Damage Control Surgery may be a Safe Option for Severe Non-Trauma Peritonitis Management: Proposal of a New Decision-Making Algorithm

Increased use of damage control laparotomy for emergency small bowel or colon surgery: does it affect patient outcomes?

PURPOSE

Evidence to guide the application of damage control laparotomy (DCL) in emergency surgery patients is limited. We assessed whether DCL use for emergent small bowel or colon surgery increased over time and its impact on outcomes. We hypothesized that DCL would be utilized more often in patients with significant comorbidities or septic shock with improved outcomes.

METHODS

National Surgical Quality Improvement Program (NSQIP) data on DCL patients from 2014 to 2020 were used. Endpoints were incidence of DCL, in-hospital mortality, hospital length of stay (LOS), complications, and 30-day readmission over time. P-values < 0.05 were considered statistically significant.

RESULTS

DCL incidence increased over time (OR = 1.07 [1.05-1.08], p < 0.001). Presence of pre-operative septic shock increased over the years (OR = 1.04 [1.01-1.07], p = 0.007). Mortality, readmission, and post-operative septic complications did not change over the study period. Average LOS significantly decreased over time (OR = 0.93 [0.92-0.95], p < 0.001).

CONCLUSION

The odds of a surgeon using DCL increased by 7% each year. Although pre-operative septic shock incidence increased, LOS decreased over time while mortality remained unchanged.

Damage control surgery in non-traumatic abdominal emergencies: prognostic value of SOFA, APACHEII, and Mannheim peritonitis index

This study aimed to analyze the prognostic value of the SOFA, APACHE II, and MPI (Mannheim Peritonitis Index) scores in the indication for Damage Control Surgery (DCS) in non-trauma. Retrospective analysis of patients undergoing DCS between 2014 and 2019. SOFA and APACHE II scores were calculated using parameters preceding DCS, while MPI was based on surgical descriptions. Statistical analysis: Qualitative variables were compared using the Chi-square test or Fisher's exact test, and quantitative variables using Pearson's correlation coefficient. The Student's T test was employed for mean comparisons. The sample comprised 104 patients (59 males), with a median age of 63.5 years, of whom 52 (50%) were ASA IV. Operative findings leading to DCS included peritonitis (54; 51.9%), intestinal ischemia (39; 37.5%), inability to close the abdomen (8; 7.6%), and bleeding (3; 2.9%). The mortality rate was 75% (78/104). Thirty patients (28.8%) died after DCS; the remainder underwent one (35; 33.6%), two (21; 20.2%); three (8; 7.7%), and four or more (10;9.7%) revision procedures. The median lengths of ICU and hospital stays were 12.5 and 20.5 days, respectively. The median score values were as follows: SOFA: 12 (0-38), APACHE II: 25 (2-47), and MPI: 26 (8-43). Besides ASA classification (p = 0.03), mortality risk was influenced by: age (≤ 65 years vs. > 65 years; p = 0.04), SOFA (≤ 10 vs. > 10; p = 0.03), APACHE II (≤ 25 vs. > 25; p = 0.04), and MPI (≤ 25 vs. > 25; p = 0.003). The SOFA, APACHE II, and MPI scores proved to be valuable tools in the prognostic assessment of patients undergoing DCS in non-traumatic abdominal emergencies.

Gastric rupture caused by intragastric perforation of splenic artery aneurysm: a case report and literature review

BACKGROUND

The rupture of splenic artery pseudoaneurysm (SAP) is life-threatening disease, often caused by trauma and pancreatitis. SAPs often rupture into the abdominal cavity and rarely into the stomach.

