Evaluación de un modelo de atención quirúrgica urgente en los resultados de eficacia, seguridad y eficiencia en el tratamiento de la apendicitis aguda

Introducción La apendicitis aguda es la urgencia quirúrgica más frecuente de la especialidad. Según las estadísticas mundiales esla causa principal de abdomen agudo quirúrgico y por tanto, sus resultados pueden reflejar en gran medida la calidad de la atención en el ámbito de la cirugía digestiva urgente y podrían ser utilizados como indicador de calidad para evaluar la gestión de las urgencias quirúrgicas. Mediante este estudio queremos evaluar si la existencia de un modelo organizativo con una unidad quirúrgica dedicada específicamente a la atención de los problemas quirúrgicos urgentes en el ámbito de la especialidad de Cirugía General y del Aparato Digestivo mejora los resultados obtenidos en el tratamiento de la apendicitis aguda en términos de seguridad, eficacia y eficiencia. Cabe esperar que los resultados obtenidos en la apendicectomía, se puedan correlacionar con lo obtenidos en otras intervenciones urgentes. Utilizamos como modelo comparativo la apendicitis por tratarse de una cirugía relativamente sencilla, ser la más frecuente, con una baja tasa de complicaciones y ser reproductible. Material y métodos Se ha llevado a cabo un estudio observacional analítico prospectivo en el que se incluyen enfermos intervenidos de forma urgente por cuadro de sospecha de apendicitis aguda durante un período de 36 meses. Estos pacientes, se han expuesto a un grupo distinto de cirujanos en función del momento y día en que se han intervenido. Un grupo de pacientes serán intervenidos por cualquiera de los 5 cirujanos de staf pertenecientes a la Unidad de Cirugía de Urgencias de HH.UU Virgen del Rocío, que se dedican en exclusiva a la atención de estos problemas quirúrgicos urgentes, en horario laboral de lunes a viernes (8-15 horas) y fuera del horario laboral 1 de cada 10 días (Grupo Urgencias). El otro grupo de pacientes serán los intervenidos por cualquiera de un total de 25 cirujanos que atienden los problemas quirúrgicos urgentes fuera del horario laboral, es decir, de lunes a viernes (15-8 horas) y sábados y festivos, realizándolo cada uno de ellos de en siguiendo turnos de 1 de cada 10 días (Grupo General). Se analizan los resultados según via de abordaje y gravedad de la apendicitis. El seguimiento del paciente se realizará hasta un mes tras la intervención a no ser que el paciente presente alguna complicación que requiera más revisiones. Se calculan los costes del material laparoscópica y la estancia media postoperatoria. Resultados Se comparan los resultados entre cada grupo de pacientes y observamos que hay diferencias estadísticamente significativas en la estancia media hospitalaria siendo de 3’1 día en el grupo de Urgencias y de 4’2 en el otro grupo. También existen diferencias significativas en el tipo de abordaje, siendo el abordaje laparoscópico más frecuente (78’73%) en el grupo de Urgencias que en el otro grupo (65’44%). En cuanto a complicaciones, se observa un 10’29% de tasa global en el grupo de la Unidad de Cirugía de Urgencias en comparación a un 18’3% del grupo del resto de Servicio (p 0’001). El coste por procedimiento es de 2420,4 en Grupo Urgencias vs 2893,6 en el Grupo General Conclusiones Estos datos, muestran que los resultados en el abordaje quirúrgico de la apendicitis aguda por una unidad quirúrgica dedicada específicamente a la atención de los problemas quirúrgicos urgentes mejoran los resultados obtenidos por cirujanos que no se dedican específicamente a atender urgencias quirúrgicas. Por tanto, concluimos que la existencia de un modelo organizativo con una unidad quirúrgica dedicada específicamente a la atención de los problemas quirúrgicos urgentes mejora los resultados obtenidos en el tratamiento de la apendicitis aguda, lo cual podría ser extrapolable a los resultados de otras urgencias quirúrgicas

Evolving Trends in the Management of Acute Appendicitis During COVID-19 Waves: The ACIE Appy II Study

