A Prospective, Double-Blind, Multicenter, Randomized Trial Comparing Ertapenem 3 Vs ≥5 Days in Community-Acquired Intraabdominal Infection

Severe secondary peritonitis is diagnosed in only 20–30% of all patients, but studies to date have persisted in using a standard fixed duration of antibiotic therapy. This prospective, double-blind, multicenter, randomized clinical study compared the clinical and bacteriological efficacy and tolerability of ertapenem (1 g/day) 3 days (group I) vs ≥5 days (group II) in 111 patients with localized peritonitis (appendicitis vs non-appendicitis) of mild to moderate severity, requiring surgical intervention. In evaluable patients, the clinical response as primary efficacy outcome were assessed at the test-of-cure 2 and 4 weeks after discontinuation of antibacterial therapy. Ninety patients were evaluable. In groups I and II, 92.9 and 89.6% of patients were cured, respectively; 95.3% in group I and 93.7% in group II showed eradication. These differences were not statistically significant. The most frequent bacteria recovered were Escherichia coli and Bacteroides fragilis. A wound infection developed in seven patients (7.7%) and an intraabdominal infection in one patient (1.1%). There was a low frequency of drug-related clinical or laboratory adverse effects in both groups. Our study demonstrated that, in patients with localized community-acquired intraabdominal infection, a 3-day course of ertapenem had the same clinical and bacteriological efficacy as a standard duration. Italian study group: Paolo Mazzocchi, Luigi Solinas, and Fulvio D’Ostuni, Department “Paride Stefanini”, University “La Sapienza”, Rome, Italy; Roberto Caronna, Department of Emergency Surgery, University “ La Sapienza”, Rome, Italy; Antonino Buffone, Department of Emergency Surgery, University of Catania, Catania, Italy; Teresa Verde and Claudia Massaiu, Department of Emergency Surgery, University of Sassari, Sassari, Italy; Dario Di Miceli, Department of Surgery, Catholic University of Rome, Rome, Italy; Salvatore Di Muria, Department of Surgery, S. Giovanni Bosco Hospital, Naples, Italy; Edoardo Cervi, Department of Surgery, University of Brescia, Brescia, Italy; Fausto Catena, Department of Emergency Surgery, University of Bologna, Bologna, Italy; Massimo Coletti and Stefano Scozzafava, Department of Emergency Surgery, University “La Sapienza”, Rome, Italy This paper was presented at the 20th meeting of the International Society for Digestive Surgery, Rome, Italy, November 29–December1, 2006.     

破裂腹主动脉瘤的外科治疗及预后

目的探讨破裂腹主动脉瘤的诊断、治疗方法及影响预后的因素。方法回顾性分析1999年4月至2005年12月期间我院收治的23例肾动脉下破裂腹主动脉瘤患者的临床资料，其中男15例，女8例；年龄35～78岁，平均65岁。自知有腹主动脉瘤者7例，有腹部搏动性包块者6例，术前行急诊彩超和（或）CT检查确诊15例。所有患者均行急诊手术治疗。根据术中情况采取肾动脉下腹主动脉钳夹阻断或腹主动脉腔内球囊阻断，控制出血后行人造血管移植术。结果手术后30d内死亡9例（39％），死亡原因为出血性休克所致的急性肾功能衰竭4例、多器官功能衰竭3例、呼吸循环衰竭2例。结论手术治疗是对破裂腹主动脉瘤的有效治疗，根据术中情况采取不同的方法阻断破裂口近端腹主动脉以控制出血是手术的关键。急性心脑血管疾病、急性肾功能衰竭及肺部并发症是术后的主要并发症及死亡原因。     

The impact of emergency medicine on surgical care in the emergency ward

The Committee on Issues of the Association for Academic Surgery surveyed the Association's membership, surgical department chairmen, and university hospital emergency department directors as to their attitudes about the role of surgeons and emergency medicine specialists in emergency care. Major differences in attitudes exist between surgeons and nonsurgeons regarding the surgeon's role in the emergency department. Although surgeons want to preserve a dominant role in emergency care, they have little interest in being in charge of emergency wards on a day to day basis. Emergency medicine specialists have a tendency to function independently, even to the point of independently performing emergency surgical procedures. In emergency departments led by nonsurgeons there is decreased participation of surgical house staff in the resuscitation of the critically injured patients. This may result in inadequate training of surgical residents in acute trauma care and ultimately result in lowered overall standards of care in critically ill patients. An important question is whether surgeons can continue to abdicate their present reponsibilities in the emergency ward and yet maintain their essential role in the preoperative care of the emergency patient.     

