Incidence, diagnosis, management and outcome of acute mesenteric ischaemia: a prospective, multicentre observational study (AMESI Study).

BACKGROUND: The aim of this multicentre prospective observational study was to identify the incidence, patient characteristics, diagnostic pathway, management and outcome of acute mesenteric ischaemia (AMI). METHODS: All adult patients with clinical suspicion of AMI admitted or transferred to 32 participating hospitals from 06.06.2022 to 05.04.2023 were included. Participants who were subsequently shown not to have AMI or had localized intestinal gangrene due to strangulating bowel obstruction had only baseline and outcome data collected. RESULTS: AMI occurred in 0.038% of adult admissions in participating acute care hospitals worldwide. From a total of 705 included patients, 418 patients had confirmed AMI. In 69% AMI was the primary reason for admission, while in 31% AMI occurred after having been admitted with another diagnosis. Median time from onset of symptoms to hospital admission in patients admitted due to AMI was 24 h (interquartile range 9-48h) and time from admission to diagnosis was 6h (1-12 h). Occlusive arterial AMI was diagnosed in 231 (55.3%), venous in 73 (17.5%), non-occlusive (NOMI) in 55 (13.2%), other type in 11 (2.6%) and the subtype could not be classified in 48 (11.5%) patients. Surgery was the initial management in 242 (58%) patients, of which 59 (24.4%) underwent revascularization. Endovascular revascularization alone was carried out in 54 (13%), conservative treatment in 76 (18%) and palliative care in 46 (11%) patients. From patients with occlusive arterial AMI, revascularization was undertaken in 104 (45%), with 40 (38%) of them in one site admitting selected patients. Overall in-hospital and 90-day mortality of AMI was 49% and 53.3%, respectively, and among subtypes was lowest for venous AMI (13.7% and 16.4%) and highest for NOMI (72.7% and 74.5%). There was a high variability between participating sites for most variables studied. CONCLUSIONS: The overall incidence of AMI and AMI subtypes varies worldwide, and case ascertainment is challenging. Pre-hospital delay in presentation was greater than delays after arriving at hospital. Surgery without revascularization was the most common management approach. Nearly half of the patients with AMI died during their index hospitalization. Together, these findings suggest a need for greater awareness of AMI, and better guidance in diagnosis and management. TRIAL REGISTRATION: NCT05218863 (registered 19.01.2022).

Personalized additive manufacturing of devices for the management of enteroatmospheric fistulas.

Additive manufacturing techniques allow the customized design of medical devices according to the patient's requirements. Enteroatmospheric fistula is a pathology that benefits from this personalization due to its extensive clinical variability since the size and morphology of the wound differ extensively among patients. Standard prosthetics do not achieve proper isolation of the wound, leading to a higher risk of infections. Currently, no effective personalized technique to isolate it has been described. In this work, we present the workflow for the design and manufacture of customized devices adapted to the fistula characteristics as it evolves and changes during the treatment with Negative Pressure Wound Therapy (NPWT). For each case, a device was designed with dimensions and morphology depending on each patient's requirements using white light scanning, CAD design, and additive manufacturing. The design and manufacture of the devices were performed in 230.50 min (184.00-304.75). After the placement of the device, the wound was successfully isolated from the intestinal content for 48-72 h. The therapy was applied for 27.71 ± 13.74 days, and the device was redesigned to adapt to the wound when geometrical evolutionary changes occur during the therapy. It was observed a decrease in weekly cures from 23.63 ± 10.54 to 2.69 ± 0.65 (p = 0.001). The fistulose size was reduced longitudinal and transversally by 3.25 ± 2.56 cm and 6.06 ± 3.14 cm, respectively. The wound depth also decreased by 1.94 ± 1.08 cm. In conclusion, customization through additive manufacturing is feasible and offers promising results in the generation of personalized devices for the treatment of enteroatmospheric fistula.

Are Spanish surgeons prepared to treat trauma patients? Multicentre descriptive observational study.

