Characteristics of emergency general surgery services in Switzerland: a nationwide survey.

OBJECTIVE Running an emergency general surgery (EGS) service is challenging and requires significant personnel and institutional resources. The aim of this study was to achieve a nationwide overview of the individual EGS service organizations in public hospitals in Switzerland. METHODS All Swiss public hospitals with a surgical and emergency department were included and contacted by telephone. General surgeons were interviewed between December 2021 and January 2022 using a standardized questionnaire. RESULTS Seventy-two out of 79 public hospitals in Switzerland (91.1%) agreed to the survey. They employed 1,581 surgeons in 19 (26.4%) hospitals with  600 beds. The median number of surgeons per hospital was 20.5 (IQR 13.0-29.0). Higher level of care (intermediate or intensive care unit) was significantly less available in small hospitals ( 600 beds). With increasing hospital size, there was a significant increase in the number of surgical units where EGS and orthopedic trauma surgery were covered by two separate teams (21.1% vs. 43.6% vs. 85.7% vs. 100%, p = 0.035). The median number of surgeons on-call per hospital and per 24 h was 5.0 (IQR 3.3-6.0). CONCLUSION Lack of higher level of care in small hospitals, limited emergency OR capacity and short rotations of on-call teams are major drawbacks of many current EGS systems in Switzerland. Centralization of critically ill EGS patients and reorganization of surgical on-call systems to designated acute care surgery teams should be considered

Work Characteristics of Acute Care Surgeons at a Swiss Tertiary Care Hospital: A Prospective One-Month Snapshot Study.

BACKGROUND Multiple acute care surgery (ACS) working models have been implemented. To optimize resources and on-call rosters, knowledge about work characteristics is required. Therefore, this study aimed to investigate the daily work characteristics of ACS surgeons at a Swiss tertiary care hospital. METHODS Single-center prospective snapshot study. In February 2020, ACS fellows prospectively recorded their work characteristics, case volume and surgical case mix for 20 day shifts and 16 night shifts. Work characteristics were categorized in 11 different activities and documented in intervals of 30 min. Descriptive statistics were applied. RESULTS A total of 432.5 working hours (h) were documented and characterized. The three main activities 'surgery,' 'patient consultations' and 'administrative work' ranged from 30.8 to 35.9% of the documented working time. A total of 46 surgical interventions were performed. In total, during day shifts, there were 16 elective and 15 emergency interventions, during night shifts 15 emergency interventions. For surgery, two peaks between 10:00 a.m.-02:00 p.m. and 08:00 p.m.-11:00 p.m. were observed. A total of 225 patient were consulted, with a first peak between 08:00 a.m. and 11:00 a.m. and a second, wider peak between 02:00 p.m. and 02:00 a.m. CONCLUSION The three main activities 'surgery,' 'patient consultations' and 'administrative work' were comparable with approximately one third of the working time each. There was a bimodal temporal distribution for both surgery and patient consultations. These results may help to improve hospital resources and on-call rosters of ACS services

Developing a reflection and analysis tool (We-ReAlyse) for readmissions to the intensive care unit: A quality improvement project

Readmissions to the intensive care unit are associated with poorer patient outcomes and health prognoses, alongside increased lengths of stay and mortality risk. To improve quality of care and patients' safety, it is essential to understand influencing factors relevant to specific patient populations and settings. A standardized tool for systematic retrospective analysis of readmissions would help healthcare professionals understand risks and reasons affecting readmissions; however, no such tool exists.; This study's purpose was to develop a tool (We-ReAlyse) to analyze readmissions to the intensive care unit from general units by reflecting on affected patients' pathways from intensive care discharge to readmission. The results will highlight case-specific causes of readmission and potential areas for departmental- and institutional-level improvements.; A root cause analysis approach guided this quality improvement project. The tool's iterative development process included a literature search, a clinical expert panel, and a testing in January and February 2021.; The We-ReAlyse tool guides healthcare professionals to identify areas for quality improvement by reflecting the patient's pathway from the initial intensive care stay to readmission. Ten readmissions were analyzed by using the We-ReAlyse tool, resulting in key insights about possible root causes like the handover process, patient's care needs, the resources on the general unit and the use of different electronic healthcare record systems.; The We-ReAlyse tool provides a visualization/objectification of issues related to intensive care readmissions, gathering data upon which to base quality improvement interventions. Based on the information on how multi-level risk profiles and knowledge deficits contribute to readmission rates, nurses can target specific quality improvements to reduce those rates.; With the We-ReAlyse tool, we have the opportunity to collect detailed information about ICU readmissions for an in-depth analysis. This will allow health professionals in all involved departments to discuss and either correct or cope with the identified issues. In the long term, this will allow continuous, concerted efforts to reduce and prevent ICU readmissions. To obtain more data for analysis and to further refine and simplify the tool, it may be applied to larger samples of ICU readmissions. Furthermore, to test its generalizability, the tool should be applied to patients from other departments and other hospitals. Adapting it to an electronic version would facilitate the timely and comprehensive collection of necessary information. Finally, the tool's emphasis comprises reflecting on and analyzing ICU readmissions, allowing clinicians to develop interventions targeting the identified problems. Therefore, future research in this area will require the development and evaluation of potential interventions

Risk factors for chronic postsurgical pain in visceral surgery: a matched case-control analysis.