All basic surgical trainees should rotate through an accident and emergency post

A 6-month post in accident and emergency is no longer compulsory for basic surgical training. Meanwhile, trauma teams have emerged in many UK hospitals to receive seriously injured patients, often with no involvement of basic surgical trainees (BSTs). This may lead to the appointment of surgical specialist registrars (SpRs) who have had little exposure to the initial management of seriously injured patients. This study documents the experience of a senior house officer undertaking a 6-month post in the accident and emergency department of a district general hospital. METHODS: Data concerning the nature of cases seen were collected retrospectively from all patient record cards signed by the author during the placement. RESULTS: During the period studied, the author was present in the resuscitation room on 41 occasions, of which 10 episodes involved the management of a multiply injured patient. A total of 159 fractures and significant soft tissue injuries in the upper limb and 122 such cases in the lower limb were seen. There were 25 head injuries, 17 spinal injuries, 5 significant cases of chest trauma, 4 of abdominal trauma and 5 significant urinary tract injuries. Some 86 practical procedures were carried out during the placement. DISCUSSION: The 6-month post in accident and emergency provided the BST with significant exposure to the care of seriously injured patients. Such a post should be compulsory to ensure that SpRs on appointment have already received exposure to managing the seriously injured. The post provided additional benefit in terms of performing practical procedures and exposure to other acute surgical conditions.     

The emergency treatment of aneurysms of the supra-aortic trunks and of the internal carotid

In the last 10 years, four patients with aneurysms of the supraaortic trunks and the internal carotid artery have been operated in emergency at Department of Vascular Surgery of University of Bari. The first case was a mycotic aneurysm of the carotid bifurcation, the second an aneurysm of internal carotid artery interesting the retropharynx, the third a post-operatory pseudoaneurysm of common carotid in a patient affected by Takayasu's disease and the last an atherosclerotic aneurysm of the innominate artery. Clinical picture suggested an immediate surgical treatment in all patients. Different procedure were used depending on size and localization of each lesion. Results in all cases have been satisfactory. The aneurysms of supraaortic trunks and of internal carotid artery are very rare; therefore when clinical picture is dramatic or quickly worsening, emergency treatment is mandatory in order to reduce mortality risk and minimize complications.     

Triage in a Bomb Disaster with 166 Casualties

Abstract Background: We describe the surgical response of the Helsinki University Hospitals to a bomb disaster with 166 casualties. According to the Helsinki Area Disaster Plan, severely injured patients were transported to several hospitals with emergency facilities to avoid overtriage. Methods: The patient data were gathered from hospitals, health centers and other doctor visit/ appointments records. Injury Severity Scores (ISS), critical mortality rate and death/wounded ratio were calculated. Results: Of the 166 injured patients, 5 died immediately at the bombing site. Sixty-six patients were transported to the six affiliated hospitals. The mean ISS score for survivors was 12. Seventeen percent of the acute survivors were critically injured (ISS>15). The critical mortality rate was 8%. There were no later deaths; the dead/wounded ratio was 4.4. Operative treatment was performed for 38% of the patients treated in surgical emergency departments. Conclusion: The bombing attack in Myyrmanni shopping center led to 166 casualties, of whom 66 patients were received at six affiliated hospitals in Helsinki and Uusimaa Area. The critical mortality rate was low. A local disaster plan was implemented. The surgical response was rapid and well coordinated. In a mass casualty disaster not all disaster victims need to go to a trauma center.     

An evaluation of the application procedure for surgical house officership.