Apendicitis aguda; Gestió; Onada de COVID-19Apendicitis aguda; Gestión; Ola de COVID-19Acute appendicitis; management; COVID-19 wavesBackground In 2020, ACIE Appy study showed that COVID-19 pandemic heavily affected the management of patients with acute appendicitis (AA) worldwide, with an increased rate of non-operative management (NOM) strategies and a trend toward open surgery due to concern of virus transmission by laparoscopy and controversial recommendations on this issue. The aim of this study was to survey again the same group of surgeons to assess if any difference in management attitudes of AA had occurred in the later stages of the outbreak. Methods From August 15 to September 30, 2021, an online questionnaire was sent to all 709 participants of the ACIE Appy study. The questionnaire included questions on personal protective equipment (PPE), local policies and screening for SARS-CoV-2 infection, NOM, surgical approach and disease presentations in 2021. The results were compared with the results from the previous study. Results A total of 476 answers were collected (response rate 67.1%). Screening policies were significatively improved with most patients screened regardless of symptoms (89.5% vs. 37.4%) with PCR and antigenic test as the preferred test (74.1% vs. 26.3%). More patients tested positive before surgery and commercial systems were the preferred ones to filter smoke plumes during laparoscopy. Laparoscopic appendicectomy was the first option in the treatment of AA, with a declined use of NOM. Conclusion Management of AA has improved in the last waves of pandemic. Increased evidence regarding SARS-COV-2 infection along with a timely healthcare systems response has been translated into tailored attitudes and a better care for patients with AA worldwide.Open access funding provided by Università degli Studi di Roma La Sapienza within the CRUI-CARE Agreement. The authors did not receive any funding for the present study

Cirugía preservadora de órgano tras traumatismo esplénico cerrado con implicación hiliar

ResumenAntecedentesLa afectación esplénica secundaria a un traumatismo abdominal cerrado es frecuentemente tratada mediante esplenectomía. Ante la gravedad de las consecuencias del síndrome postesplenectomía (pérdidas hemáticas, sepsis, etc.) cada vez se tiende más a la preservación del órgano afectado. Presentamos un caso clínico de preservación de bazo tras traumatismo abdominal cerrado con implicación hiliar de dicho órgano, en el que se recurre al papel esencial del Floseal® como agente hemostático.Caso clínicoMujer de 22 años que presenta traumatismo abdominal cerrado tras accidente de tráfico, con diagnóstico de lesión esplénica del polo inferior con compromiso hiliar que implica la vascularización de dicha región. Se procede a la intervención quirúrgica urgente con preservación esplénica mediante esplenectomía parcial y control del sangrado con Floseal® y con el empleo de una malla de refuerzo de ácido poliglicólico. La evolución postoperatoria es satisfactoria y sale del hospital al 5.o día sin incidencias.ConclusiónEl empleo de agentes hemostáticos como el gel de gelatina y trombina (Floseal®) y el uso de mallas envolventes de ácido poliglicólico posibilitan la cirugía de preservación esplénica tras un traumatismo abdominal, representando una alternativa segura y factible a la esplenectomía completa clásica, con el beneficio de la conservación del órgano y de sus funciones.AbstractBackgroundSplenic involvement secondary to blunt abdominal trauma is often treated by performing a splenectomy. The severity of the post-splenectomy syndrome is currently well known (blood loss, sepsis), so there is an increasing tendency to preserve the spleen. The case is presented of splenic preservation after blunt abdominal trauma with hilum involvement, emphasising the role of Floseal® as a haemostatic agent, as well as the use of resorbable meshes to preserve the spleen.Clinical caseA 22-year-old woman presenting with a grade IV splenic lesion secondary to a blunt abdominal trauma after a traffic accident. Partial splenic resection was performed and bleeding was controlled with Floseal® and use of a reinforcing polyglycolic acid mesh. No postoperative complications occurred, being discharged on day 5. The long-term follow-up has been uneventful.ConclusionThe use of haemostatic agents such as thrombin and the gelatine gel (FloSeal®) and the use of polyglycolic acid meshes enable spleen-preserving surgery, making it a feasible and reproducible procedure and an alternative to classical splenectomy

SARS-CoV-2 vaccination modelling for safe surgery to save lives: data from an international prospective cohort study

