surgical management, and 47.05% with ATC criteria). Conclusions: According with our results conventional clotting tests are quite sensitive tools for identifying patients at high risk of early death and good predictors of poor outcomes in the treatment.

A prospective comparative study among Alvarado score, appendicitis inflammatory response (AIR) score, and adult appendicitis score (AAS) in the diagnosis of acute appendicitis in adults

Background Acute appendicitis (AA) is the most common condition presenting with acute abdomen requiring emergency surgery. Several clinical scores were developed to diagnose AA. Aim This study aimed to compare the diagnostic accuracy of three clinical scores (Alvarado score, appendicitis inflammatory response (AIR) score, and adult appendicitis score (AAS)) in the diagnosis of AA. Methods This prospective study was conducted on 100 adult patients (aged ≥ 18 years) presenting with acute abdomen suspicious of noncomplicated AA. Patients with complicated AA (abscess, mass, or diffuse peritonitis) and patients with uncomplicated AA subjected to nonoperative management (NOM) were excluded from our study. The histopathological results were used as the gold standard for diagnosis of AA to which the three clinical scores results were compared. Results Our study included 100 patients (60 males and 40 females), all of whom, had histopathologically proven AA. Due to this outcome, we could only conclude and compare the sensitivities of the three scores. Alvarado score had the highest overall sensitivity (91% at cut-off value &gt; 4 points), followed by AAS (80% at cut-off value &gt; 10 points), then AIR score (71% at cut-off value &gt; 4 points) however, the difference between Alvarado score and AAS was not statistically significant. In males, the Alvarado score had the highest sensitivity (88.3%), followed by AAS (86.7%), then the AIR score (71.7%) at the same cut-off values however, the difference between the Alvarado score and AAS was also not statistically significant. In females, Alvarado score had the highest sensitivity (95%) followed by AAS and AIR scores (70% for both) with a statistically significant difference. Obesity did not influence the outcome of the three scores. Conclusions Alvarado score and AAS are more sensitive than the AIR score. In relation to sex, Alvarado’s score is the most sensitive in females.

Left side perforated appendicitis with intestinal non-rotation: a case report

BackgroundAcute appendicitis is the most common cause of acute abdominal pain, requiring emergency surgery. Symptoms and signs of acute appendicitis usually occur in the right lower quadrant. However, approximately one-third of cases have pain unexcepted location due to its various anatomical locations. Acute appendicitis is a very rare cause of left lower quadrant pain; if it occurs, situs inversus (SI) and midgut malrotation (MM) are uncommon anatomic anomalies that complicate its diagnosis and management.Clinical presentationHere we present a 23-year-old Ethiopian male patient who presented with epigastric and left paraumbilical abdominal pain, fever, and vomiting of a day duration. On examination at admission, the patient had left lower quadrant tenderness. Later, with the help of imaging studies, the patient was diagnosed with left-side acute perforated appendicitis with intestinal nonrotation, and he was operated on and discharged improved after 6 days of hospital stay.ConclusionPhysicians should be aware that acute appendicitis in patients with intestinal mal-rotation may be present with left-side abdominal pain. Although it is extremely rare, acute appendicitis should always be considered in the differential diagnosis of left-side abdominal pain. An increase in awareness of this anatomical variant is essential for physicians.

Role of C reactive protein, hyperbilirubinemia and mean platelet volume in diagnosis of acute appendicitis and its correlation post operatively with histo-pathological examination

Background: Acute appendicitis is one of the most common abdominal emergencies requiring emergency surgery. The diagnosis based on the onset of symptoms and physical examination. Therefore, inaccuracies caused by subjective interpretation are frequent. This raises the need for tests to help diagnose acute appendicitis and predict the severity of the condition. aim of the study to investigate whether mean platelet volume, C-reactive protein, and hyperbilirubinemia can be used as inflammatory markers for the diagnosis of acute appendicitis and its correlation with histopathological examination. Methods: we prospectively analyzed 60 patients who were full fulling the inclusion criteria patients analysed for CBC, LFT and CRP and underwent for appendicectomy (Laparoscopic/open). Per-operative diagnosis was confirmed by histopathological examination from November 2020 to November 2022. Results: patients with CRP level &gt; 6 and hyperbilirubinemia patients most likely to have acute appendicitis. Mean CRP level was 13.21±4.0 and mean bilirubin level 1.04±0.29 in case of acute appendicitis. CRP, hyperbilirubinemia levels were significantly higher in cases of acute appendicitis (p&lt;0.01) while MPV value was not found significant. All patients was confirmed with histopathology examination. Conclusions: Serum bilirubin level and CRP estimation, which is a simple, cheap, and easily available laboratory test, can be added to the routine investigations in the diagnosis and severity of acute appendicitis and help in decreasing negative appendicectomy rates, especially in low modified Alvarado score.

