Incidence of complicated appendicitis during the COVID-19 pandemic: A systematic review and meta-analysis.

Introduction: Measures taken to prevent the spread of coronavirus disease 2019 (COVID-19) slow surgical processes, and patients are avoiding presenting at emergency departments during the outbreak because of fears of contracting the contagious disease. To analyze the rate of complicated appendicitis before and during the COVID-19 pandemic. Methods: We systematically reviewed the PubMed and SCOPUS databases for articles published from 2000 to 2021. Including the retrospective review data collected from our hospital of patients aged ≥18 years old who were diagnosed with acute appendicitis. The primary outcome of complicated appendicitis incidence was compared between before and during the COVID-19 pandemic period. We performed a meta-analysis using a random-effects model analysis. Results: A total 3559 patients were included for meta-analysis. The overall rate of complicated appendicitis was significantly higher during the pandemic (relative risk, 1.55; 95% confidence interval [CI], 1.26-1.89). The time from onset of symptoms to hospitalisation was 0.41 h longer during the pandemic, which was not significantly different (standardized mean difference, 0.41, 95% CI, -0.03 to 1.11). The operating time during the pandemic was significantly shorter than that before the pandemic (83.45 min and 71.65 min, p = 0.01). Conclusion: There are correlation between the pandemic and severity of acute appendicitis. The higher rate of complicated appendicitis in the pandemic indicates that patients require timely medical attention and appropriate treatment despite fears of contracting disease.

Usefulness and outcome of whole-body computed tomography (pan-scan) in trauma patients: A prospective study.

Background: Severe trauma can cause multi-organ injuries, and the mortality rate may increase if significant organ injuries are missed. This study was performed to determine whether whole-body computed tomography scan (pan-scan) can detect significant injury and leads to proper management, including alteration the priority of management. Methods: This prospective study was conducted from January 2019 to March 2021 and involved trauma patients level 1, level 2, and dangerous mechanism of trauma. Additionally, the data of trauma patients who had selective computed tomography scan were retrospectively reviewed to compared the clinical benefits. Results: Twenty-two patients were enrolled in the prospective study. The pan-scan detected significant organ injury in 86% of the patients. Prioritization of organ injury management changed after performance of the pan-scan in 64% (major change in 64.29% and minor change in 35.71%). Skull base fracture, small bowel injury, retroperitoneal injury, kidney and bladder injury, and occult pneumothorax were the majority of injuries which was not consider before underwent pan-scan (p < 0.05). The door-to-scan time tended to be shorter in the pan-scan group than in the selective scan group without a significant difference [mean (SD), 59.5 (34) and 72.0 (86) min, respectively; p = 0.13]. Pan-scan contribute 100% confidence for trauma surgeon in diagnosis of specific organ injuries in severe injured patients. Conclusions: The pan-scan facilitates timely detection of significant unexpected organ injuries such as the skull base, occult pneumothorax, small bowel, and retroperitoneum. It also helps to prioritize management and increases the diagnostic confidence of trauma surgeons, leading to better outcomes without delay.

Z-per-oral endoscopic myotomy as definitive prevention of a bleeding ulcer in Zenker's diverticulum: A case report.

BACKGROUND: Bleeding from Zenker's diverticulum is extremely rare. At present, there are no guidelines for the management of bleeding Zenker's diverticulum because of its rarity. Per-oral endoscopic myotomy (Z-POEM) is a precision myotomy technique and minimally invasive procedure for the treatment of Zenker's diverticulum. We present a systematic review and a rare case of bleeding Zenker's diverticulum that was effectively treated using Z-POEM. CASE SUMMARY: A 72-year-old presented after 3 d of hematemesis. He had a 2-year history of progressive dysphagia and reported no antiplatelet, anticoagulant, or non-steroidal anti-inflammatory drug use. His vital signs were stable, and the hematocrit was 36%. Previous gastroscopy and barium swallow had revealed Zenker's diverticulum before the bleeding occurred. We performed gastroscopy and found a 5-mm ulcer with a minimal blood clot and spontaneously resolved bleeding. Z-POEM for definitive treatment was performed to reduce accumulation of food and promote ulcer healing. He had no complications and no bleeding; at the follow-up 6 mo later, the ulcer was healed. CONCLUSION: Z-POEM can be definitive prevention for bleeding ulcer in Zenker's diverticulum that promotes ulcer healing, reducing the risk of recurrent bleeding. Z-POEM is also a definitive endoscopic surgery for treatment of Zenker's diverticulum.

