Emergency surgery and Limitation of therapeutic effort in relation to neurologic deterioration in elderly patients – a survey of European surgeons

Background. In emergency surgery, a very heterogeneous approach is required in the decision making process, especially when considering the patient’s postoperative quality of life as well as medical, ethical, and legal factors. In some cases, the presence of an Advance Directive (AD) form may potentially help resolve the surgeon’s dilemma. Objectives. The primary objective of this survey was to investigate the opinions of surgeons across a representative cross-section of European countries regarding the decision making process using a specific case scenario so as to identify similarities and differences in practice. A secondary objective was to identify the possibility of establishing a more uniform approach and best practice. Method. A survey was conducted of surgeons from a range of European countries. Questionnaires were designed to obtain an overview of decision making in relation to the Limitation of Therapeutic Effort (LTE) using a specific case study and the level of awareness and practical use of ADs. Surveys were distributed via email to the members of the ESTES (European Society for Trauma and Emergency Surgery) and AEC (Association of Spanish surgeons), with voluntary, anonymous participation. Conclusions. Clear and additional support in the form of legal and ethical guidance with clinical protocols for surgical practice in such case scenarios is necessary. Wider use of ADs, together with education about their role and support for patients and relatives, would benefit the type of patient described in our scenario. A multidisciplinary team should play a more active role in decision making in order to avoid surgical procedures that are potentially futile. The concepts of LTE and Quality of life need a broader understanding among surgeons as well as more consistent application

Realtime elastosonography of the penis in patients with Peyronie's disease

Objective: To evaluate the performance of real time elastosonography (RTE) in the iden- tification of different types of penile lesions in patients with Peyronie’s disease. Materials and methods: Seventy four consecutive patients with complaints of Peyronie’s disease underwent B-Mode ultrasonography (US) and RTE of the penis in the same sit- ting. In each patient all sequences of elastosonography and B-Mode US were recorded and compared to evaluate the diagnostic performance of the new imaging technique. Results: B-Mode US detected penile plaques in 64 patients (86.41%) and elastosonography con- firmed these data. In the remaining 10 patients elastosonography documented, in five of them, areas of reducing elasticity suggesting the presence of initial fibrosis. Cohen’s K was used to eval- uate the discordances between B-Mode US and Elastosonography scan. A p value 30°, and the penile plaque evalua- tions were completely concordant. Conclusions: RTE is a simple, non invasive, rapid complementary imaging technique that may improve the accuracy of B-Mode US in detecting penile lesions in patients with Peyronie’s disease

Damage Control in Hinchey III and IV Acute Diverticulitis

Acute diverticulitis is one of the most common surgical causes of admission to Emergency Departments in Western Countries. Although most of the cases can be managed conservatively or electively, a number of them will require an emergency surgical treatment. Among these patients, an even smaller number of them will present with a full-blown catastrophic septic shock. These minorities of cases have accounted for a significant part of the overall mortality and morbidity of complicated acute diverticulitis itself. The implementation of Damage Control strategies has shown to be useful also in these septic catastrophes, where a profound derangement of physiology makes unsafe a classic approach. Damage Control, as we intend it, is not a surgical “technique.” A close collaboration between different specialties brought forth a strategy of treatment. The Surgeon, the Anesthetist, and the Intensivist are the three most involved specialists in the treatment of these cases. It is paramount for them to learn how to work side by side and in harmony, since the patients will benefit from each-one’s input in their care

Evaluation of appendicitis risk prediction models in adults with suspected appendicitis

Background Appendicitis is the most common general surgical emergency worldwide, but its diagnosis remains challenging. The aim of this study was to determine whether existing risk prediction models can reliably identify patients presenting to hospital in the UK with acute right iliac fossa (RIF) pain who are at low risk of appendicitis. Methods A systematic search was completed to identify all existing appendicitis risk prediction models. Models were validated using UK data from an international prospective cohort study that captured consecutive patients aged 16–45 years presenting to hospital with acute RIF in March to June 2017. The main outcome was best achievable model specificity (proportion of patients who did not have appendicitis correctly classified as low risk) whilst maintaining a failure rate below 5 per cent (proportion of patients identified as low risk who actually had appendicitis). Results Some 5345 patients across 154 UK hospitals were identified, of which two‐thirds (3613 of 5345, 67·6 per cent) were women. Women were more than twice as likely to undergo surgery with removal of a histologically normal appendix (272 of 964, 28·2 per cent) than men (120 of 993, 12·1 per cent) (relative risk 2·33, 95 per cent c.i. 1·92 to 2·84; P < 0·001). Of 15 validated risk prediction models, the Adult Appendicitis Score performed best (cut‐off score 8 or less, specificity 63·1 per cent, failure rate 3·7 per cent). The Appendicitis Inflammatory Response Score performed best for men (cut‐off score 2 or less, specificity 24·7 per cent, failure rate 2·4 per cent). Conclusion Women in the UK had a disproportionate risk of admission without surgical intervention and had high rates of normal appendicectomy. Risk prediction models to support shared decision‐making by identifying adults in the UK at low risk of appendicitis were identified

Importance of ultrasound elastography prior to testicular surgery: clinical evidence

The elastosonographic study is a comparative study of the density of the lesions investigated in comparison with the surrounding of the body that uoy are looking at. We used this technique of investigation to assess the nature of a testicular lesion in a patient affected by Carney Complex Syndrom