PURPOSE: Specific training in the management of trauma patients is beneficial for surgeons. Training through specific courses in this area has a direct impact on the care of these patients. The aim of this work is to understand the participation and specific training in the care of trauma patients by Spanish surgeons. METHODS: A national survey was conducted and administered to all members of the Spanish Association of Surgeons. The survey assessed their degree of participation in emergency surgery, and therefore the probability of attending trauma patients, their assessment of the initial care of trauma patients in their centre, and their specific training in this field. RESULTS: The survey was completed by 510 surgeons from 47 Spanish provinces, with Catalonia and Andalusia being the most represented regions. In total, 456 (89.41%) of those surveyed work in the emergency department on a routine basis. Only 171 (33.53%) refer to having a registry of trauma patients in their hospital. While 79.02% of surgeons reported that general surgeons are not involved in care of severe trauma from the outset, only 66.47% have completed the ATLS course, 40.78% the DSTC course and 18.82% the MUSEC course. Despite this, 85.69% believe that the ATLS course should be compulsory during residency and 43.33% believe that severe trauma care in their hospital is poor or very poor. CONCLUSION: Only 40% have received specific training in definitive surgical management of severe trauma. Despite this, a large percentage of surgeons work in the emergency department on a routine basis and potentially face the challenge of managing these patients.

Is the use of endoloops safe and efficient for the closure of the appendicular stump in complicated and uncomplicated acute appendicitis?

INTRODUCTION: There is still controversy regarding the ideal technique to close the appendicular stump in laparoscopic appendectomy (LA). The objective of this study was to determine the safety and efficiency of the use of an endoloop (EL) and endostapler (ES) in complicated and uncomplicated acute appendicitis. METHODS: Retrospective cohort study of patients undergoing LA from February 2013 to December 2019. Acute uncomplicated and complicated appendicitis were analysed separately, establishing two groups according to the stump closure technique: EL or ES. Seven hundred-nine patients were included (535 uncomplicated and 174 complicated). In uncomplicated appendicitis, an EL was used in 447 of the patients (83.55%) and an ES was used in 88 patients (16.45%). In complicated appendicitis, an EL was used in 85 patients (48.85%) and an ES was used in 89 patients (51.15%). An analysis of effectiveness and a cost analysis of each technique were performed. RESULTS: In uncomplicated appendicitis, we found no differences with respect to global complications, although there were significant differences in the total mean hospital stay (EL group 1.55 (SD 1.48) days; ES group 2.21 (SD 1.69) days; p = 0.046). This meant a savings of 514.12€ per patient using the EL p < 0.001). In complicated appendicitis, the reoperations classified as Clavien-Dindo IIIB in the EL group (6.4%) were greater than in the ES group (0%) (p = 0.012), although the rate of postoperative abscesses (p = 0.788) and the mean volume of abscesses (p = 0.891) were similar. CONCLUSION: The systematic use of an EL could reduce costs in uncomplicated appendicitis, while in complicated cases, both options are valid. Prospective studies with a greater number of patients are needed to observe differences in postoperative complications.

Análisis de los resultados en seguridad de pacientes y profesionales durante la pandemia COVID-19 en el contexto de la cirugía urgente / Analysis of the safety of patients and professionals during the COVID-19 pandemic in the context of emergency surgery

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Using a bio-scanner and 3D printing to create an innovative custom made approach for the management of complex entero-atmospheric fistulas.

Enteroatmospheric fistulae are challenging clinical conditions that require surgical expertise and that can result in chronic debilitating conditions placing the patient in a vicious cycle characterized by non healing wounds and malnutrition. They are a complex entity that presents great variability depending on the number, shape, and size of the fistulous orifices, their debit, and the dimensions of the wound. This means that, at present, there is no device that adapts to the anatomical characteristics of each patient and manages to control the spillage of intestinal effluvium from the wound. The aim of this study is to describe the manufacturing technique and to assess the preliminary results of a custom device designed through bioscanner imaging and manufactured using 3D printing for use with negative pressure wound therapy (NPWT) in the management of enteroatmospheric fistula. A proof of concept is given, and the design of the device is presented for the first time. After obtaining images of each fistula with a bioscanner, a personalised device was designed for each patient by 3D printing shape of a prism and a hollow base, taking into account the dimensions of the fistulous area in order to perform a floating ostomy to isolate the wound from the debit enteric. The polycaprolactone (PCL) device was placed including inside the fistulous surface and surrounding it with the NPWT system in order to accelerate wound healing.