Impact of the COVID-19 pandemic on the outcome, morbidity, and mortality of acute care surgery patients: A retrospective cohort study.

BACKGROUND: Coronavirus disease (COVID-19) has impacted both emergency and elective surgical management owing to its highly infectious nature and the shortage of personal protective equipment. This study aimed to review the outcomes of emergency surgical conditions and trauma during the pandemic lockdown. MATERIAL AND METHODS: We retrospectively reviewed and collected data from patients who attended the Acute Care Surgery Service from 1st April to May 31st, 2020 during Thailand's COVID-19 pandemic lockdown. We separated staff and performed preoperative COVID-19 swab testing on all patients to assess the requirement for personal protective equipment. Compared with previous years of service, of 2018 and 2019. Preoperative COVID-19 testing was performed using multiplex and manual RT-PCR. Morbidity and mortality, consultation time, and waiting time to surgery were analyzed. RESULTS: A total of 61 patients were enrolled. The average age of patients was 53.8 years. The average consultation time, waiting time to surgery, and surgical duration were 10 min, 660 min, and 88.77 min, respectively. The average time taken to obtain the preoperative COVID-19 test result was 227.26 min. The morbidity and mortality rates were 9.84% and 1.64%, respectively. Compared with the same period in 2018 and 2019, consultation time was significantly faster (10 min; p = 0.033) and waiting time to surgery was significantly longer (660 min, respectively; p = 0.011). Morbidity and mortality between pandemic period and the previous year of service were not significantly different. No medical workers were infected with COVID-19. CONCLUSIONS: During the COVID-19 pandemic, optimal triage of emergency patients is key. Waiting for preoperative COVID-19 swab testing in emergency case is safe and results in good outcomes. Although the waiting time to surgery was significantly longer owing to the time required to receive preoperative COVID-19 swab results, morbidity and mortality rates were unaffected.

Morbidity, mortality, and risk factors of emergency colorectal surgery among older patients in the Acute Care Surgery service: A retrospective study.

BACKGROUND: Acute Care Surgery (ACS) is a rapid response system in emergency surgical conditions. The patients who over 60 year-old have numerous factors associated with high mortality and morbidity in emergency colorectal surgery. We aimed to identify potentially preventable risk factors, to improve patients' outcomes. METHODS: A retrospective review of patients age over 60 year-old undergoing emergency colorectal surgery in the ACS service from August 1, 2017 through November 30, 2019. RESULTS: Ninety-two patients were analyzed, average age 72.41 years. The most common diagnosis was complicated colorectal cancer (76, 83.52%) with locations on the right (37, 41.51%), left (35,39.33%), and rectum (17, 19.10%). Clinical presentations were obstruction without perforation (61, 67.03%), perforation (25, 27.17%), and ischemia (2, 2.17%). Overall mortality was 6.52%. Cause of death included septic shock (3, 50%); respiratory failure (3, 50%); and pulmonary embolism (1, 16.67%). Morbidity from surgical and medical complications were 41.30% and 26.08%, respectively. For all causes, operations included resection with primary anastomosis (62, 71.26%); Hartmann's operation (11, 12.64%); and loop colostomy (12, 13.79%). Average operative time was 159.86 min. In emergency colorectal surgery, pre-existing heart disease, clinical perforation, and ventilator dependency increased risk of death 7.6-, 16.5-, and 0.08-fold, respectively. CONCLUSION: Clinical perforation leads to sepsis and septic shock in older patients, this may be modifiable to improve mortality by developing an early, rapid, protocol-driven surgical sepsis fast-track process. Ventilator dependency is potentially modifiable with postoperative advanced surgical critical care. The non-modifiable risk factor of co-morbid heart disease might be improved by postoperative advanced critical care for close monitoring.

Effects of thiamine on vasopressor requirements in patients with septic shock: a prospective randomized controlled trial.