The application procedure for surgical house officership was evaluated at 25 university affiliated surgical training programs. Major inadequacies were found with the present system. The prospective house officer often does not receive relevant, up-to-date or useful literature, and interviews and tours were frequently conducted in a haphazard manner. Recommendations are offered to improve the application process and criteria are provided, which should assure adequate levels of information and help the candidate arrive at an appropriate decision with regard to postgraduate training.     

A history of the American Board of Surgery: vignettes from the certifying examination : The Edgar J. Poth Memorial Lecture

The American Board of Surgery was established in 1937 to certify surgeons who through training, experience, and examination meet the highest standards of surgical care. This lecture was given as the Edgar Poth lecture at the April 2015 meeting of the Southwestern Surgical Congress. Dr Poth was a surgical educator from the University of Texas Medical Branch, Galveston who was President of the Southwestern in 1963. The paper presents the history of the founding of the American Board of Surgery, with particular emphasis on the certifying examination—Part 2. Vignettes of occurrences associated with the “Oral” examination are given. The examination has changed substantially from a 2-day event involving an actual surgical procedure to the 90-minute quiz given today. The oral examinations remain an important part in the process of certification of surgeons of the highest quality.     

The surgical therapy for the lower limb varices in day surgery

1775 varicose patients (1318 female, 457 male) with mean age 47.7 years have been operated in One Day Surgery in III Department of General Surgery and in the Phlebology Centre of the University of Siena between June 1 1985 and May 30 1996. 1274 (71.7%) patients underwent internal saphenectomy of which 947 (53.3%) through short stripping, 327 (18.4%) through long stripping, 106 (5.9%) external saphenectomy, 90 (5.1%) revision of the saphenous-femoral junction, 258 (14.5%) phlebectomies; 16 (0.9%) external valvuloplasty sec. Mancin, 31 (1.7%) other operations. All patients were discharged on the same day of operation. The obtained instrumental and clinical results show an improvement of haemodynamics, with 21% varicose residue for incontinence perforating veins on long stripping internal saphenectomy. In their experience in the surgical treatment of varicose veins, the authors affirm that the policy of One Day Surgery is not greatly affected by the surgical technique adopted but more so by the anaestesiological technique used and the clinical condition of the patients.     

Paediatric surgery: trends in UK surgical trainees' operative experience

Aim

This study assesses the effects of the reconfiguration of postgraduate surgical training and changes to work patterns through legislation within UK on the operative experience of trainees completing specialty training in paediatric surgery.

Methods

Data were collected from the consolidation record of operative experience submitted by every candidate sitting the Intercollegiate Specialty Board Examination in Paediatric Surgery in UK from 1996 through 2004. A number of index procedures were chosen as surrogates of the overall operative experience and underwent detailed analysis. These comprised operations performed in the following categories: Neonatal Surgery, General Paediatric Surgery, Paediatric Urology, Paediatric Oncology, and Emergency Paediatric Surgery.

Results

Sixty-three sets of data comprising 12,866 operations were ultimately identified as being suitable for analysis. The average number of operations performed annually by trainees increased over the study period as did the number in each of the operative categories. The number of operations performed with senior assistance or supervision increased over this period by an average of 12.5%. This trend was also evident in emergency surgery where the average number of sample procedures performed by trainees increased by 28% over the study period.

Conclusion

In 1995, reforms to the training grade within UK reduced the time spent in specialist training from a previously unregulated period to 72 months of higher surgical training. Subsequent directives in response to health and safety legislation have further abbreviated the length of time spent at the workplace, initially to 72 hours and more recently to 58 hours per week. This combination has been generally perceived throughout the surgical community as prejudicial to acquisition of clinical and operative competence. This study, however, fails to endorse this perception and suggests to the contrary that perhaps through increased delegation, the volume of training operations is being preserved and that operative training is now better supervised than ever before.     