Toracoscopia como alternativa a esternotomía en herida por empalamiento en opérculo torácico en paciente hemodinámicamente estable / Thoracoscopy as an alternative to sternotomy in impalement injury of the thoracic outlet of a hemodynamically stable patient

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Diferencias en la presentación clínica, manejo y resultados de la apendicitis aguda en el embarazo / Acute appendicitis during pregnancy: differences in clinical presentation, management, and outcome

Objetivo: Evaluar la presentación clínica, el manejo y los resultados de la apendicitis aguda (AA) en mujeres de edad fértil en función de la presencia de embarazo y su estado evolutivo. Método: Estudio observacional de dos cohortes (gestantes [G] y no gestantes [NG]), apareadas según técnicas de propensión de riesgo, que incluyó mujeres adultas en edad fértil sometidas a apendicectomía urgente por la sospecha clínica de AA. Se recogieron variables relacionadas con la edad, los antecedentes personales, la presentación clínica, el manejo y los resultados. Se realizó un análisis según la presencia de embarazo y el trimestre de gestación. Resultados: Se incluyeron 153 mujeres (51 G y 102 NG). La edad media fue de 28,8 (DE 6,5) años (G: 29,7 [DE 5,8] vs NG: 28,3 [DE 6,8]; p = 0,242). La puntuación de la escala de Alvarado fue de 7,1 (DE 1,6) (G: 6,7 [DE 1,7] vs NG: 7,3 [DE 1,5]; p = 0,016). Las G presentaron mayor incidencia de AA complicada (G: 19,6% vs NG: 2,9%; p < 0,001), infección del sitio quirúrgico (G: 14,0% vs NG: 3,0; p = 0,016), estancia media (G: 5,1 [DE 4,8] vs NG: 1,7 [DE 1,0]; p < 0,001). Los resultados fueron peores, entre las G del tercer trimestre (p = 0,031, p = 0,003 y p < 0,001, respectivamente). Conclusiones: La presentación clínica atípica de la AA durante el embarazo dificulta su diagnóstico, lo que podría traducirse en una mayor incidencia de AA complicada, infección del sitio quirúrgico y tiempo de estancia hospitalaria, sobre todo si se presenta la AA durante el tercer trimestre de gestación

Objective: To analyze the clinical presentation, management, and outcome of acute appendicitis (AA) in pregnant and nonpregnant women of childbearing age. Methods: Descriptive study of 2 cohorts of women (pregnant -P- and nonpregnant -NP-). The women, who were matched according to risk factors, were included when they underwent an emergency appendectomy based on clinical suspicion of AA. We recorded age, medical history, clinical presentation, management, and outcome. Pregnant women were classified according to gestational age of the fetus (trimester). Results: We included 153 women (51 P, 102 NP). The mean (SD) age was 28.8 (6.5) years (P women, 29.7 [5.8] years; NP, 28.3 [6.8]; P=.242). The mean Alvarado score was 7.1 (1.6) (P, 6.7 [1.7]; NP, 7.3 [1.5]; P=.016). The rate of complicated AA was higher in P (19.6%) than NP (2.9%) women (P<.001). Pregnancy was also associated with higher rates of surgical wound infection (P, 14.0%; NP, 3.0%; P=.016) and a longer mean hospital stay (P, 5.1 [4.8] days; NP, 1.7 [1.0]; P<.001). In the third trimester of P, poorer outcomes were recorded in relation to these risks (P=.031; P=.003, and P<.001, respectively). Conclusions: The atypical clinical presentation of AA during pregnancy makes diagnosis difficult and may lead to a higher incidence of complicated AA and surgical wound infection as well as longer hospital stays, particularly when AA presents in the third trimester

Acute appendicitis during pregnancy: differences in clinical presentation, management, and outcome. / Diferencias en la presentación clínica, manejo y resultados de la apendicitis aguda en el embarazo.