Background Preoperative SARS-CoV-2 vaccination could support safer elective surgery. Vaccine numbers are limited so this study aimed to inform their prioritization by modelling. Methods The primary outcome was the number needed to vaccinate (NNV) to prevent one COVID-19-related death in 1 year. NNVs were based on postoperative SARS-CoV-2 rates and mortality in an international cohort study (surgical patients), and community SARS-CoV-2 incidence and case fatality data (general population). NNV estimates were stratified by age (18–49, 50–69, 70 or more years) and type of surgery. Best- and worst-case scenarios were used to describe uncertainty. Results NNVs were more favourable in surgical patients than the general population. The most favourable NNVs were in patients aged 70 years or more needing cancer surgery (351; best case 196, worst case 816) or non-cancer surgery (733; best case 407, worst case 1664). Both exceeded the NNV in the general population (1840; best case 1196, worst case 3066). NNVs for surgical patients remained favourable at a range of SARS-CoV-2 incidence rates in sensitivity analysis modelling. Globally, prioritizing preoperative vaccination of patients needing elective surgery ahead of the general population could prevent an additional 58 687 (best case 115 007, worst case 20 177) COVID-19-related deaths in 1 year. Conclusion As global roll out of SARS-CoV-2 vaccination proceeds, patients needing elective surgery should be prioritized ahead of the general population

Timing of surgery following SARS-CoV-2 infection: an international prospective cohort study

Peri-operative SARS-CoV-2 infection increases postoperative mortality. The aim of this study was to determine the optimal duration of planned delay before surgery in patients who have had SARS-CoV-2 infection. This international, multicentre, prospective cohort study included patients undergoing elective or emergency surgery during October 2020. Surgical patients with pre-operative SARS-CoV-2 infection were compared with those without previous SARS-CoV-2 infection. The primary outcome measure was 30-day postoperative mortality. Logistic regression models were used to calculate adjusted 30-day mortality rates stratified by time from diagnosis of SARS-CoV-2 infection to surgery. Among 140,231 patients (116 countries), 3127 patients (2.2%) had a pre-operative SARS-CoV-2 diagnosis. Adjusted 30-day mortality in patients without SARS-CoV-2 infection was 1.5% (95%CI 1.4–1.5). In patients with a pre-operative SARS-CoV-2 diagnosis, mortality was increased in patients having surgery within 0–2 weeks, 3–4 weeks and 5–6 weeks of the diagnosis (odds ratio (95%CI) 4.1 (3.3–4.8), 3.9 (2.6–5.1) and 3.6 (2.0–5.2), respectively). Surgery performed ≥ 7 weeks after SARS-CoV-2 diagnosis was associated with a similar mortality risk to baseline (odds ratio (95%CI) 1.5 (0.9–2.1)). After a ≥ 7 week delay in undertaking surgery following SARS-CoV-2 infection, patients with ongoing symptoms had a higher mortality than patients whose symptoms had resolved or who had been asymptomatic (6.0% (95%CI 3.2–8.7) vs. 2.4% (95%CI 1.4–3.4) vs. 1.3% (95%CI 0.6–2.0), respectively). Where possible, surgery should be delayed for at least 7 weeks following SARS-CoV-2 infection. Patients with ongoing symptoms ≥ 7 weeks from diagnosis may benefit from further delay

Global overview of the management of acute cholecystitis during the COVID-19 pandemic (CHOLECOVID study)

Background: This study provides a global overview of the management of patients with acute cholecystitis during the initial phase of the COVID-19 pandemic. Methods: CHOLECOVID is an international, multicentre, observational comparative study of patients admitted to hospital with acute cholecystitis during the COVID-19 pandemic. Data on management were collected for a 2-month study interval coincident with the WHO declaration of the SARS-CoV-2 pandemic and compared with an equivalent pre-pandemic time interval. Mediation analysis examined the influence of SARS-COV-2 infection on 30-day mortality. Results: This study collected data on 9783 patients with acute cholecystitis admitted to 247 hospitals across the world. The pandemic was associated with reduced availability of surgical workforce and operating facilities globally, a significant shift to worse severity of disease, and increased use of conservative management. There was a reduction (both absolute and proportionate) in the number of patients undergoing cholecystectomy from 3095 patients (56.2 per cent) pre-pandemic to 1998 patients (46.2 per cent) during the pandemic but there was no difference in 30-day all-cause mortality after cholecystectomy comparing the pre-pandemic interval with the pandemic (13 patients (0.4 per cent) pre-pandemic to 13 patients (0.6 per cent) pandemic; P= 0.355). In mediation analysis, an admission with acute cholecystitis during the pandemic was associated with a non-significant increased risk of death (OR 1.29, 95 per cent c.i. 0.93 to 1.79, P= 0.121). Conclusion:CHOLECOVID provides a unique overview of the treatment of patients with cholecystitis across the globe during the firstmonths of the SARS-CoV-2 pandemic. The study highlights the need for system resilience in retention of elective surgical activity. Cholecystectomy was associated with a low risk of mortality and deferral of treatment results in an increase in avoidable morbidity that represents the non COVID cost of this pandemic