Below-knee revascularization in patients with critical limb ischemia: long-term comparison of redo vs primary interventions

AIM: The aim of this study was to evaluate the authors' experience in below-knee revascularization in patients with critical limb ischemia, comparing long-term outcomes in primary and secondary interventions. METHODS: From January 2000 to December 2006, 140 consecutive below-knee revascularizations in patients with critical limb ischemia were performed at the Department of Vascular Surgery of the University of Florence (Italy). In 105 patients (75%) a primary intervention was performed (Group 1). Early and long-term results in terms of survival, patency and limb salvage were compared with those obtained in the remaining 35 patients (25%) secondarily operated on in the same period for a late (>30 days) bypass graft thrombosis (Group 2). RESULTS: One patient died in the early postoperative period. Thirty-day thrombosis and amputation rates were poorer in Group 2 than in Group 1 (17.1% and 4.8%, P=0.02; 37.1% and 16.2%, P=0.01, respectively). Mean duration of follow-up was 25.1 months. At 60 months there were no differences between the two groups in terms of survival (90.1% in Group 1 and 90.9% in Group 2; P=NS), primary patency (43.5% in Group 1 and 31.9% in Group 2; P=NS) and secondary patency (48.4% in Group 1 vs 43.8% in Group 2; P=NS). Estimated 60-month limb salvage rate was significantly poorer in Group 2 than in Group 1 (64.1% and 77.7%, respectively; P=0.05). In Group 2 prosthetic graft material significantly affects 60-month limb salvage rate. CONCLUSION: Redo below-knee revascularization in patients with critical limb ischemia provides acceptable long-term results in terms of primary and secondary patency; however, limb salvage appeared to be slightly worse in patients undergone redo surgery.     

The surgical approach to non-neoplastic abdominal pathology in the geriatric patient]

BACKGROUND: The authors evaluate the most suitable approach to be used in elderly patients suffering from non-neoplastic abdominal pathology. METHODS: A retrospective evaluation was made of cases observed over the past two years. Follow-up continued for at least three months after treatment. SETTING: General Surgery 1, Department of Surgical and Anatomic Disciplines, Policlinico, University of Palermo. PATIENTS: A total of 92 patients were treated aged between 65 and 94 years old (mean age 79.5). The most frequently observed pathologies were cholelithiasis and hernia, treated both electively and in emergency. OPERATIONS: 76 patients were treated electively and 16 underwent emergency surgery. Parameters examined: The authors evaluated postoperative progress, morbidity and mortality. RESULTS: Morbidity was equal to 6.5%. Death occurred in three patients, one of whom had been operated a month earlier. CONCLUSIONS: Surgery is considered appropriate in the elderly patient provided an adequate pre-, intra- and postoperative approach is used. The preoperative phase should include a multidisciplinary evaluation to assess surgical risk (ASA and APACHE). During surgery, the most beneficial solution should be found which takes account of the patient's life expectancy; whenever possible, is it advantageous to resort to video-laparoscopy owing to the diagnostic accuracy of this method, as well as the capacity to adjust subsequent surgery whether it is performed using video-assisted laparoscopy or targeted mini-laparotomy. This causes less surgical aggression and therefore a more comfortable postoperative recovery. During the latter phase, vital and biohumoral parameters should be accurately monitored to ensure the prompt recognition of organic collapse and/or metabolic disorders consequent to surgical stress.     

Comparison of histidine-tryptophan ketoglutarate solution and University of Wisconsin solution in prolonged cold preservation of kidney allografts

Although University of Wisconsin (UW) solution is the standard preservation solution for organ transplantation, Histidine-Tryptophan Ketogluatarate (HTK) solution has been increasingly used. This study compared HTK or UW for cold static storage of kidney allografts. In all, 149 renal transplants were performed with cold ischemic times (CI) greater than 16 hr (UW 87, HTK 62) and a subset analysis was performed with CI over 24 hr (HTK 31, UW 38). Data from receiving renal transplant centers focused on delayed graft function (DGF), patient and allograft survival. In CI greater than 16 hr, graft and patient survival were comparable. HTK cohort had lower DGF. In CI greater than 24 hr, there was no difference in patient survival, a trend towards improved graft survival in HTK, and decreased rate of DGF in HTK. This data suggests that UW and HTK have at least similar efficacy in kidney preservation at longer ischemic times.     

