Comparing Emergent and Elective Colectomy Outcomes in Elderly Patients: A NSQIP Study

Introduction. With the increasing prevalence of colorectal cancer (CRC) worldwide, especially in the elderly, and the variability between physiological and chronological age and its impact on functional status, acute symptoms leading to emergent surgery due to colorectal malignancy may lead to increased morbidity and mortality. The aim of this study is to identify the outcome differences of elective vs. emergent open colectomy in patients above 80 years. Methods. The National Surgical Quality Improvement Program (NSQIP) database was reviewed from 2010 to 2014 for open colectomy based on CPT codes. Comparison between groups was done based on the clinical context at presentation as elective or emergent surgery. Data were analyzed using SAS. Results. Elective colectomies were performed in 8289 (70.8%) vs. emergent colectomies in 3409 (29.1%). Emergent colectomy patients had higher American Society of Anesthesiologists (ASA) preoperative classification III-IV, 1429 (42.0%) and 224 (6.6%), vs. 1238 (14.9%) and 21 (0.2%) in elective colectomy patients p < 0.0001 . Emergent colectomy patients had more comorbidities such as chronic obstructive pulmonary disorder (493 (14.5%) vs. 796 (9.6%)), congestive heart failure (206 (6.0%) vs. 310 (3.8%)), dialysis (106 (3.1%) vs. 56 (0.7%)), and acute renal failure (166 (4.9%) vs. 46 (0.6%)) p < 0.0001 , respectively. Postoperative morbidity and mortality were significantly higher in emergent colectomy (1651 (48.4%) and 872 (25.6%)) vs. elective colectomy (1859 (22.4%) and 567 (6.8%)) p < 0.0001 , respectively. Conclusion. Emergent open colectomy in elderly patients carries a higher risk of morbidity and mortality when compared to elective open colectomy with risk factors being higher ASA classification and more comorbidities.

Bentracimab for Ticagrelor Reversal in Patients Undergoing Urgent Surgery

Ticagrelor is a reversible oral P2Y12 platelet inhibitor used in patients with many forms of heart and vascular disease. Because patients receiving ticagrelor may bleed or need emergent surgery, bentracimab was studied as a ticagrelor reversal agent. In this study in 150 patients, treatment had a significant salutary impact on laboratory measured platelet function. Adjudicated hemostasis was achieved in over 90% of patients, most of whom had cardiac surgery; thrombotic events occurred in just over 5% of treated patients.

A Fatal Masquerade in Pneumonia: Ruptured Thoracic Aortic Aneurysm

we described an 87-year-old man who presented with fever and hemoptysis. Nosocomial pneumonia was initially impressed. However, the patient has worsening hemoptysis despite defervescence. Computed tomography of chest disclosed ruptured thoracic aortic aneurysm. Emergent surgery was then commenced for adequate treatment.

TP6.1.4 Risk factors for post-cholecystectomy bile duct injuries: Systematic review and meta-analysis

Aims Bile duct injury (BDI) is a major complication of cholecystectomy resulting in long-term consequences. The relatively low incidence (0.23% – 1.5%) of BDI makes the identification of risk factors challenging. The aim of this study was to systematically analyse available literature on BDI post-cholecystectomy to provide an update on the incidence and determine current risk factors. Methods The study was pre-registered on PROSPERO (CRD42020177318). A search was conducted of MEDLINE, EMBASE, Scopus, Cochrane Central, Web of Science databases and the grey literature from inception to February 2020. 1583 unique papers were identified and screened for eligibility. English language, retrospective and prospective studies were included where the population age was &gt; 16 and underwent cholecystectomy. Results Outcomes analysed were incidence of BDI and risk estimates for possible risk factors. 30 studies (6,420,667 patients) were included in the meta-analysis. Gender, BMI&gt;30, acute cholecystitis (AC), emergent surgery, the operative approach, intraoperative cholangiography (IOC) and the impact of surgeon’s experience were analysed. Male gender and AC were determined to be statistically significant risk factors (OR 1.25 (1.13-1.39)) and 1.74 (1.27-2.39) respectively). Furthermore, IOC use was found to be significantly associated with BDI risk (OR 1.27 (1.17 – 1.37), while BMI&gt;30, open surgical approach, emergent surgery and surgeon’s experience were not statistically significant; however, significant heterogeneity among included studies limited the interpretation of these factors. Conclusion Male gender and AC were found to be predictors of BDI, while better quality evidence is needed to show the effect of other factors.