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.

Emergency surgical intervention in acute corrosive ingestion: single-center experience from India.

Surgical intervention for acute corrosive injury is often required. It is associated with considerable morbidity and mortality. Sparce data is available on the types and timing of surgery after acute corrosive ingestion and complications associated with the same. This is a retrospective single-center study from a tertiary care center in India. All patients who underwent surgical exploration after acute corrosive intake between January 2003 and June 2014 were enrolled in the study. Data on patients' presentation, their endoscopic findings, indications of surgery, type of surgery and post-operative follow-up was retrieved. Out of 170 patients who presented with acute corrosive ingestion, 24 patients (14.11%) required emergency surgery. The mean interval between ingestion and surgery was 9.92 ± 9.03 days. Presence of peritonitis was the most common indication for surgery (n = 10; 41.7%) followed by mediastinitis (n = 7; 29.2%). A total of 17 resectional and 7 non-resectional procedures were performed. Thirteen (54%) patients succumbed to their illness post-operatively due to multi-organ failure (n = 9), refractory shock (n = 3) or pulmonary thromboembolism (n = 1). Patients with early surgery (≤7 days) after corrosive ingestion had similar mortality compared to patients with late surgery (>7 days) (50% versus 67%; P = 0.30). Of the 11 surviving patients, eight patients (72%) underwent successful reconstructive surgery on follow-up. Emergency surgery after corrosive ingestion carries high morbidity and mortality. However, after the initial stormy acute phase, majority of patients can undergo successful reconstructive surgery on follow-up.

When Should We Operate on the Elderly with Acute Pancreatitis Requiring Emergency Surgery? A 10-Year Study of a National Inpatient Sample Using a Generalized Additive Model of 110,289 Patients.

Elderly patients with acute pancreatitis have longer hospital length of stay (HLOS) and higher mortality compared to adult patients. We aimed to assess the optimal timing to operate for acute pancreatitis and to evaluate the relationship between HLOS and mortality. This was a retrospective cohort study of 110,289 elderly patients diagnosed with acute pancreatitis requiring emergency admission using the National Inpatient Sample (NIS) between 2005-2014. The ICD9 code 577.0 was used to select patients with a diagnosis of acute pancreatitis. Stratified analysis was performed to compare male versus female, survived versus deceased, and no operation versus operation. Multivariable logistic regression models were created to assess independent risk factors of mortality. Generalized additive models (GAM) were created to assess the linearity of the relationship between HLOS and in-hospital mortality. The mean age of the cohort was 76 years old, and 56.3% were female. The mean frailty index was 1.65. Twenty-five percent of patients underwent an operation, with a mean time to operation being 3.44 days for females and 3.77 days for males. Overall mortality was 2.3%. For patients who had an operation, each additional day of delay until operation increased the odds of mortality by 8.8%. Each additional point for the modified frailty index increased the odds of mortality by 30.2%. HLOS had a non-linear relationship with mortality, with an estimated degree of freedom of 22.05 and a nadir at three to seven days. Each additional day in hospital after day seven increased the odds of mortality by 6.7%. In those who required an operation, every day of delay in operation increased the odds of mortality by almost 9%. The lowest mortality for elderly patients with acute pancreatitis occurred with a hospital length of stay of three to seven days. After seven days, each additional day increased the odds of mortality by 6.7%.

Evaluating the Natural History of Groin Hernia from an "Unplanned" Watchful Waiting Strategy.

