The Hellenic emergency laparotomy study (HELAS): a prospective multicentre study on the outcomes of emergency laparotomy in Greece

Background Emergency laparotomy (EL) is accompanied by high post-operative morbidity and mortality which varies significantly between countries and populations. The aim of this study is to report outcomes of emergency laparotomy in Greece and to compare them with the results of the National Emergency Laparotomy Audit (NELA). Methods This is a multicentre prospective cohort study undertaken between 01.2019 and 05.2020 including consecutive patients subjected to EL in 11 Greek hospitals. EL was defined according to NELA criteria. Demographics, clinical variables, and post-operative outcomes were prospectively registered in an online database. Multivariable logistic regression analysis was used to identify independent predictors of post-operative mortality. Results There were 633 patients, 53.9% males, ASA class III/IV 43.6%, older than 65 years 58.6%. The most common operations were small bowel resection (20.5%), peptic ulcer repair (12.0%), adhesiolysis (11.8%) and Hartmann’s procedure (11.5%). 30-day post-operative mortality reached 16.3% and serious complications occurred in 10.9%. Factors associated with post-operative mortality were increasing age and ASA class, dependent functional status, ascites, severe sepsis, septic shock, and diabetes. HELAS cohort showed similarities with NELA patients in terms of demographics and preoperative risk. Post-operative utilisation of ICU was significantly lower in the Greek cohort (25.8% vs 56.8%) whereas 30-day post-operative mortality was significantly higher (16.3% vs 8.7%). Conclusion In this study, Greek patients experienced markedly worse mortality after emergency laparotomy compared with their British counterparts. This can be at least partly explained by underutilisation of critical care by surgical patients who are at high risk for death

Development and internal validation of a clinical prediction model for serious complications after emergency laparotomy

Purpose Emergency laparotomy (EL) is a common operation with high risk for postoperative complications, thereby requiring accurate risk stratification to manage vulnerable patients optimally. We developed and internally validated a predictive model of serious complications after EL. Methods Data for eleven carefully selected candidate predictors of 30-day postoperative complications (Clavien-Dindo grade >  = 3) were extracted from the HELAS cohort of EL patients in 11 centres in Greece and Cyprus. Logistic regression with Least Absolute Shrinkage and Selection Operator (LASSO) was applied for model development. Discrimination and calibration measures were estimated and clinical utility was explored with decision curve analysis (DCA). Reproducibility and heterogeneity were examined with Bootstrap-based internal validation and Internal–External Cross-Validation. The American College of Surgeons National Surgical Quality Improvement Program’s (ACS-NSQIP) model was applied to the same cohort to establish a benchmark for the new model. Results From data on 633 eligible patients (175 complication events), the SErious complications After Laparotomy (SEAL) model was developed with 6 predictors (preoperative albumin, blood urea nitrogen, American Society of Anaesthesiology score, sepsis or septic shock, dependent functional status, and ascites). SEAL had good discriminative ability (optimism-corrected c-statistic: 0.80, 95% confidence interval [CI] 0.79–0.81), calibration (optimism-corrected calibration slope: 1.01, 95% CI 0.99–1.03) and overall fit (scaled Brier score: 25.1%, 95% CI 24.1–26.1%). SEAL compared favourably with ACS-NSQIP in all metrics, including DCA across multiple risk thresholds. Conclusion SEAL is a simple and promising model for individualized risk predictions of serious complications after EL. Future external validations should appraise SEAL’s transportability across diverse settings

Global disparities in surgeons’ workloads, academic engagement and rest periods: the on-calL shIft fOr geNEral SurgeonS (LIONESS) study

: The workload of general surgeons is multifaceted, encompassing not only surgical procedures but also a myriad of other responsibilities. From April to May 2023, we conducted a CHERRIES-compliant internet-based survey analyzing clinical practice, academic engagement, and post-on-call rest. The questionnaire featured six sections with 35 questions. Statistical analysis used Chi-square tests, ANOVA, and logistic regression (SPSS® v. 28). The survey received a total of 1.046 responses (65.4%). Over 78.0% of responders came from Europe, 65.1% came from a general surgery unit; 92.8% of European and 87.5% of North American respondents were involved in research, compared to 71.7% in Africa. Europe led in publishing research studies (6.6 ± 8.6 yearly). Teaching involvement was high in North America (100%) and Africa (91.7%). Surgeons reported an average of 6.7 ± 4.9 on-call shifts per month, with European and North American surgeons experiencing 6.5 ± 4.9 and 7.8 ± 4.1 on-calls monthly, respectively. African surgeons had the highest on-call frequency (8.7 ± 6.1). Post-on-call, only 35.1% of respondents received a day off. Europeans were most likely (40%) to have a day off, while African surgeons were least likely (6.7%). On the adjusted multivariable analysis HDI (Human Development Index) (aOR 1.993) hospital capacity > 400 beds (aOR 2.423), working in a specialty surgery unit (aOR 2.087), and making the on-call in-house (aOR 5.446), significantly predicted the likelihood of having a day off after an on-call shift. Our study revealed critical insights into the disparities in workload, access to research, and professional opportunities for surgeons across different continents, underscored by the HDI

Short-term evaluation of liver tumors after transarterial chemoembolization: Limitations and feasibility of contrast-enhanced ultrasonography