CASE PRESENTATION

A 70-year-old male with no previous medical history was transported to our emergency center with transient loss of consciousness and tarry stools. After admission, the patient become hemodynamically unstable and his upper abdomen became markedly distended. Contrast-enhanced computed tomography performed on admission showed the presence of a splenic artery aneurysm (SAP) at the bottom of a gastric ulcer. Based on the clinical picture and evidence on explorative tests, we established a preliminary diagnosis of ruptured SAP bleeding into the stomach and performed emergency laparotomy. Intraoperative findings revealed the presence of a large intra-abdominal hematoma that had ruptured into the stomach. When we performed gastrotomy at the anterior wall of the stomach from the ruptured area, we found pulsatile bleeding from the exposed SAP; therefore, the SAP was ligated from inside of the stomach, with gauze packing into the ulcer. We temporarily closed the stomach wall and performed open abdomen management, as a damage control surgery (DCS) approach. On the third day of admission, total gastrectomy and splenectomy were performed, and reconstruction surgery was performed the next day. Histopathological studies of the stomach samples indicated the presence of moderately differentiated tubular adenocarcinoma. Since no malignant cells were found at the rupture site, we concluded that the gastric rupture was caused by increased internal pressure due to the intra-abdominal hematoma.

CONCLUSIONS

We successfully treated a patient with intragastric rupture of the SAP that was caused by gastric cancer invasion, accompanied by gastric rupture, by performing DCS. When treating gastric bleeding, such rare causes must be considered and appropriate diagnostic and therapeutic strategies should be designed according to the cause of bleeding.

Damage Control Surgery and Transfer in Emergency General Surgery

Selective non traumatic emergency surgery patients are targets for damage control surgery (DCS) to prevent or treat abdominal compartment syndrome and the lethal triad. However, DCS is still a subject of controversy. As a concept, DCS describes a series of abbreviated surgical procedures to allow rapid source control of hemorrhage and contamination in patients with circulatory shock to allow resuscitation and stabilization in the intensive care unit followed by delayed return to the operating room for definitive surgical management once the patient becomes physiologic stable. If appropriately applied, the DCS morbidity and mortality can be significantly reduced.

Consensus Guidelines for Perioperative Care for Emergency Laparotomy Enhanced Recovery After Surgery (ERAS®) Society Recommendations Part 2-Emergency Laparotomy: Intra- and Postoperative Care

BACKGROUND

This is Part 2 of the first consensus guidelines for optimal care of patients undergoing emergency laparotomy (EL) using an Enhanced Recovery After Surgery (ERAS) approach. This paper addresses intra- and postoperative aspects of care.

METHODS

Experts in aspects of management of high-risk and emergency general surgical patients were invited to contribute by the International ERAS® Society. PubMed, Cochrane, Embase, and Medline database searches were performed for ERAS elements and relevant specific topics. Studies on each item were selected with particular attention to randomized clinical trials, systematic reviews, meta-analyses, and large cohort studies and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Recommendations were made on the best level of evidence, or extrapolation from studies on elective patients when appropriate. A modified Delphi method was used to validate final recommendations. Some ERAS® components covered in other guideline papers are outlined only briefly, with the bulk of the text focusing on key areas pertaining specifically to EL.

RESULTS

Twenty-three components of intraoperative and postoperative care were defined. Consensus was reached after three rounds of a modified Delphi Process.

CONCLUSIONS

These guidelines are based on best available evidence for an ERAS® approach to patients undergoing EL. These guidelines are not exhaustive but pull together evidence on important components of care for this high-risk patient population. As much of the evidence is extrapolated from elective surgery or emergency general surgery (not specifically laparotomy), many of the components need further evaluation in future studies.