PURPOSE Chronic postsurgical pain (CPSP) after abdominal visceral surgery is an underestimated long-term complication with relevant impact on health-related quality of life and socioeconomic costs. Early identification of affected patients is important. We aim to identify the incidence and risk factors for CPSP in this patient population. METHODS Retrospective case-control matched analysis including all patients diagnosed with CPSP after visceral surgery in our institution between 2016 and 2019. One-to-two case-control matching was based on operation category (HPB, upper-GI, colorectal, transplantation, bariatric, hernia and others) and date of surgery. Potential risk factors for CPSP were identified using conditional multivariate logistic regression. RESULTS Among a cohort of 3730 patients, 176 (4.7%) were diagnosed with CPSP during the study period and matched to a sample of 352 control patients. Independent risk factors for CPSP were age under 55 years (OR 2.64, CI 1.51-4.61), preexisting chronic pain of any origin (OR 3.42, CI 1.75-6.67), previous abdominal surgery (OR 1.99, CI 1.11-3.57), acute postoperative pain (OR 1.29, CI 1.16-1.44), postoperative use of non-steroidal anti-inflammatory drugs (OR 3.73, OR 1.61-8.65), opioid use on discharge (OR 3.78, CI 2.10-6.80) and length of stay over 3 days (OR 2.60, CI 1.22-5.53). Preoperative Pregabalin intake was protective (OR 0.02, CI 0.002-0.21). CONCLUSION The incidence of CPSP is high and associated with specific risk factors, some of them modifiable. Special attention should be given to sufficient treatment of preexisting chronic pain and acute postoperative pain

Liver Transplantation for Acute Intermittent Porphyria.

Funder: Alnylam Pharmaceuticals; Id: http://dx.doi.org/10.13039/100006400Recurrent attacks of acute intermittent porphyria (AIP) result in poor quality of life and significant risks of morbidity and mortality. Liver transplantation (LT) offers a cure, but published data on outcomes after LT are limited. We assessed the pretransplant characteristics, complications, and outcomes for patients with AIP who received a transplant. Data were collected retrospectively from the European Liver Transplant Registry and from questionnaires sent to identified transplant and porphyria centers. We studied 38 patients who received transplants in 12 countries from 2002 to 2019. Median age at LT was 37 years (range, 18-58), and 34 (89%) of the patients were women. A total of 9 patients died during follow-up, and 2 patients were retransplanted. The 1-year and 5-year overall survival rates were 92% and 82%, which are comparable with other metabolic diseases transplanted during the same period. Advanced pretransplant neurological impairment was associated with increased mortality. The 5-year survival rate was 94% among 19 patients with moderate or no neuropathy at LT and 83% among 10 patients with severe neuropathy (P = 0.04). Pretransplant renal impairment was common. A total of 19 (51%) patients had a GFR < 60 mL/minute. Although few patients improved their renal function after LT, neurological impairments improved, and no worsening of neurological symptoms was recorded. No patient had AIP attacks after LT, except for a patient who received an auxiliary graft. LT is a curative treatment option for patients with recurrent attacks of AIP. Severe neuropathy and impaired renal function are common and increase the risk for poor outcomes. If other treatment options fail, an evaluation for LT should be performed early

Effectiveness of terlipressin for prevention of complications after major liver resection - A randomized placebo-controlled trial.

BACKGROUND Elevated portal pressure in response to major liver resection is associated with impaired liver regeneration and increased postoperative complications. Terlipressin, a splanchnic vasoconstrictor used for treatment of hepatorenal syndrome, was tested for reduction of complications and renal protection after liver resection. METHODS A randomized double-blinded placebo-controlled trial including patients undergoing elective major liver resection was performed. Terlipressin was administered to patients in the intervention group for five days. The primary outcome parameter was the incidence of a clinical composite endpoint of following liver specific complications 6 weeks after surgery: liver failure, ascites, bile leakage, intra-abdominal abscess and operative mortality. Postoperative kidney function was assessed as a secondary endpoint. RESULTS 150 patients (mean age 63.4 years, 73.3% male) were included. No difference was found in the composite endpoint between the placebo and intervention group (32.8% versus 30.8%, relative risk 1.066, 95%CI 0.643 to 1.769, p = 0.85). Patients receiving terlipressin showed a significant lower decrease in postoperative estimated glomerular filtration rate compared to placebo (two way ANOVA, p = 0.005). CONCLUSION Perioperative administration of terlipressin during major liver surgery did not affect a composite endpoint of liver specific complications, but significantly protected from postoperative deterioration of kidney function compared to placebo. CLINICALTRIALS. GOV IDENTIFIER NCT01921985

Impact of changing the surgical team for wound closure on surgical site infection: A matched case-control study.