Purpose: To evaluate the limitations and the feasibility of contrast-enhanced ultrasonography (CEUS) for the assessment of tumor response shortly after transarterial chemoembolization (TACE). Materials and methods: Fifty seven patients (41 patients with hepatomas, 16 patients with metastases) were studied with CEUS before, 1 day after, and 30 days after TACE. A CEUS-efficiency score (CEUS-ES) was calculated, which evaluated: (a) the completeness of visualization of the target tumor(s) (2: good, 1: adequate, 0: poor) and (b) the quality of delineation of post-TACE necroses (2: good, 1: adequate, 0: poor). A CEUS study was considered as "diagnostic," if each of the aforementioned parameters was associated with grade 1 or 2. Results: CEUS studies were "diagnostic" in 36/57 patients (63.1%). Patients with hepatomas were more likely to undergo "diagnostic" CEUS than patients with metastases (70.7% vs. 43.7%, P = 0.0728). Lesions' multiplicity, deep location, hypoenhancement on pretreatment CEUS, and diffuse growth had a statistically significant (P < 0.05) negative impact on CEUS-ES. Hyperechogenicity on pre-treatment, unenhanced US had a non-statistically significant (P = 0.176) negative impact. Differences between "diagnostic" CEUS studies and CT/MR regarding detection of residual tumor were insignificant (P = 0.8178). Conclusion: The percentage of lesions which are unsuitable for post-TACE evaluation with CEUS is not negligible. For the rest, the respective role of CEUS is promising. © 2011 Springer Science+Business Media, LLC

Urine 8-Hydroxyguanine (8-OHG) in Patients Undergoing Surgery for Colorectal Cancer

Purpose Cellular RNA is less compact than DNA, more easily accessible to ROS and therefore could be more susceptible to oxidative damage. This study was conceived in order to analyze the RNA oxidative damage in the urine of patients undergoing operation for colorectal cancer (CRC), to compare with healthy controls, and correlate with the stage. Materials and methods The study population was constituted by a group of 147 patients and a group of 128 healthy controls. Urine and blood samples were collected before the colonoscopy in all participants and 24 hours post-operatively for those who underwent surgery. Urine 8-hydroxyguanine (8-OHG) was determined as marker of RNA oxidation, and serum uric acid (UA) as antioxidant marker. Results Preoperatively, 8-OHG (ng/ml) values of CRC patients were found to be significantly higher than those of controls (p = 0.001). More specifically, stages II/III had significantly higher 8-OHG values (p < 0.001 and p = 0.007) than stages 0/I. Post-operatively, 8-OHG values were similar to controls (p = 0.053). Preoperatively, UA values (mg/dl) were significantly lower (p = 0.001), while postoperatively were similar to controls (p = 0.069). Conclusion Oxidative RNA damage occurs in CRC patients. Stages II/III are associated with higher values of 8-OHG than stages 0/I. 8-OHG could act as a marker for the identification of patients with advanced disease

Medical, Endoscopic and Surgical Management of Stricturing Crohn’s Disease: Current Clinical Practice

The development of fibrostenotic intestinal disease occurs in approximately one-third of patients with Crohn’s disease and is associated with increased morbidity. Despite introducing new biologic agents, stricturing Crohn’s disease remains a significant clinical challenge. Medical treatment is considered the first-line treatment for inflammatory strictures, and anti-TNF agents appear to provide the most considerable benefit among the available medical treatments. However, medical therapy is ineffective on strictures with a mainly fibrotic component, and a high proportion of patients under anti-TNF will require surgery. In fibrotic strictures or cases refractory to medical treatment, an endoscopic or surgical approach should be considered depending on the location, length, and severity of the stricture. Both endoscopic balloon dilatation and endoscopic stricturoplasty are minimally invasive and safe, associated with a small risk of complications. On the other hand, the surgical approach is indicated in patients not suitable for endoscopic therapy. This review aimed to present and analyze the currently available medical, endoscopic, and surgical management of stricturing Crohn’s disease

Prospective multicenter external validation of postoperative mortality prediction tools in patients undergoing emergency laparotomy

BACKGROUND Accurate preoperative risk assessment in emergency laparotomy (EL) is valuable for informed decision-making and rational use of resources. Available risk prediction tools have not been validated adequately across diverse healthcare settings. Herein, we report a comparative external validation of 4 widely cited prognostic models. METHODS A multicenter cohort was prospectively composed of consecutive patients undergoing EL in 11 Greek hospitals from January 2020 to May 2021 using the National Emergency Laparotomy (NELA) audit inclusion criteria. 30-day mortality risk predictions were calculated using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP), NELA, Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (P-POSSUM) and Predictive Optimal Trees in Emergency Surgery Risk (POTTER) tools. Surgeons’ assessment of postoperative mortality using pre-defined cutoffs was recorded, and a surgeon-adjusted ACS-NSQIP prediction was calculated when the original model’s prediction was relatively low. Predictive performances were compared using scaled Brier scores, discrimination and calibration measures and plots, and decision curve analysis. Heterogeneity across hospitals was assessed by random-effects meta-analysis. RESULTS 631 patients were included and 30-day mortality was 16.3%. The ACS-NSQIP and its surgeon-adjusted version had the highest scaled Brier scores. All models presented high discriminative ability, with concordance statistics ranging from 0.79 for P-POSSUM to 0.85 for NELA. However, except the surgeon-adjusted ACS-NSQIP (Hosmer-Lemeshow test p = 0.742), all other models were poorly calibrated (p < 0.001). Decision curve analysis revealed superior clinical utility of the ACS-NSQIP. Following recalibrations, predictive accuracy improved for all models but ACS-NSQIP retained the lead. Between-hospital heterogeneity was minimum for the ACS-NSQIP model and maximum for P-POSSUM. CONCLUSION The ACS-NSQIP tool was most accurate for mortality predictions after EL in a broad external validation cohort, demonstrating utility for facilitating preoperative risk management in the Greek healthcare system. Subjective surgeon assessments of patient prognosis may optimise ACS-NSQIP predictions. Level of Evidence Level II, Diagnostic test/criteri