Source control in emergency general surgery: WSES, GAIS, SIS-E, SIS-A guidelines

Intra-abdominal infections (IAI) are among the most common global healthcare challenges and they are usually precipitated by disruption to the gastrointestinal (GI) tract. Their successful management typically requires intensive resource utilization, and despite the best therapies, morbidity and mortality remain high. One of the main issues required to appropriately treat IAI that differs from the other etiologies of sepsis is the frequent requirement to provide physical source control. Fortunately, dramatic advances have been made in this aspect of treatment. Historically, source control was left to surgeons only. With new technologies non-surgical less invasive interventional procedures have been introduced. Alternatively, in addition to formal surgery open abdomen techniques have long been proposed as aiding source control in severe intra-abdominal sepsis. It is ironic that while a lack or even delay regarding source control clearly associates with death, it is a concept that remains poorly described. For example, no conclusive definition of source control technique or even adequacy has been universally accepted. Practically, source control involves a complex definition encompassing several factors including the causative event, source of infection bacteria, local bacterial flora, patient condition, and his/her eventual comorbidities. With greater understanding of the systemic pathobiology of sepsis and the profound implications of the human microbiome, adequate source control is no longer only a surgical issue but one that requires a multidisciplinary, multimodality approach. Thus, while any breach in the GI tract must be controlled, source control should also attempt to control the generation and propagation of the systemic biomediators and dysbiotic influences on the microbiome that perpetuate multi-system organ failure and death. Given these increased complexities, the present paper represents the current opinions and recommendations for future research of the World Society of Emergency Surgery, of the Global Alliance for Infections in Surgery of Surgical Infection Society Europe and Surgical Infection Society America regarding the concepts and operational adequacy of source control in intra-abdominal infections.

Intraoperative Surgical Strategy in Abdominal Emergency Surgery

BACKGROUND

Emergency abdominal surgery is associated with a high rate of postoperative complications and death. Pre- and immediate postoperative bundle-care strategies have improved outcome, but so far, no standardized intraoperative strategies have been proposed. We introduced a quality improvement model of specific intra- and postoperative strategies for the heterogenous group of patients undergoing emergency abdominal surgery. The objective was to evaluate a quality improvement strategy, using an intraoperative, multidisciplinary time-out model in emergency abdominal surgery to apply one of three surgical strategies; definitive-palliative-or damage control surgery.

METHODS

All patients scheduled for any gastrointestinal emergency procedure were stratified dynamically according to standardized criteria for performing definitive-palliative-or damage control surgery. Pre- intra- and postoperative data were collected according to the intraoperative strategy applied. Postoperative complications were displayed according to the Clavien-Dindo-score and the CCI (Comprehensive Complication Index). 30-90-day- and 1-year mortality was presented.

RESULTS

We included 436 consecutive patients undergoing emergency laparotomy or laparoscopy in 2019. Intraoperative strategy was definitive in 326(75%)-palliative in 90(21%) and damage control approach in 20(4%) patients. CCI was 21(0,45), 30(17,54) and 78(54,100) in the definitive-, the palliative-, and the damage control group, respectively. 30-day mortality was; 11.7%, 26.7% and 30%, and the 1-year mortality was 16.9%, 56.7% and 40% in the definitive- the palliative- and the damage control group, respectively.

CONCLUSIONS

We present a multidisciplinary, intraoperative decision-making standard as a potential quality improvement tool of ensuring individualized intra- and postoperative treatment for every emergency surgical patient and for future research-protocols.

Damage-control surgery in patients with nontraumatic abdominal emergencies: A systematic review and meta-analysis

BACKGROUND

After the successful implementation in trauma, damage-control surgery (DCS) is being increasingly used in patients with nontraumatic emergencies. However, the role of DCS in the nontrauma setting is not well defined. The aim of this study was to investigate the effect of DCS on mortality in patients with nontraumatic abdominal emergencies.

METHODS

Systematic literature search was done using PubMed. Original articles addressing nontrauma DCS were included. Two meta-analyses were performed, comparing (1) mortality in patients undergoing nontrauma DCS versus conventional surgery (CS) and (2) the observed versus expected mortality rate in the DCS group. Expected mortality was derived from Acute Physiology And Chronic Health Evaluation, Simplified Acute Physiology Score, and Portsmouth Physiological and Operative Severity Score for enUmeration of Mortality and Morbidity scores.