Comparison of Histidine-Tryptophan-Ketoglutarate and University of Wisconsin Preservation in Renal Transplantation

Histidine-tryptophan-ketoglutarate (HTK) is replacing University of Wisconsin (UW) solution as the preservation fluid for renal allografts in many centers, but recent large-scale data to support this transition are lacking. We conducted a retrospective analysis of patient and graft outcomes after renal transplantation at our center, comparing 475 consecutive living donor and 317 deceased donor transplants since the adoption of HTK with equal numbers of grafts preserved using UW solution. Data collected included donor and recipient age, race, sex, comorbidities and graft ischemia time. Graft and patient survival, as well as the incidence of delayed graft function (DGF), were studied by Kaplan–Meier and Cox regression analysis. No significant difference was seen in either patient or graft survival. Deceased donor kidneys in the HTK group had a higher incidence of DGF than the UW cohort, whereas this trend was reversed in the case of living donor organs. In multivariate analysis, HTK was associated with a significant risk reduction on the incidence of DGF. Prolonged preservation with HTK compared to UW was not associated with excess risk to the graft or patient. In summary, HTK demonstrated efficacy similar to UW in terms of patient and graft survival.     

Histidine–tryptophan–ketoglutarate solution for organ preservation in human liver transplantation—a prospective multi-centre observation study

Based on experimental work and clinical small studies, histidine–tryptophan–ketoglutarate (HTK) solution was found to be suitable not only for heart and kidney preservation but also for liver preservation. We decided, therefore, to use this preservation solution for clinical liver preservation in a prospective multi-centre trial. Enrolment to the study was from 1996 to 1999 in four European centres, and the results of 214 patients with HTK-preserved organs were analysed. Analysis showed a primary dysfunction (PDF) rate of 8.8%, with a primary non-function (PNF) rate of 2.3% and initial poor function (IPF) in 6.5%. Patient survival rate at 1 year was 83% and 1-year graft survival rate was 80%. In a univariate and a multivariate analysis PDF, early surgical complications and tendentiously severe infections (septicaemia, pneumonia, cholangitis) were identified as independent risk factors for graft and patient survival. Preservation with HTK can be regarded as an established alternative to preservation with University of Wisconsin (UW) solution when preservation times are short. Definitive assessment of the efficacy of preservation solutions requires further prospective randomised clinical trials that compare HTK and UW.     

University of Wisconsin solution versus Celsior solution in clinical pancreas transplantation

INTRODUCTION: This study compared the safety and efficacy of University of Wisconsin solution (UW) and Celsior solution (C) in pancreas transplantation (PTx). METHODS: A retrospective review of 154 PTx performed over a 61-month period included 77 grafts preserved with UW and 77 with C. The two groups were comparable for both donor and recipient characteristics. RESULTS: After a mean cold ischemia time of 624 minutes (range 360 to 945 minutes) for UW versus 672 minutes (range 415 to 1005 minutes) for C (P = NS), no primary endocrine nonfunction occurred. Delayed endocrine function was diagnosed in two grafts in the UW group (2.6%) versus none in the C group (P = NS). After a minimum follow-up of 4 months (mean 26.5 +/- 15.2 months), 22 recipients (UW = 11 vs C = 11; P = NS) required relaparotomy. Overall, 18 pancreata were lost due to either patient death with functioning graft (UW = 4 vs C = 1; P = NS) or graft loss due to other reasons (UW = 8 vs C = 5; P = NS). Actuarial 1- and 5-year patient survival rates were 93.5% and 86.8% for UW compared with 98.7% and 98.7% for C (P = .04). Actuarial graft survival rates at the same times were 88.3% and 75.0% for UW compared with 90.4% and 90.4% for C (P = NS). CONCLUSIONS: Within the range of cold ischemia times reported in this study, UW and C show similar safety and efficacy profiles for PTx.     

