Determining a multidisciplinary intraoperative strategy in emergency surgery for bowel obstruction and its impact on outcomes.

PURPOSE: Bowel obstruction accounts for around 50% of all emergency laparotomies. A multidisciplinary (MDT) standardized intraoperative model was applied (definitive, palliative, or damage control surgery) to identify patients suitable for a one-step, definitive surgical procedure favoring anastomosis over stoma, when undergoing surgery for bowel obstruction. The objective was to present mortality according to the strategy applied and to compare the rate of laparoscopic interventions and stoma creations to a historic cohort in surgery for bowel obstruction. METHODS: In a retrospective cohort study, we included patients undergoing emergency surgery for bowel obstruction during a 1-year period at two Copenhagen University Hospitals (2019 and 2021). The MDT model consisted of a 30- and 60-min time-out with variables such as functional and hemodynamic status, presence of malignancy, and surgical capabilities (lap/open). Pre-, intra-, and postoperative data were collected to investigate associations to postoperative complications and mortality. Stoma creation rates and laparoscopies were compared to a historic cohort (2009-2013). RESULTS: Three hundred sixty-nine patients underwent surgery for bowel obstruction. Intraoperative surgical strategy was definitive in 77.0%, palliative in 22.5%, and damage control surgery in 0.5%. Thirty-day mortality was significantly lower in the definitive patient population (4.6%) compared to the palliative population (21.7%) (p < 0.000). Compared to the historic cohort, laparoscopic surgery for bowel obstruction increased from 5.0 to 26.4% during the 10-year time span, the rate of stoma placements was reduced from 12.0 to 6.1%, p 0.014, and the 30-day mortality decreased from 12.9 to 4.6%, p < 0.000. CONCLUSION: An intraoperative improvement strategy can address the specific surgical interventions in patients undergoing surgery for bowel obstruction, favoring anastomosis over stoma whenever resection was needed, and help adjust specific postoperative interventions and care pathways in cases of palliative need.

Small bowel anastomosis in emergency surgery.

BACKGROUND: Emergency laparotomy is associated with a high morbidity and mortality rate. The decision on whether to perform an anastomosis or an enterostomy in emergency small bowel resection is guided by surgeon preference alone, and not evidence based. We examined the risks involved in small bowel resection and anastomosis in emergency surgery. METHODS: A retrospective study from 2016 to 2019 in a university hospital in Denmark, including all emergency laparotomies, where small-bowel resections, ileocecal resections, right hemicolectomies and extended right hemicolectomies where performed. Demographics, operative data, anastomosis or enterostomy, as well as postoperative complications were recorded. Primary outcome was the rate of bowel anastomosis. Secondary outcomes were the anastomotic leak rate, mortality and complication rates. RESULTS: During the 3.5-year period, 370 patients underwent emergency bowel resection. Of these 313 (84.6%) received an anastomosis and 57 (15.4%) an enterostomy. The 30-day mortality rate was 12.7% (10.2% in patients with anastomosis and 26.3% in patients with enterostomy). The overall anastomotic leak rate was 1.6%, for small-bowel to colon 3.0% and for small-bowel to small-bowel 0.6%. CONCLUSION: A primary anastomosis is performed in more than eight out of 10 patients in emergency small bowel resections and is associated with a very low rate of anastomotic leak.

Inter-hospital variation in management of patients with small bowel obstruction in Denmark.

INTRODUCTION: Inter-hospital variation in the management of small bowel obstruction (SBO) has been described in other countries, but the extent to which similar variations exist in Denmark remains unknown. This study aimed to compare the management of SBO between hospitals in Denmark and identify potential areas for improvement METHODS. This was a multicentre prospective study performed at six emergency hospitals. Patients aged ≥ 18 years with a diagnosis of SBO were eligible for inclusion. The primary study endpoints were the proportion of patients undergoing operative versus non-operative management, laparoscopic surgery versus open surgery and the success rate of non-operative management. RESULTS: A total of 316 patients were included. No differences were noted in diagnostic pathways or operative versus non-operative management. However, variations were noted in compliance with peri-operative care bundles, ranging from 63.2% to 95.8%. The surgical approach also varied, with the use of laparoscopic surgery ranging from 20.7% to 71.0% (p less-than 0.001). Variations were also noted in duration of surgery (63-124 minutes, p less-than 0.001), time to re-introduction of normal diet and length of hospital stay (3-8.5 days, p less-than 0.001). No differences were observed in 30-day or 90-day mortality rates. CONCLUSION: The management of SBO in Denmark is relatively standardised. Future efforts should focus on improving adherence to multidisciplinary peri-operative protocols, optimising patient selection for laparoscopic surgery and standardising nutritional therapy. FUNDING: None. TRIAL REGISTRATION: NCT04750811.

Intraperitoneally displaced intrauterine device.