BACKGROUND: Thiamine, an essential vitamin for aerobic metabolism and glutathione cycling, may decrease the effects of critical illnesses. The objective of this study was to determine whether intravenous thiamine administration can reduce vasopressor requirements in patients with septic shock. METHODS: This study was a prospective randomized double-blind placebo-controlled trial. We included adult patients with septic shock who required a vasopressor within 1-24 h after admission between March 2018 and January 2019 at a tertiary hospital in Thailand. Patients were divided into two groups: those who received 200 mg thiamine or those receiving a placebo every 12 h for 7 days or until hospital discharge. The primary outcome was the number of vasopressor-free days over 7 days. The pre-defined sample size was 31 patients per group, and the study was terminated early due to difficult recruitment. RESULTS: Sixty-two patients were screened and 50 patients were finally enrolled in the study, 25 in each group. There was no difference in the primary outcome of vasopressor-free days within the 7-day period between the thiamine and placebo groups (mean: 4.9 days (1.9) vs. 4.0 days (2.7), p = 0.197, mean difference - 0.9, 95% CI (- 2.9 to 0.5)). However, the reductions in lactate (p = 0.024) and in the vasopressor dependency index (p = 0.02) at 24 h were greater among subjects who received thiamine repletion vs. the placebo. No statistically significant difference was observed in SOFA scores within 7 days, vasopressor dependency index within 4 days and 7 days, or 28-day mortality. CONCLUSIONS: Thiamine was not associated to a significant reduction in vasopressor-free days over 7-days in comparison to placebo in patients with septic shock. Administration of thiamine could be associated with a reduction in vasopressor dependency index and lactate level within 24 h. The study is limited by early stopping and low sample size. TRIAL REGISTRATION: TCTR, TCTR20180310001. Registered 8 March 2018, http://www.clinicaltrials.in.th/index.php?tp=regtrials&menu=trialsearch&smenu=fulltext&task=search&task2=view1&id=3330 .

FAST accuracy in major pelvic fractures for decision-making of abdominal exploration: Systematic review and meta-analysis.

BACKGROUND: Major pelvic fractures are often associated with intra-abdominal organ injuries. Considering patients' hemodynamic status, Focused Assessment with Sonography for Trauma (FAST) can facilitate decision-making for abdominal exploration. Non-therapeutic exploratory laparotomy from pelvic fractures should be avoided. Aim of this study is to determine the accuracy of FAST in diagnosing significant intraabdominal hemorrhage that leads to determine whether or not to pursue therapeutic abdominal exploration in patients with major pelvic fractures. MATERIAL AND METHODS: We systematically reviewed the PubMed and SCOPUS databases from 2009 to 2019 and also using a retrospective review of patients admitted to the Acute Care Surgery service from 2016 to 2019. We performed a meta-analysis by using a random effects model. RESULTS: A total 677 patients were analyzed, 28 cases from our hospital. Mean patient age was 40.8 years. Leading mechanism of injury were motor vehicle collision (44.72%), fall from height (13.41%), and motorcycle collision (13.69%). Average injury severity score (ISS) was 32.5 (range: 24.1-50), and overall mortality rate was 11.65%. The pooled sensitivity, specificity, and accuracy of FAST to identify significant intra-abdominal hemorrhage was 79%,90%, and 93%, respectively (95% confidence interval: 89%-94%). Meta-regression revealed no significant correlation between injury severity score and the accuracy of FAST. CONCLUSION: Our meta-analysis revealed that FAST in major pelvic fracture accurately detected significant intra-abdominal hemorrhage. Using FAST in the presence of unstable hemodynamics, we can decide to perform abdominal exploration with the expectation of finding significant intra-abdominal hemorrhage require surgically control.

Successful advanced third-space endoscopic surgery by per-oral endoscopic myotomy (Z-POEM) for Zenker's diverticulum: A case report and review of literature.