OBJECTIVES: To analyze the clinical presentation, management, and outcome of acute appendicitis (AA) in pregnant and nonpregnant women of childbearing age. MATERIAL AND METHODS: Descriptive study of 2 cohorts of women (pregnant -P- and nonpregnant -NP-). The women, who were matched according to risk factors, were included when they underwent an emergency appendectomy based on clinical suspicion of AA. We recorded age, medical history, clinical presentation, management, and outcome. Pregnant women were classified according to gestational age of the fetus (trimester). RESULTS: . We included 153 women (51 P, 102 NP). The mean (SD) age was 28.8 (6.5) years (P women, 29.7 [5.8] years; NP, 28.3 [6.8]; P=.242). The mean Alvarado score was 7.1 (1.6) (P, 6.7 [1.7]; NP, 7.3 [1.5]; P=.016). The rate of complicated AA was higher in P (19.6%) than NP (2.9%) women (P<.001). Pregnancy was also associated with higher rates of surgical wound infection (P, 14.0%; NP, 3.0%; P=.016) and a longer mean hospital stay (P, 5.1 [4.8] days; NP, 1.7 [1.0]; P<.001). In the third trimester of P, poorer outcomes were recorded in relation to these risks (P=.031; P=.003, and P<.001, respectively). CONCLUSION: The atypical clinical presentation of AA during pregnancy makes diagnosis difficult and may lead to a higher incidence of complicated AA and surgical wound infection as well as longer hospital stays, particularly when AA presents in the third trimester.

OBJETIVO: Evaluar la presentación clínica, el manejo y los resultados de la apendicitis aguda (AA) en mujeres de edad fértil en función de la presencia de embarazo y su estado evolutivo. METODO: Estudio observacional de dos cohortes (gestantes [G] y no gestantes [NG]), apareadas según técnicas de propensión de riesgo, que incluyó mujeres adultas en edad fértil sometidas a apendicectomía urgente por la sospecha clínica de AA. Se recogieron variables relacionadas con la edad, los antecedentes personales, la presentación clínica, el manejo y los resultados. Se realizó un análisis según la presencia de embarazo y el trimestre de gestación. RESULTADOS: Se incluyeron 153 mujeres (51 G y 102 NG). La edad media fue de 28,8 (DE 6,5) años (G: 29,7 [DE 5,8] vs NG: 28,3 [DE 6,8]; p = 0,242). La puntuación de la escala de Alvarado fue de 7,1 (DE 1,6) (G: 6,7 [DE 1,7] vs NG: 7,3 [DE 1,5]; p = 0,016). Las G presentaron mayor incidencia de AA complicada (G: 19,6% vs NG: 2,9%; p < 0,001), infección del sitio quirúrgico (G: 14,0% vs NG: 3,0; p = 0,016), estancia media (G: 5,1 [DE 4,8] vs NG: 1,7 [DE 1,0]; p < 0,001). Los resultados fueron peores, entre las G del tercer trimestre (p = 0,031, p = 0,003 y p < 0,001, respectivamente). CONCLUSIONES: La presentación clínica atípica de la AA durante el embarazo dificulta su diagnóstico, lo que podría traducirse en una mayor incidencia de AA complicada, infección del sitio quirúrgico y tiempo de estancia hospitalaria, sobre todo si se presenta la AA durante el tercer trimestre de gestación.

Prevertebral cervical approach: a pure endoscopic surgical technique for posterior mediastinum parathyroid adenomas.

BACKGROUND: Parathyroid gland mediastinal ectopia is an unusual but challenging condition in surgical management of hyperparathyroidism. Posterior mediastinum parathyroid ectopia is rare, and glands need to be removed either with a broad open cervical or thoracic approach. In recent years, several minimally invasive approaches to mediastinal parathyroid glands have been described, but for posterior mediastinum adenomas, proposed techniques are transthoracic. METHODS: The aim of this paper is to describe, to our best knowledge for the first time, a standardized pure endoscopic cervical technique to approach posterior mediastinal parathyroid adenomas which we have used in three patients. RESULTS: The technique was applied in three patients which excellent surgical, postoperative, and cosmetic results. CONCLUSIONS: Endoscopic prevertebral approach is a feasible, sure and inexpensive standardized pure endoscopic cervical approach to posterior mediastinal parathyroid adenomas, which may result in a less aggressive surgical option when compared with thoracic approaches.