RESULTS

A total of five nonrandomized prospective and 16 retrospective studies were included. Nontrauma DCS was performed in 1,238 and nontrauma CS in 936 patients. Frequent indications for surgery in the DCS group were (weighted proportions) hollow viscus perforation (28.5%), mesenteric ischemia (26.5%), anastomotic leak and postoperative peritonitis (19.6%), nontraumatic hemorrhage (18.4%), abdominal compartment syndrome (17.8%), bowel obstruction (15.5%), and pancreatitis (12.9%). In meta-analysis 1, including eight studies, mortality was not significantly different between the nontrauma DCS and CS group (risk difference, 0.09; 95% confidence interval, -0.06 to 0.24). Meta-analysis 2, including 14 studies, revealed a significantly lower observed than expected mortality rate in patients undergoing nontrauma DCS (risk difference, -0.18; 95% confidence interval, -0.29 to -0.06).

CONCLUSION

This meta-analysis revealed no significantly different mortality in patients undergoing nontrauma DCS versus CS. However, observed mortality was significantly lower than the expected mortality rate in the DCS group, suggesting a benefit of the DCS approach. Based on these two findings, the effect of DCS on mortality in patients with nontraumatic abdominal emergencies remains unclear. Further prospective investigation into this topic is warranted.

LEVEL OF EVIDENCE

Systematic review and meta-analysis, level III.

Comparison of Fenestrating and Reconstituting Subtotal Cholecystectomy Techniques in Difficult Cholecystectomy

Purpose

Cholecystectomy is one of the most frequently performed surgeries. Although laparoscopy is considered the gold standard approach, it cannot prevent biliary injuries. Subtotal cholecystectomy has been performed mainly to prevent biliary injuries during difficult cholecystectomies. This study aimed to analyse our subtotal cholecystectomy results for difficult cholecystectomy cases and to evaluate the fenestrating and reconstituting techniques.

Methods

Retrospective data were collected and analysed statistically for cases that underwent subtotal cholecystectomy in a single referral centre between 2015 and 2020. Comparisons were made of the patients’ age, gender, preoperative American Society of Anaesthesiologists (ASA) score, comorbidities, surgical timing, surgical procedure choice, postoperative complications, and mortality.

Results

The number of patients who underwent subtotal cholecystectomy was 46; 30.4% underwent emergent surgery and 69.6% underwent elective surgery. Twelve patients had subtotal fenestrating cholecystectomy and 34 had subtotal reconstituting cholecystectomy. Wound issues were noted in 17.4% of the patients, while 10.9% had temporary biliary fistulas that resolved spontaneously. Reoperation was performed in one patient due to high-output biliary drainage. Patients with postoperative complications had significantly higher co-morbid conditions (p=0.000), but surgery timing (p=0.192) and type of subtotal cholecystectomy (p=0.409) had no statistically significant effect on complications. Mortality showed a statistically significant correlation with patient comorbidities, surgery timing, and the type of procedure (p<0.05). Postoperative complications showed a statistically significant correlation with mortality (p<0.05).

Conclusion

Subtotal cholecystectomy prevents major biliary complications after cholecystectomy. Yet, the frequency of postoperative complications after subtotal cholecystectomy is incontrovertible. Intraoperative characteristics and the surgeon’s expertise decide the optimal choice of the subtotal cholecystectomy technique.

The WSES/SICG/ACOI/SICUT/AcEMC/SIFIPAC guidelines for diagnosis and treatment of acute left colonic diverticulitis in the elderly

Acute left colonic diverticulitis (ALCD) in the elderly presents with unique epidemiological features when compared with younger patients. The clinical presentation is more nuanced in the elderly population, having higher in-hospital and postoperative mortality. Furthermore, geriatric comorbidities are a risk factor for complicated diverticulitis. Finally, elderly patients have a lower risk of recurrent episodes and, in case of recurrence, a lower probability of requiring urgent surgery than younger patients. The aim of the present work is to study age-related factors that may support a unique approach to the diagnosis and treatment of this problem in the elderly when compared with the WSES guidelines for the management of acute left-sided colonic diverticulitis. During the 1° Pisa Workshop of Acute Care & Trauma Surgery held in Pisa (Italy) in September 2019, with the collaboration of the World Society of Emergency Surgery (WSES), the Italian Society of Geriatric Surgery (SICG), the Italian Hospital Surgeons Association (ACOI), the Italian Emergency Surgery and Trauma Association (SICUT), the Academy of Emergency Medicine and Care (AcEMC) and the Italian Society of Surgical Pathophysiology (SIFIPAC), three panel members presented a number of statements developed for each of the four themes regarding the diagnosis and management of ALCD in older patients, formulated according to the GRADE approach, at a Consensus Conference where a panel of experts participated. The statements were subsequently debated, revised, and finally approved by the Consensus Conference attendees. The current paper is a summary report of the definitive guidelines statements on each of the following topics: diagnosis, management, surgical technique and antibiotic therapy.

