Management of Appendicitis

Appendicitis is one of the most common causes of acute abdomen with life time risk between 6 and 8% and it’s a most common non obstetric surgical emergency during pregnancy. Appendicitis is claimed to be unknown in the villages of India and China in paper by A. M. Spencer. The reason is simply due to the fact that diagnostic facilities do not exist and cases are not recognized. So diagnosing acute appendicitis accurately and efficiently can reduce morbidity and mortality from perforation and other complications. Surgical intervention is the first choice for appendicitis with medical management being reserved for special situations.

COVID-19 and Digestive Surgical Emergencies: Experience of the General Surgery Department of Tangier University Hospital.

On March 11, 2020, the WHO declared that the epidemic of COVID-19 had become a pandemic, and this disrupted all the regulated operative programs. On the other hand and by its urgent nature, the emergency surgery was maintained with particularity in some situations, an association with infection by COVID-19. The circumstances of diagnosis of the association of infection by COVID-19 and surgical emergency are based on clinical, radiological, and biological criteria. In this work we report the experience of the University Hospital of Tangier concerning the management of three patients with the particularity of associating a covid infection and a digestive surgical emergency, we will discuss through these cases, the necessary protective measures in intraoperative and the impact of the covid infection on the morbi-mortality Concerning the impact of covid infection on postoperative morbidity and mortality, there are generally two situations: When the covid infection is benign, the prognosis depends on the severity of the surgical emergency and in this situation the prognosis is the same as for patients not infected by covid, this is the case of the first and third cases. The second situation; when the covid infection is severe, it has a great impact on the prognosis and the postoperative care in intensive care. With this publication, we are trying to provide information to help surgeons better manage this category of patients, especially in view of the panic caused by the pandemic, and the difficulty of adapting to the new patient circuit, but more studies recruiting more cases are needed to confirm our findings.

Rapidly Spreading Deep Dissecting Hematoma Occurring One Month After A Minor Trauma: A Case Report.

Background: Deep dissecting hematoma (DDH) is a rapidly extending blood collection that splits the hypodermis from muscle fascia, constituting a medical surgical emergency. The natural history of this condition includes trauma (even minor physical injury) shortly before onset of the lesion, occurring in a patient with advanced dermatoporosis. A delay of several weeks between the appearance of a superficial haematoma following a minor trauma and its sudden decompensation into a rapidly spreading DDH has been scarcely mentioned in the medical literature. Case presentation: We report the admission of a 70-year-old woman under anticoagulation to the emergency department of our hospital for the sudden appearance of a rapidly evolving hematoma one month after a negligible trauma to the right leg. A complete skin examination revealed clinical signs (spontaneous superficial skin haematomas, lacerations, wrinkles, stellate pseudo-scars) of advanced dermatoporosis, especially on the forearms. The initial biological testing disclosed an International Normalized Ratio of 3.15. The clinical aspect of the haematoma, its rapid extension and the cutaneous signs of dermatoporosis on the forearms allowed the diagnosis of DDH. Bedside ultrasound examination was used to eliminate differential or additional diagnoses and to assess the main features of the hematoma (dimensions, existence of blood supply). Due the extent of the lesion and the risk of extended skin necrosis, surgical debridement and hematoma drainage were performed. The operative report confirmed the diagnosis of DDH. Wound healing was obtained spontaneously after three months. Conclusion: DDH is the most serious complication of dermatoporosis. Given its rapid horizontal extension and the risk of skin necrosis it induces, DDH is a medical-surgical emergency and must be diagnosed early. This observation emphasises that in patients with severe dermatoporosis, on the occasion of a Vitamin K Antagonist overdose, a limb-threatening DDH can develop suddenly, even several weeks after a minor impact.

Surgical techniques in acute Type A aortic dissection: How we do it

Acute Type A aortic dissection (ATAAD), a surgical emergency, has high mortality and morbidity. More than half of the patients dies within 2 weeks and the 30-day mortality is 90%. Here we describe our technique of ATAAD repair.

Ileo-Sigmoidian Node: About A Case in the Visceral Surgery Department of the Donka National Hospital

The aim of this study was to report a clinical case of ileocaecal node in the visceral surgery department of Donka. The ileosigmoid node or the ileosigmoid knot (ISK), is an exceptional clinical entity, it is a surgical emergency characterized by strangulation of the small intestine forming a knot around the base of the sigmoid colon with risk of rapid necrosis of the small intestine. And the colon. The preoperative diagnosis of this condition is difficult because of its rarity and atypical radiographic results. We report a case of an ileosigmoid node discovered in a 62-year-old subject who consulted in our department for an occlusive syndrome.

IMPACT OF COVID 19 PANDEMIC ON ACUTE GENERAL SURGICAL EMERGENCY MANAGEMENT- A TERTIARY CARE HOSPITAL BASED STUDY

BACKGROUND: The COVID-19 pandemic is standing as a never before threat to the healthcare systems and hospital operations worldwide.Transmission of coronavirus (COVID-19) is a considerable risk during the perioperative period of surgery. Treatment algorithms have changed in general surgery clinics, as in other medical disciplines providing emergency services. OBJECTIVES: This study was aimed to evaluate the changes in approach to management and the perioperative outcome of patients with acute surgical emergency during COVID-19 pandemic. STUDY DESIGN AND METHODS:We performed a retrospective observational study in patients presented with acute surgical emergency between April 2020 to June 2021. RESULTS: A total of 298 patients were included, among whom 12 (3.4%) were COVID 19 positive. 274 non-COVID patients and 8 COVID-19 positive patients underwent emergency surgery.While 12 non-COVID (4.1%) and 4 COVID-19 positive patients (40%) underwent conservative management. None of the hospital staff involved in the surgeries of COVID-19 positive patients developed any symptoms related to COVID-19. CONCLUSION: This study showed that the patients with surgical emergency both with or without COVID-19 infection were successfully treated,without influencing each other,through appropriate isolation measures,although managed in the same hospital. Importance can also be given towards conservative management particularly for COVID-19 positive patients presenting with surgical emergency selectively with proper monitoring. So it can be concluded that, although the management of surgical patients during the COVID-19 pandemic is a global challenge,adequate preparedness and strategic plan to adjust the surgical services can reduce the exposures to this highly contagious virus.