Groin hernia is one of the most common surgical diagnoses worldwide. The indication for surgery in asymptomatic or mildly symptomatic patients is discussed. Some trials have demonstrated the safety of a watchful waiting strategy. During the pandemic, waiting lists for hernia surgery dramatically increased the opportunity to evaluate the natural history of groin hernias. The present study aimed to evaluate the incidence of emergency hernia surgery in a large cohort of patients that were selected and were waiting for elective surgery. This is a retrospective cross-sectional cohort study including all patients evaluated and selected for elective groin hernia surgery at San Gerardo Hospital between 2017 and 2020. Elective and emergency hernia surgeries were recorded for all patients. The incidence of adverse events was also evaluated. Overall, 1423 patients were evaluated, and 964 selected patients (80.3%) underwent elective hernia surgery, while 17 patients (1.4%) required an emergency operation while waiting for an elective operation. A total of 220 (18.3%) patients were still awaiting surgery in March 2022. The overall cumulative risk levels for emergency hernia surgeries were 1%, 2%, 3.2%, and 5% at 12, 24, 36, and 48 months, respectively. There was no association between longer waiting periods and an increased need for emergency surgery. Our study indicates that up to 5% of patients with groin hernia require emergency surgery at 48 months from the evaluation; the increased waiting time for surgery for elective groin hernia repair was not associated with an increased incidence of adverse events.

Laparoscopic vs. Open Approach in Emergent Inguinal Hernia: Our Experience and Review of Literature.

There is currently no consensus or homogeneous recommendation about the role of the laparoscopic approach in emergent inguinal hernia surgery. The aim of this manuscript is showing our experience and results of laparoscopic approach for emergent groin hernia repair comparing with open approach. A retrospective review of a prospectively maintained database between January 2011 and December 2021 of acute incarcerated groin hernia that were operated at Virgen del Rocio University Hospital. In this period, they were identified 463 patients with groin hernia that required an emergency repair. 454 patients underwent open surgery (group 1) and 36 patients underwent laparoscopic approach (TAPP procedure) (group 2). Median length stay was 1day in lap group and 2days in open approach. Reintervention was necessary in 20 cases (4.40%) from group 1 and one (2.27%) from group 2. In laparoscopic approach, no mortality was described but in open approach, 10 patients (2.20%) died. Globally, 58 cases (12.77%) from group 1 and six patients (16.66%) from group 2 presented any complication. Wound infection was higher in group of open repairs (5.94% vs. 2.77%). Non-surgical complications were higher in open approach (19 vs. 0). There is no statistical significance in any of these items. Laparoscopic approach is a safe, feasible and effective therapeutic option for the treatment of incarcerated groin hernia that require emergency surgery, but prospective and randomized comparative studies are needed to establish the best approach.

Tracheal bifurcation repair for blunt thoracic trauma in a patient with COVID-19

BackgroundTracheobronchial injury (TBI) is a rare but potentially life-threatening trauma that requires prompt diagnosis and treatment. We present a case in which a patient with COVID-19 infection was successfully treated for a TBI through surgical repair and intensive care with extracorporeal membrane oxygenation (ECMO) support.Case presentationThis is the case of a 31-year-old man transported to a peripheral hospital following a car crash. Tracheal intubation was performed for severe hypoxia and subcutaneous emphysema. Chest computed tomography showed bilateral lung contusion, hemopneumothorax, and penetration of the endotracheal tube beyond the tracheal bifurcation. A TBI was suspected; moreover, his COVID-19 polymerase chain reaction screening test was positive. Requiring emergency surgery, the patient was transferred to a private negative pressure room in our intensive care unit. Due to persistent hypoxia and in preparation for repair, the patient was started on veno-venous ECMO. With ECMO support, tracheobronchial injury repair was performed without intraoperative ventilation. In accordance with the surgery manual for COVID-19 patients in our hospital, all medical staff who treated this patient used personal protective equipment. Partial transection of the tracheal bifurcation membranous wall was detected and repaired using 4-0 monofilament absorbable sutures. The patient was discharged on the 29th postoperative day without postoperative complications.ConclusionsECMO support for traumatic TBI in this patient with COVID-19 reduced mortality risk while preventing aerosol exposure to the virus.

Have we overlooked the role of mifepristone for the medical management of tubal ectopic pregnancy?