Plasma asymmetric dimethylarginine (ADMA) levels and atherosclerotic disease in ankylosing spondylitis: a cross-sectional study

Conclusive data about the prevalence of endothelial dysfunction and atherosclerotic process in ankylosing spondylitis (AS) patients with respect to the general population are lacking. Elevated plasma levels of asymmetric dimethylarginine (ADMA), an endogenous inhibitor of nitric oxide synthase, have been reported in clinical conditions associated with endothelial dysfunction and atherosclerotic disease. We performed a cross-sectional study to evaluate plasma ADMA levels and atherosclerotic disease in AS patients. Seventeen consecutive AS patients free of any cardiovascular disease and 17 healthy controls [strictly matched for sex, age (±5 years) and atherosclerotic risk factors] were recruited. Plasma ADMA levels were assessed by capillary electrophoresis. Common carotid artery intima–media thickness (CCA-IMT), flow-mediated dilatation (FMD) and arterial stiffness (aS) were registered as surrogate markers of atherosclerotic disease. Plasma ADMA levels appeared significantly (p=0.001) higher in AS patients (0.65 ± 0.10 μmoli/L) than in the control subjects (0.54 ± 0.07 μmoli/L) while no statistically significant differences between AS and controls were demonstrated in CCA-IMT, FMD, and aS. AS patients showed increased plasma ADMA levels with respect to control subjects. On the contrary, we were not able to document a significant difference in atherosclerotic process between patients and controls

Enhanced Recovery After Surgery (ERAS) - The Evidence in Geriatric Emergency Surgery: A Systematic Review

Background: Geriatric surgery is rising and projected to continue at a greater rate. There is already concern about the poor outcomes for the emergency surgery in elderly. How to manage the available resources to improve outcomes in this group of patients is an important object of debate.Objectives: We aimed to determine the feasibility and safety of applying ERAS pathways to emergency elderly surgical patients.Method: Two searches were undertaken for ERAS protocols in elderly patients and emergency surgery, in order to gather evidence in relation to ERAS in geriatric emergency patients. Primary outcomes were postoperative complications, mortality, hospital length of stay and readmission rates.Results. Eighteen studies were included. The majority of patients were older than 70. Elderly patients had fewer postoperative complications and a reduced hospitalization with ERAS compared to conventional care. Emergency surgical patients also had fewer postoperative complications with ERAS compared to conventional care. Hospital stay was reduced in 2 out of 3 studies for emergency surgery.Conclusions: ERAS can be safely applied to elderly and emergency patients with a reduction in postoperative complications, hospitalization and readmission rates. There is evidence to suggest that ERAS is feasible and beneficial for geriatric emergency patients

Correction to: Surgeon-performed point-of-care ultrasound for acute cholecystitis: indications and limitations: a European Society for Trauma and Emergency Surgery (ESTES) consensus statement.

Unfortunately, the author Luca Ponchietti was omitted in the original publication. Please find the correct author list here

Not only FAST The MUSEC® experience in training surgeons

For a long time surgeons have been discussing the need to improve their skills in the use of ultrasound (US). However in the recent years it has become evident the importancxe for general aklnd trauma surgeons treating critically-ill patients to learn basic and advanced US. The two last editions (9th and 10th) of the ATLS manual have officially included FAST and e-FAST in the primary assessment of trauma patients, making this tool an essential skill for surgeons. In the acute care setting FAST, e-FAST and other applications have gained a pivotal, evidence-based role in this fields. Nevertheless, surgeons are rarely performing US exams by themselves, losing a major decision-making tool. The Modular Ultrasound ESTES Course (MUSEC®) was developed to provide both fundamental and advanced US training for surgeons in trauma and acute care settings. We are strongly convinced, in the light of the results from both the surveys carried out and the customer satisfaction tests administered to all the participants in the MUSEC courses, that US courses such as these should be part of the general surgery residency programs

Impact of Personal Protective Equipment on Surgical Performance During the COVID-19 Pandemic.

The Severe Acute Respiratory Syndrome Coronavirus 2 pandemic has exposed surgeons to hazardous working conditions, imposing the need for personal protective equipment (PPE) use during surgery. The use of such equipment may affect their non-technical skills, augment fatigue, and affect performance. This study aimed to assess the surgeons' perceptions of the impact of wearing PPE during emergency surgery throughout the pandemic. An international cooperation group conducted an anonymous online survey among surgeons from over 30 countries, to assess perceptions about the impact of PPE use on non-technical skills, overall comfort, decision making, and surgical performance during emergency surgery on COVID-19 patients. Responses to the survey (134) were received from surgeons based on 26 countries. The vast majority (72%) were males. More than half of the respondents (54%) felt that their surgical performance was hampered with PPE. Visual impairment was reported by 63%, whereas 54% had communication impediments. Less than half (48%) felt protected with the use of PPE, and the same proportion perceived that the use of such equipment influenced their decision making. Decreased overall comfort was cited by 66%, and 82% experienced increased surgical fatigue. Surgeons perceived impediment for both visibility and communication, and other non-technical skills while using PPE on emergency surgery in COVID-19 patients. Their perceived lack of protection and comfort and increased fatigue may have inhibited their optimal surgical performance. More attention should be placed in the design of more user-friendly equipment, given the possibility of a second wave of the pandemic