Intra-abdominal displacement of an intrauterine device (IUD) is a rare but serious complication. This is a case report of a 44-year-old woman who was referred to a surgical department with intermittent abdominal pain. Gynaecological examination and ultrasound failed to identify the patient's IUD. An abdominal CT scan confirmed the diagnosis of the intra-abdominally migrated IUD and the device was extracted by laparoscopy. Surgical removal of the migrating IUD is recommended to prevent long-term complications such as intra-abdominal adhesions, organ perforation, and fistula formation.

Small bowel anastomosis in peritonitis compared to enterostomy formation: a systematic review.

PURPOSE: Anastomotic leakage after small bowel resection in emergency laparotomy is a severe complication. A consensus on the risk factors for anastomotic leakage has not been established, and it is still unclear if peritonitis is a risk factor. This systematic review aimed to evaluate if an entero-entero/entero-colonic anastomosis is safe in patients with peritonitis undergoing abdominal acute care surgery. METHODS: A systematic literature review based on PRISMA guidelines was performed, searching the databases Pubmed/MEDLINE, Cochrane Library, and Science Direct for studies of anastomosis in peritonitis. Patients with an anastomosis after non-planned small bowel resection (ischemia, perforation, or strangulation), including secondary peritonitis, were included. Elective laparotomies and colo-colonic anastomoses were excluded. Due to the etiology, traumatic perforation, in-vitro, and animal studies were excluded. RESULTS: This review identified 26 studies of small-bowel anastomosis in peritonitis with a total of 2807 patients. This population included a total of 889 small-bowel/right colonic resections with anastomoses, and 242 enterostomies. All studies, except two, were retrospective reviews or case series. The overall mortality rates were 0-20% and anastomotic leakage rates 0-36%. After performing a risk of bias evaluation there was no basis for conducting a meta-analysis. The quality of evidence was rated as low. CONCLUSION: There was no evidence to refute performing a primary small-bowel anastomosis in acute laparotomy with peritonitis. There is currently insufficient evidence to label peritonitis as a risk factor for anastomotic leakage in acute care laparotomy with small-bowel resection. TRIAL REGISTRATION: The review was registered with the PROSPERO register of systematic reviews on 14/07/2020 with the ID: CRD42020168670.

[Acute cholangitis due to metal clips in the ductus choledochus after laparoscopic cholecystectomy].

Acute cholangitis caused by migrating clips is a possible complication following laparoscopic cholecystectomy. In this case report, a 50-year-old woman was admitted to the hospital with fever, icterus, and epigastric pain. Blood samples and blood cultures showed cholestasis, signs of infection and three different types of bacteria in the blood stream. Magnetic resonance cholangiopancreatography showed a migrating clip in the common bile duct and was extracted using endoscopic retrograde cholangiopancreatography. Migrating clip following laparoscopic cholecystectomy is a cause of cholangitis and should be considered in patients presenting with relevant symptoms.

[Internal bowel herniation due to clip adhaesion].

Small bowel obstruction (SBO) due to clip adhaesions from the line of staples is a rare complication and is scarcely reported in the literature. In this case report, a ten-year-old boy underwent laparoscopic appendectomy and five days later developed early postoperative SBO. Diagnostic laparoscopy revealed internal herniation of bowel through a defect created by clip adhesion from the staple line to the adjacent mesentery. The clip was removed, the internal hernia resolved, and the patient discharged the same day. We recommend reviewing the line of staples after surgery.

Perioperative clinical management in relation to emergency surgery for perforated peptic ulcer: A nationwide questionnaire survey.

BACKGROUND & AIMS: Perforation is a severe complication of peptic ulcer disease. Evidence regarding perioperative management of patients undergoing surgery for perforated peptic ulcer is scarce without any clear guidelines. This study aimed to investigate the clinical practice and possible differences in the perioperative management of patients undergoing emergency surgery for perforated peptic ulcers in Denmark. METHODS: The study was an anonymous, nationwide questionnaire survey. All doctors working at general surgical departments in Denmark were included. The questionnaire consisted of four parts; 1) demographic details including job position, subspecialty, geographic location, and surgical experience, 2) pre- and postoperative use of nasoenteral tubes, 3) routine use of nil-by-mouth (NBM) regime, 4) questions regarding postoperative nutrition.Subgroup analyses were performed according to job position and subspecialty. RESULTS: In total, the questionnaire was answered by 287 surgeons, of which 74% were experienced surgeons being able to perform surgery for perforated peptic ulcers independently.Pre- and postoperative nasoenteral tubes were used routinely by the majority of the respondents. One of five surgeons routinely practiced a postoperative NBM regime. Generally, the respondents allowed clear fluids postoperatively without restrictions but were reluctant to allow free fluids or solid foods. Two of three surgeons routinely used tube- or parental nutrition. The results varied depending on job position and subspecialty. CONCLUSIONS: After emergency surgery, the postoperative management of patients with perforated peptic ulcers varies considerably among general surgeons in Denmark. Evidence-based national or international guidelines are needed to standardize and optimize the clinical practice.

Early laparoscopic cholecystectomy for acute cholecystitis is safe regardless of timing.