Ectopic pregnancy is a risk of both spontaneous and assisted reproduction pregnancies. The majority of ectopic pregnancies abnormally implant within a fallopian tube (extrauterine pregnancies). In haemodynamically stable women, medical or expectant treatment can be offered. Currently accepted medical treatment is using a drug called methotrexate. However, methotrexate has potential adverse effects, and a significant proportion of women will still require emergency surgery (up to 30%) to remove the ectopic pregnancy. Mifepristone (RU-486) has anti-progesterone effects and has a role in managing intrauterine pregnancy loss and termination of pregnancy. On reviewing the literature and given progesterone's pivotal role in sustaining pregnancy, we propose that we may have overlooked the role of mifepristone in the medical management of tubal ectopic pregnancy in haemodynamically stable women.

Initial experience of transpapillary gallbladder biopsy using newly designed device delivery system.

Transpapillary gallbladder biopsy has been reported for the diagnosis of gallbladder disease, and this procedure requires special biopsy forceps or a large-diameter pusher catheter. We retrospectively examined consecutive patients who underwent transpapillary gallbladder biopsy using a newly designed device delivery system (Endosheather; Piolax Medical Device, Kanagawa, Japan). We evaluated 11 patients (median age, 71 years [28-85]) who underwent transpapillary gallbladder biopsy from June 2021 to July 2022. The selective gallbladder cannulation and delivery system insertion success rate was 90.9% (10/11). The target lesion biopsy success rate was 63.6% (7/11). The biopsy time (i.e., time to completion of biopsy after successful guidewire placement) was 8.7 (5.4-32.7) min. In 1 patient in whom all 6 gallbladder bile juice cytology results were benign, the biopsy result was suspicious of adenocarcinoma. The final diagnosis for this patient was gallbladder cancer. Adverse events occurred in 2 patients. In 1 patient, acute cholecystitis occurred and required emergency surgery. Transpapillary gallbladder biopsy using the Endosheather is a potential option for the diagnosis of gallbladder disease. A good indication for this technique is considered to be wall thickening at the gallbladder fundus, where it is difficult to differentiate between benign and malignant lesions by imaging modalities such as ultrasonography or endoscopic ultrasound. The addition of transpapillary gallbladder biopsy may be advantageous when performing bile juice cytology using a nasogallbladder drainage tube for the diagnosis of gallbladder disease.

A COMPARATIVE STUDY OF LAPAROSCOPIC APPENDICECTOMY VERSUS OPEN APPENDICECTOMY IN TERMS OF DURATION OF SURGERY,LENGTH OF HOSPITAL STAY,RESUMPTION OF DIET, POST OPERATIVE COMPLICATIONS IN THANJAVUR MEDICAL COLLEGE A PROSPECTIVE STUDY

Introduction: Appendicitis is most common intra abdominal condition requiring emergency surgery. The life time rate of appendicectomy is 12% for men and 25% in women, with approximately 7% of all people undergoing appendicectomy for acute appendicitis during their lifetime. Laparoscopic appendicectomy combines the advantages of treatment and diagnosis in one procedure with the least morbidity3. Patients are likely to have less post operative pain and to be discharged from hospital and return to regular activities quicker than those who underwent an open appendicectomy Methodology: Patients admitted in surgical wards, with clinical diagnosis of acute or recurrent appendicitis for a period of one year. The following parameters were observed between the two procedures. Duration of procedure ,Postoperative pain,Duration of surgery in minutes, Postoperative complications and wound infection, Post operative length of hospital stay in number of days, Resumption of diet. Results: The gold standard treatment for acute appendicitis is appendicectomy. Though open appendicectomy remains gold standard, nowadays laparoscopic appendicectomy has gained a lot of importance now. Laparoscopic appendicectomy9 is equally safe and less postoperative pain and morbidity as compared to open appendicectomy. Laparoscopic appendicectomy is a useful procedure for reducing the hospital stay, return to work early, less complications encountered. With better training now in minimal access surgery now, laparoscopy has been popular now. Conclusion: On analysing the data, we found a definite difference in outcome between open and laparoscopic appendicectomy in consecutively selected patients. The laparoscopic appendicectomy was better than the open appendicectomy with respect to pain, postoperative complications like vomiting, and wound infection rate. Postoperative recovery was good in respect with duration of hospital stay, resumption of diet. The only drawback of laparoscopic appendicectomy was with the duration of surgery. However with the above mentioned advantages outweighs the time drawback for laparoscopic appendicectomy. Overall laparoscopic appendicectomy is better than open appendicectomy in selected patients with acute or recurrent appendicitis.