Histidine-tryptophan-ketoglutarate versus University of Wisconsin solution in living donor liver transplantation: Results of a prospective study

The grafts obtained from a living donor hepatectomy are perfused on the back table with either University of Wisconsin solution (UW) or histidine-tryptophan-ketoglutarate solution (HTK). The efficacy and safety of these solutions have been studied in cadaveric liver transplantation, however, there is no study comparing the two solutions in adult-to-adult living donor liver transplantation. In this study, UW and HTK were used in the perfusion of right living donor grafts. The grafts were perfused with a predetermined sequence and volume of one of the solutions. Liver biochemistries, complications, and graft and patient survival were analyzed. From January 2001 to September 2002, 30 grafts were alternately perfused with either UW (UW group) or HTK (HTK group). The perfusion was performed first via the artery and then via the portal vein with a predetermined volume. At a mean follow-up of 13 ± 7 months, no significant statistical difference between groups UW and HTK in posttransplantation liver biochemistries, complications, or patient and graft survival (84% and 80%, respectively) was observed. In conclusion, UW and HTK are equally effective and safe in the perfusion of the living donor liver grafts. HTK has a slight practical advantage over UW because it does not need to be flushed away before reperfusion of the graft and is less expensive. (Liver Transpl 2003;9:822-826.)     

Colovaginal anastomosis: A totally unacceptable surgical error

IntroductionThe low anterior rectal resection and double stapling technique are well-established surgical procedures with well-known pitfalls, potential complications, and preventive measures. Colovaginal anastomosis is a surgical error which should not occur.Presentation of caseA 39-year old woman underwent low anterior resection with double stapling technique, for rectal carcinoma in the City Hospital. On the fifth postoperative day she noticed passage of gas and two days later passage of feces from vagina. The surgeons who performed the operation explained to her that it is a normal condition for such modern procedure that is supervised by international educator engaged by the Government. The patient lived with this condition, passage of gas and feces from the vagina and nothing from anus for three months when her oncologist referred her for a second opinion at the University Clinic for Digestive Surgery. The digital examinations revealed a blind rectal stump, and feces in vagina; thus having the patient’s history in mind, we assumed that the patient had a colovaginal anastomosis. Our assumption was confirmed by two succeeding radiological examinations. Initially, water soluble contrast enema was performed to assess the colon, when a clear-cut blind rectal stump was detected. Afterwards, the vaginography revealed a copious flow of contrast material from the vagina toward the sigmoid colon. After a few days, a restorative surgery was done.DiscussionMost of the early postoperative complications are a result of surgical errors.ConclusionWe believe that there is no excuse for such a surgical error and postoperative follow-up.     

Kostenanalyse der Chirurgie des infrarenalen Bauchaortenaneurysmas nach Einführung der Bundespflegesatzverordnung

Purpose. According to the new German Health Care Law (Bundespflegesatzverordnung), hospital payments have been restructured. Services are now refunded by health care insurance companies either by payments for given surgical procedures (Sonderentgelt) and fixed daily refunds or by case-related reimbursements, including all costs of the hospital stay (Fallpauschale). Procedures on infrarenal aortic aneurysms are related to payments for defined surgical procedures. This study was undertaken to show if cost effectiveness can be achieved with this new health care law at a university hospital for both emergency and elective procedures. Methods. During a 2-year period, 141 patients were included in this prospective study. The perioperative data were analyzed. The resulting overall costs as well as the costs of the operation were compared with the health insurance payments. Statistical analysis was undertaken with the Mann-Whitney U test. Results. Cost analysis differentiated according to the criteria emergency (n=26) and elective (n=115) surgery showed a positive balance of the surgical procedure costs in our elective patient group with +300 DM/ patient and a negative balance in the patient group who underwent an emergency procedure of ?3660 DM/patient. In consideration of the overall costs, we found a positive balance of +3788 DM/patient in the elective procedure group and a negative balance of ?12.200 DM/patient in the emergency procedure group. Regarding emergency and elective procedure groups together, a positive balance of 840 DM/patient was achieved. Conclusions. Surgery of infrarenal aortic aneurysms is cost-effective at a university hospital under the new German health care laws. A negative balance in operation costs as well as in the overall costs was only tallied in the emergency procedure group.