INTRODUCTION: Zenker's diverticulum is a rare condition caused by herniation of the mucosa at the pharyngoesophageal junction, resulting in dysphagia. Third-space endoscopic surgery now plays an important role in its management, facilitating precise surgery with good outcomes. The aim of report is to demonstrate technical steps and outcomes of per-oral endoscopic myotomy (Z-POEM). PRESENTATION OF CASE: We report two male patients presented with dysphagia. Esophagograms revealed Zenker's diverticula of 2.1 and 2.0 cm, respectively, and diagnostic gastroscopy showed the diverticula to be 17 cm from the incisors, with tight, thick septal muscle. A 2-cm mucosal incision was made with a triangle-tipped knife, and submucosal tunneling was created by spray coagulation. The gastroscope was advanced into the submucosal space of the esophageal lumen and the diverticulum site until the bottom of the diverticulum could be clearly identified. The septal muscle was completely divided, immediately allowing the gastroscope to pass through easily, and the mucosal defect was reapproximated with hemoclips. DISCUSSION: As compared Z-POEM to previous technique; endoscopic septotomy, staple-assisted diverticulotomy, or open neck surgery, Z-POEM is less recurrent of symptoms and complications. Different types of endoscopic knife and lifting materials were used, but all provided the same outcomes. Most of the cases use though-the-scope clips to close the mucosal defect. CONCLUSION: Z-POEM provided precise treatment and complete view of the entire septal muscle can helps to avoid inadequate myotomy.

Traumatic Blunt Force Renal Injury in a Diseased Horseshoe Kidney with Successful Embolization to Treat Active Bleeding: A Case Report and Literature Review.

BACKGROUND: Blunt force injuries in patients with preexisting kidney disease account for 19% of all kidney injuries, suggesting that diseased kidneys are more vulnerable than normal kidneys. When a horseshoe kidney (a rare anomaly: prevalence of 0.2%) is injured, treatment is challenging, especially when nonoperative management is desired. In high-grade blunt force normal kidney injury, nonoperative management has high succession rate (94.8%) with kidney-related complication (13.6%). Surgical reconstruction and preservation of a damaged horseshoe kidney is difficult because of variations in its vascular anatomy. We report successful nonoperative management of a blunt horseshoe kidney injury with active bleeding and review previous outcomes and complications. Case Presentation. A 57-year-old man had a head-on collision motorcycle road traffic accident. On arrival, blood pressure was 90/60 mmHg, pulse rate 140 bpm, and clear yellow urine output 200 ml. The patient was transiently responsive to fluid and blood component. Whole body computed tomography showed a high-volume retroperitoneal hematoma and multiple-lacerated lower pole of the kidney, compatible with preexisting horseshoe kidney disease with active contrast-enhanced extravasation from the accessory right renal artery. Embolization was performed. Renal function, transiently impaired after embolization, normalized on day 3. An infected hematoma found on day 7 was successfully controlled with antibiotics. His recovery was uneventful. At the 6-month follow-up, his serum creatinine level had returned to normal. The average age of blunt force horseshoe kidney injury is 31.75 years and occurred more common in male (87.5%). CONCLUSION: Diseased horseshoe kidneys are prone to injury even with low-velocity impact such as a road traffic accident speed < 15 km/h. Embolization is considered the first choice for management, with its high clinical success rate leading to less need for surgical repair. Not removing a hematoma is likely to result in complications. If embolization fails to stop bleeding, life-saving surgical exploration should be mandated.

Effect of bowel preparation with oral sodium phosphate on serum potassium level in patients undergoing colonoscopy under IV anesthesia.

OBJECTIVE: To determine the effect of oral sodium phosphate solution, as a colon preparation agent, on the serum potassium level in patients undergoing colonoscopy under IV anesthesia. MATERIAL AND METHOD: Patients set to undergo elective colonoscopy under IV anesthesia (propofol infusion) were recruited to participate in the present study during the period between October 2008 and January 2009. All patients had normal serum potassium level prior to colon preparation, and all ingested 90 ml of sodium phosphate solution one day before colonoscopy. Blood samples for post preparation potassium level determination were taken immediately before administering IV propofol. Baseline data including age, gender, diagnosis, indication for colonoscopy, underlying illness, concurrent medications and serum potassium and creatinine levels were recorded The serum potassium levels were compared before and after colon preparation, and potentially important baseline risk factors for low potassium levels after colon preparation were determined. RESULTS: In 48 patients, there was a 0.57 mmol/L (from 4.11 to 3.54 mmol/L) average reduction in the serum potassium level after colon preparation. There were no significant adverse events during colonoscopy. No significant risk factors were identified on multivariable linear regression analysis. CONCLUSION: There was a mild reduction in serum potassium level after colon preparation with oral sodium phosphate solution, which was probably not clinically significant. Prophylactic potassium supplement or routine serum potassium monitoring after oral sodium phosphate colon preparation did not seem to be necessary for this group of patients.