Evolution of damage control surgery in non-traumatic abdominal pathology: a light in the darkness

Damage control surgery is based on temporal control of the injury, physiologic recovery and posterior deferred definitive management. This strategy began in the 1980s and became a formal concept in 1993. It has proven to be a strategy that reduces mortality in severely injured trauma patients. Nevertheless, the concept of damage control in non-traumatic abdominal pathology remains controversial. This article aims to gather historical experiences in damage control surgery performed in non-traumatic abdominal emergency pathology patients and present a novel management algorithm. This strategy could be a surgical option to treat hemodynamically unstable patients in catastrophic scenarios such as hemorrhagic and septic shock caused by peritonitis, pancreatitis, acute mesenteric ischemia, among others. Therefore, damage control surgery is light amid better short- and long-term results.

WSES/GAIS/SIS-E/WSIS/AAST global clinical pathways for patients with intra-abdominal infections

Intra-abdominal infections (IAIs) are common surgical emergencies and have been reported as major contributors to non-trauma deaths in hospitals worldwide. The cornerstones of effective treatment of IAIs include early recognition, adequate source control, appropriate antimicrobial therapy, and prompt physiologic stabilization using a critical care environment, combined with an optimal surgical approach. Together, the World Society of Emergency Surgery (WSES), the Global Alliance for Infections in Surgery (GAIS), the Surgical Infection Society-Europe (SIS-E), the World Surgical Infection Society (WSIS), and the American Association for the Surgery of Trauma (AAST) have jointly completed an international multi-society document in order to facilitate clinical management of patients with IAIs worldwide building evidence-based clinical pathways for the most common IAIs. An extensive non-systematic review was conducted using the PubMed and MEDLINE databases, limited to the English language. The resulting information was shared by an international task force from 46 countries with different clinical backgrounds. The aim of the document is to promote global standards of care in IAIs providing guidance to clinicians by describing reasonable approaches to the management of IAIs.

Large intestinal perforation secondary to COVID-19: A case report

Introduction

COVID-19 infection is generally characterized by the presence of respiratory symptoms. However, a small percentage of these patients also have gastrointestinal symptoms and complications that are associated with high morbidity and mortality.

Presentation of case

A 50-year-old male patient with COVID-19 infection was being treated for COVID-19 and pneumonia in the ICU. He presented with gastrointestinal symptoms, and the computed tomography (CT) scan revealed a hollow viscus perforation. Ultimately, the patient was taken to surgery, where a spontaneous perforation was found in the right colon. The defect was sutured with separate stitches. There were no complications postoperatively.

Discussion

Although respiratory symptoms are the most common presentation of COVID-19, about 18% of these patients may present with gastrointestinal symptoms. However, an even smaller percentage of critically ill patients may develop serious gastrointestinal complications such as perforation of the large intestine. This unusual complication requires immediate diagnosis and surgical management.

Conclusion

At the time of the COVID-19 pandemic, physicians must recognize COVID-19 in patients presenting gastrointestinal symptoms. A high degree of clinical suspicion enables timely diagnosis and management, thereby preventing major complications.

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Bowel perforation is an uncommon complication of COVID-19. It has been rarely reported in the literature.

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Patients with severe COVID-19 have an increased risk of gastrointestinal complications, including bowel perforation.

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Bowel perforation secondary to COVID-19 in critically ill patients has a nonspecific presentation; thus, it only confers a high degree of suspicion.