PURPOSE: The optimal timing for laparoscopic cholecystectomy for acute cholecystitis (AC) has not been resolved. In the revised Tokyo Guidelines from 2018 (TG18), early laparoscopic cholecystectomy (ELC) is recommended regardless of the duration of symptoms. The aim of this study was to evaluate the safety of ELC compared with delayed laparoscopic cholecystectomy (DLC) for AC. In addition, we assessed the perioperative outcomes after ELC based on duration of symptoms. METHODS: A retrospective cohort study of patients operated for acute calculous cholecystitis from January 1, 2017, to June 30, 2018, at Copenhagen University Hospital, Herlev. ELC was divided into three subgroups based on the duration of symptoms from onset to operation, ≤ 72 h, > 72-120 h, > 120 h. RESULTS: Two hundred twenty-two patients underwent ELC and 26 (10.5%) patients underwent DLC. We found no difference in mortality, morbidity, conversion rate, or bile duct injuries between DLC and ELC or in the subgroups based on duration of symptoms. We found significantly longer total hospital length of stay for patients with symptoms > 72 h (4.1-5.6 days) compared to ≤ 72 h (3.1 days) and the longest in DLC (9.9 days). Twenty-three percent of DLC needed an emergency operation in the waiting period with a high conversion rate (1/3). CONCLUSION: ELC for AC even beyond 5 days of symptoms is safe and not associated with increased complications. The duration of symptoms in AC is not an independent predictor and should not influence the surgeonsmsdecision to perform an ELC. Delaying cholecystectomy has a high failure rate.

[Mortality rate after acute laparotomy can be reduced].

Acute abdomen is a common cause of admission to hospital. Emergency laparotomy is associated with a significant morbidity and mortality due to deranged physiology and surgery-induced stress. Damage control laparotomy is on the rise as an operative strategy for the septic abdomen as well as for trauma laparotomy but lacks definition in the non-trauma setting. Principles of perioperative care in elective surgery are currently applied to the emergency abdominal surgery patients and should be further studied in the future to reduce morbidity and mortality.

[Gastric necrosis four years after fundoplication causing a dead foetus].

A 31-year-old pregnant woman was admitted and treated for diabetic ketoacidosis. As the patient deteriorated and the viability of the foetus was uncertain a CT scan was done which showed free fluid and air intraabdominally. Surgery was performed. A dead foetus was delivered and a 2 × 5 cm necrotic area of the gastric wall with a perforation was found. The gastric necrosis was a complication to a fundoplication in the patient.

Capsule endoscopy: a cause of late small bowel obstruction and perforation.

Case Report. A 71-year-old man was admitted to the department of gastroenterology with diffuse abdominal pain. Through the previous 12 months, the patient had experienced episodes of vomiting and watery diarrhea of increasing intensity as well as weight loss. The patient was evaluated with ultrasound, MRI, and subsequently a capsule endoscopy. Six months later, the patient presented, and an abdominal CT-scan showed mechanical small bowel obstruction with suspicion of metallic foreign body and perforation. Laparotomy showed perforation, stenosis, and foreign body, approximately 5 cm from the ileocecal valve. A right hemicolectomy and distal ileectomy (60 cm) with an ileostomy were performed. On further inspection of resection, a capsule endoscope was found impacted in a stenosis. The ileostomy was later reversed without complications. Conclusion. It is important to be aware of the possibility of capsule retention, especially in patients with known or suspected Crohn's disease, due to the propensity of Crohn's disease to form stenosis of the bowel. In cases where a stenosis is suspected, it is warranted to perform a patency capsule swallow before subjecting the patient to a capsule endoscopy.

[Necrotizing fasciitis]. / Nekrotiserende fasciitis.

INTRODUCTION: Necrotizing fasciitis (NF) is an acute soft-tissue infection, associated with a high mortality and morbidity. To reduce the mortality, an early diagnosis and treatment is essential. Our study aims to identify the number of patients, the microorganisms involved, and NF treatment outcomes among patients admitted to our unit. MATERIAL AND METHODS: This retrospective cohort study enrolled 85 patients admitted to the multidisciplinary, tertiary Intensive Care Unit, Abdominal Center, Rigshospitalet, Denmark in 2005-2007. All received the same protocolled treatment of intensive care, extensive surgical débridements, broad-spectrum antibiotics, intravenous immunoglobulin and hyperbaric oxygen. RESULTS: The microbiological analyses of specimens demonstrated that 51% were positive for polymicrobial infection, 40% for a single pathogen, 74% of these caused by beta-hemolytic streptococci, and 9% of the analyses were inconclusive. Of the patients, 91% required treatment in a respirator, 67.5% presented with septic shock and 25.3% developed acute renal failure needing dialysis. Intensive care unit mortality was 6% and 30-day mortality was 9.5%. Expected mortality based on SAPS II and APACHE II scoring was 38%. Our patients had a significantly higher body mass index than other patients admitted to the unit. CONCLUSION: NF is a complex disease, often associated with multi-organ failure. A protocolled treatment plan with close cooperation between the intensive care, clinical microbiology, medical and surgical specialties seems to reduce mortality considerably in this vulnerable group of patients.