BACKGROUND Wound closure is performed at the end of the procedure, when the attention of the surgical team may decrease due to tiredness. The aim of this study was to assess the influence of changing the surgical team for wound closure on the rate of surgical site infection (SSI). METHODS A two-armed observational monocentric matched case-control study was performed in a time series design. During the baseline period, closure of the abdominal wall was performed by the main surgical team. The intervention consisted of closure of the abdominal wall and skin by an independent surgical team. Matching was based on gender, BMI, length of surgery, type of surgery, elective versus emergency surgery and ASA score. The primary outcome was SSI rate 30 days after surgery. RESULTS A total of 72 patients in the intervention group were matched with 72 patients in the baseline group. The SSI rate after 30 days in the intervention group was 10% (n = 7) and in the baseline group 21% (n = 15) (p = 0.064). Redo-Surgery as result of infection (e.g. opening the wound, drainage or reoperation) was significantly higher in the baseline group (19.4% vs 2.7%; p = 0.014). Mortality, length of stay, rehospitalisation and complication rates 30 days after surgery did not differ significantly. CONCLUSION Changing the surgical team for wound closure did not reduce the overall rate of SSI, but the rate of redo-surgery as a result of SSI. Despite being potentially beneficial, organizational factors are a main limiting factor of changing the surgical team for the wound closure. TRIAL REGISTRATION Clinicaltrial.gov NCT04503642

Prophylaxe von Narbenhernien – Lassen sie sich verhindern?

Prophylaxis of incisional hernia - Are they preventable? Abstract. Following abdominal surgery, incisional hernias are common. Weight reduction and smoking cessation prior to elective surgery positively influence relevant risk factors. Laparoscopic operation technique prevents incisional hernia formation. Patients at increased risk for incisional hernia undergoing open abdominal surgery should be evaluated for prophylactic implantation of a non-absorbable mesh.Zusammenfassung. Narbenhernien sind eine häufige Komplikation von abdominalen Eingriffen. Mittels Gewichtsabnahme und Rauchstopp lassen sich etablierte Risikofaktoren vor elektiven Operationen verbessern. Zur Verhinderung von Narbenhernien sollten laparoskopische Operationstechniken offenen Techniken vorgezogen werden. Bei Risikopatienten, die einen offenen abdominalen Eingriff benötigen, empfiehlt sich eine prophylaktische Einlage eines nicht-resorbierbaren Netzes

Fasciola hepatica in a country of low incidence: a tricky diagnosis.

Background Fasciola hepatica is a foodborne trematode present worldwide. Definitive hosts are mostly ruminants such as cattle and sheep, as well as humans. In Switzerland, Fasciola infection in humans is rare. Unfortunately, many patients are likely to undergo multiple unnecessary investigations before the parasite is suspected and fascioliasis diagnosed, especially if symptoms are unspecific. Methods Retrospective analysis of all patients diagnosed with Fasciola hepatica at the University Hospital of Bern between 2005 and 2018. Diagnosis was positive if a positive serology and/or eggs in stool samples correlated with clinical presentation (symptoms and/or imaging). Patients were excluded if serology was weakly positive and another diagnosis more likely. Personal data, laboratory results, imaging, proposed treatment and outcome were collected from patient files. Results Sixty patients had a positive serology during this time period. Forty-seven of them had a more plausible alternative diagnosis and were not included in the study, leaving 13 patients for analyses; 46.2% (6/13) were male, mean age was 45.8 years old (range, 17-80 years old). Four patients (4/13, 30.8%) were asymptomatic, nine (9/13, 69.2%) presented with symptoms ranging from right upper quadrant abdominal pain (44.4%) and generalized pruritus (33.3%) to weight loss and night sweats (33.3%). The mean duration of symptoms until correct diagnosis was 8.9 months (range, 1-48 months). Five patients (5/13, 38.5%) had documented eosinophilia, four (4/13, 30.8%) elevated liver enzymes and seven (7/13, 53.8%) elevated cholestasis parameters. Mean antibody level on serology was 88 AU/mL (range, 3-134 AU/mL). Ultrasound was used most frequently (7/13, 53.8%), followed by magnetic resonance imaging (4/13, 30.8%), computed tomography and endoscopic retrograde cholangiopancreatography (3/13, 23.1%). The most common findings were bile duct dilatation, followed by hepatic lesions. Treatment consisted of Triclabendazole 10 mg/Kg. One patient needed a second treatment course for persistent disease. There were no recurrences. Conclusions With a low incidence of Fasciola hepatica in Switzerland, correct diagnosis is often substantially delayed. Raising awareness among Swiss physicians is paramount, and a higher level of suspicion necessary when confronted with unspecific symptoms or liver imaging, thus avoiding a long delay in diagnosis, as well as unnecessary tests