EP.WE.433Assessment of the temporary Surgical ED Study and Audit

Aims To ascertain the effectiveness of the newly formed surgical ED during Covid-19 outbreak in terms of: Methods/Study design Retrospective cohort of 992 patients were identified and included from the period of the 5th April to 5th May 2020 Inclusion criteria: All patients attended and triaged in the new surgical emergency department. Exclusion criteria: Patients who were not triaged. Results The temporary surgical emergency department was successful in accommodating all surgical patients categorized 2, 3 and 4 with category 4 being the highest number at 45%. Hospital services were successfully accessed in 771(77.72%) during patients stay in ED including Bloods and imaging with X-ray as the most service used at 42.33%. 221(22.27%) patients didn’t require any investigations and were discharged after review by the surgical doctor within the 4-hour window. Conclusion Presence of a dedicated surgical emergency during the covid period was essential to separate medical patients from non-medical patients. Having a decision maker on the front line right after triage has reduced the overall number of admissions, number of emergency breeches and unnecessary investigations. Having a dedicated space with dedicated team could make a huge impact on the service in terms of time, effort and money spent.

EP.TU.673Optimising the referral process to the Surgical Emergency Clinic through mutual education of primary and secondary care teams: an audit cycle

Aims The Surgical Emergency Clinic (SEC) in our Hospital facilitates access to General Surgical consultant-led emergency assessment. Anecdotally, referrals are often (likely inadvertently) inappropriate and / or incomplete, which may delay assessment by the correct specialist. We audited the quality of GP referrals to the SEC against four standards: Methods Retrospective analysis of 50 GP referrals to the SEC between November - December 2017, after recording data pertinent to the above standards in a spreadsheet. Results were presented at a local GP development day, a re-designed referral form incorporating GP feedback received was uploaded onto the Trust’s intranet and an email inbox created for e-referrals. 50 further referrals between September - November 2018 were analysed. Results Full completion of the referral form increased from 0% (initial audit) to 29% (re-audit), and appropriateness of referrals from 62% to 90%. The proportion of patients having had specified blood and urine tests in advance improved overall also. Conclusions Our experience demonstrates that primary and secondary care teams actively communicating and working closely together can improve the referral process for both parties, and most importantly enhance patient access to timely, appropriate specialist care.

SP3.1.10 Surgical Emergency Assessment Unit and Emergency Surgeon of the Week’ : A Paradigm shift to providing Emergency Surgical Care

Aims Ever increasing number of A&E attendance and admissions cause immense strain on hospital beds with drainage of our finite health resources. This prompted the need for implementation and review of alternative schemes: Surgical Emergency Assessment Unit (SEAU) and ‘Emergency Surgeon of the Week’ (ESW) and its impact on our depleted health system. Patients and Method Retrospective analysis of a prospectively collected data from SEAU activity logs, patient information center and friends and family questionnaire following implementation of SEAU (November 2014) and ESW (November 2017) in a large DGH.SEAU operates on a five day policy (Monday – Friday, 0800-2000) aided by dedicated imaging pathway and ESW works on a 1:5 (Monday – Thursday, 0800-1800) rota with full complement of the surgical team. Results SEAU has attended to 16057 patients (New 9811; Follow Up 6246) from November 2014-October 2019. Emergency general surgical admission pre and post SEAU implementation was 309* and 202*/month respectively, a drop of 35% with a further reduction after introduction of ESW by another 24% to 153*/month. Thus, a total reduction of emergency admission by almost 60%. Stay in SEAU was 4* hours and re-admission rate was 6%. SEAU received 98% friends and family recommendation to others. Conclusions A paradigm shift in providing emergency surgical care is required in the face of a strained health care system; the positive outcome achieved after implementation of SEAU and ESW could be the answer to relieving bed capacity and financial pressures, possibly a solution to providing high quality and safe patient care.

EP.TH.625Consenting for a Bedside Procedure: A Prospective Observational Analysis of Consenting Practice in the Surgical Emergency Admissions Unit of a District General Hospital

Aims Consent is necessary to enable patient autonomy and essential to providing good clinical care. Recent case law has grown around consent and practice guidance has evolved. This was a prospective, observational study consisting of two cycles. It investigated the quality of consent for bedside incision and drainage (I&D) procedures performed in the surgical emergency admissions unit (SEAU) at a district general hospital compared with GMC guidance. Methods A prospective analysis of consent documentation was performed from August to September 2020. Data was gathered for quality of consent including risk and benefit discussions, local anaesthetic used, operation note documentation and procedure discussion. We communicated these results at a departmental level, increased awareness of available consent forms and placed them in more accessible locations. Data to see the benefit of these interventions were gathered from November 2020 to January 2021. Results In cycle one, of 20 cases (n = 20), 5.0% had written consent documentation, and 75.0% had verbal consent documentation. 20.0% of cases had no consent documented. Following interventions, of 14 cases (n = 14), 57.1% of cases had written consent documentation, and 7.14% had verbal consent documentation. 35.0% of cases had no consent documented. Conclusion This study highlighted a deviation from GMC guidance. Interventions have shown to increase the proportion of cases with written consent. Overall cases with no written evidence of consent remain high and further work is required to increase compliance. We aim to refine the interventions we have implemented in order to promote the highest quality of consent documentation.