Predictors for dementia during long-term follow-up after aortic valve replacement in an elderly population

Introduction Patients undergoing surgical aortic valve replacement (SAVR) with a biological prosthesis usually receive this type of valve because higher age and comorbid conditions. This is the type of patient for whom transcatheter valve implantation (TAVI) has been developed and applied as a mean for less invasive treatment. However, this is also the age group at risk for dementia, a condition which severely reduces the quality of life. Purpose The predictors for the development of dementia during long-term follow-up after SAVR need identification. Methods From January 2008 to June 2017, 1305 patients underwent SAVR with a biological valve. Of these patients, 1221 left the hospital alive (93.6%). In a retrospective file study, the effect of age, gender, preoperative comorbid condition (chronic renal or pulmonary disease, diabetes, treated or treatable cancer, hypertension, stroke) and cardiac status (left ventricular function, coronary artery disease, myocardial infarction, prior CABG or PCI, severity of symptoms, atrial fibrillation, ventricular arrhythmias, conduction defects with or without a need for permanent pacemaker), operative data (bypass time&gt;120 minutes, concomitant CABG, mitral valve repair, maze procedure, procedure on the ascending aorta) and in-hospital postoperative complications (endocarditis, thromboembolism, bleeding, atrial fibrillation, heart failure, pulmonary and renal complications) on the development of dementia was studied. Factors with an effect in a univariate Kaplan-Meier survival analysis were entered in a Cox' proportional hazard analysis. Results There was a follow-up of 7726 patient-years (mean 5.9y). Five-year survival was 78.8±1.3%. At 10 year, this was 50.7±2.1%. Dementia during long-term follow-up was diagnosed in 162/1080 patients (15%). Predictors for the development of dementia are grouped as 1) preoperative, 2) operative and 3) postoperative, and ranked according the p-value. 1) Preoperative predictors – Age &gt;75 years: Odds ratio: 2.89, with 95% Confidence interval between 2.02–4.14 and p&lt;0.001 – Need for emergent surgery: OR=2.84 (1.56–5.19), p=0.001 – Coronary artery disease: OR=1.57 (1.12–2.21), p=0.009 – Diabetes mellitus: OR=1.56 (1.08–2.24), p=0.017 – Atrial fibrillation: OR=1.51 (1.07–2.15), p=0.020 2) Operative predictors – Bypass time &gt;120 minutes: OR=1.40 (1.01–1.94), p=0.043 3) Postoperative predictors – Delirium: OR=3.35 (2.26–4.97), p&lt;0.001 – Acute renal injury: OR=1.98 (1.39–2.81),p&lt;0.001 – Thromboembolism: OR=2.10 (1.02–4.30), p=0.043 Conclusions Development of dementia during long-term follow-up after SAVR in elderly is not uncommon. High age and need for emergent surgery are the dominant preoperative predictors. Long cardiopulmonary bypass, which is usually a marker for more complex procedures is the only operative predictor. Postoperative delirium during hospital stay is a warning sign. The only modifiable factor is need for emergent surgery. FUNDunding Acknowledgement Type of funding sources: None.

Assessment of bowel vascularity using indocyanine green fluorescence in incarcerated hernia

Intra-operative assessment of bowel vascularity is often needed during emergent surgery. An objective test to determine the viability could reduce postoperative ischemic complications. Indocyanine green dye has been used for assessing bowel vascularity in colorectal surgery. The following study involving two patients demonstrates its use for assessing the viability of bowel in obstructed hernias after intraoperative intravenous injection. Stryker 1588 AIM laparoscopic setup was used for intraoperative fluorescence. In both cases, dusky areas were noted over the obstructed bowel segment on visual inspection. However, satisfactory fluorescence was seen after dye injection, and hence mesh repair was done without resecting the bowel. All the patients had a good post-operative recovery. Indocyanine green fluorescence may be a good modality to intraoperatively assess bowel vascularity.

Study Protocol: Assessment of Racial/Ethnic Disparities in the Timeliness and Comprehensiveness of Surgery for Colorectal Cancer v1

This retrospective cohort study will investigate the timeliness of surgery based on the racial/ethnic group of patients who under colorectal surgery for cancer. Patients are included if they underwent surgical procedures for colon cancer between January 1, 2015 and April 30, 2020. The primary exposure of interest is the racial/ethnic group of the patient. The primary outcome is the the timeliness of surgery, defined as having urgent/emergent surgery (less timely) vs. elective surgery (more timely). Secondary outcomes relate to comprehensiveness of surgery, and include performance of preoperative staging tests, preoperative lab testing, and preoperative teaching of patients, as well as length of stay and additional clinical outcomes. Multivariable logistic regression models will be used to adjust for other demographic and clinical differences between study groups.

Abdominal Tuberculosis: A Report Outlining Surgical and Unique Pharmacologic Management in the Absence of Enteral Access

Abdominal tuberculosis (TB) occurs only in a subset of TB-infected persons. With a higher incidence in the immunocompromised population, successful treatment includes early diagnosis and initiation of anti-TB medications. This case report discusses a 22-year-old immunocompetent male diagnosed with advanced duodenal and peritoneal TB after perforation requiring emergent surgery and intravenous anti-TB treatment secondary to lack of enteral access.