Jakub Kenig

Complicated intra-abdominal infections in Europe: a comprehensive review of the CIAO study

The CIAO Study (“C omplicated Intra-A bdominal infection O bservational” Study) is a multicenter investigation performed in 68 medical institutions throughout Europe over the course of a 6-month observational period (January-June 2012).Patients with either community-acquired or healthcare-associated complicated intra-abdominal infections (IAIs) were included in the study.2,152 patients with a mean age of 53.8 years (range: 4–98 years) were enrolled in the study. 46.3% of the patients were women and 53.7% were men. Intraperitoneal specimens were collected from 62.2% of the enrolled patients, and from these samples, a variety of microorganisms were collectively identified.The overall mortality rate was 7.5% (163/2.152).According to multivariate analysis of the compiled data, several criteria were found to be independent variables predictive of patient mortality, including patient age, the presence of an intestinal non-appendicular source of infection (colonic non-diverticular perforation, complicated diverticulitis, small bowel perforation), a delayed initial intervention (a delay exceeding 24 hours), sepsis and septic shock in the immediate post-operative period, and ICU admission.Given the sweeping geographical distribution of the participating medical centers, the CIAO Study gives an accurate description of the epidemiological, clinical, microbiological, and treatment profiles of complicated intra-abdominal infections (IAIs) throughout Europe.

Complicated Intra-Abdominal Infections in a Worldwide Context: An Observational Prospective Study (CIAOW Study)

Despite advances in diagnosis, surgery, and antimicrobial therapy, mortality rates associated with complicated intra-abdominal infections remain exceedingly high. The World Society of Emergency Surgery (WSES) has designed the CIAOW study in order to describe the clinical, microbiological, and management-related profiles of both community- and healthcare-acquired complicated intra-abdominal infections in a worldwide context. The CIAOW study (Complicated Intra-Abdominal infection Observational Worldwide Study) is a multicenter observational study currently underway in 57 medical institutions worldwide. The study includes patients undergoing surgery or interventional drainage to address complicated intra-abdominal infections. This preliminary report includes all data from almost the first two months of the six-month study period. Patients who met inclusion criteria with either community-acquired or healthcare-associated complicated intra-abdominal infections (IAIs) were included in the study. 702 patients with a mean age of 49.2 years (range 18–98) were enrolled in the study. 272 patients (38.7%) were women and 430 (62.3%) were men. Among these patients, 615 (87.6%) were affected by community-acquired IAIs while the remaining 87 (12.4%) suffered from healthcare-associated infections. Generalized peritonitis was observed in 304 patients (43.3%), whereas localized peritonitis or abscesses was registered in 398 (57.7%) patients.The overall mortality rate was 10.1% (71/702). The final results of the CIAOW Study will be published following the conclusion of the study period in March 2013.

A proposal for a CT driven classification of left colon acute diverticulitis

Computed tomography (CT) imaging is the most appropriate diagnostic tool to confirm suspected left colonic diverticulitis. However, the utility of CT imaging goes beyond accurate diagnosis of diverticulitis; the grade of severity on CT imaging may drive treatment planning of patients presenting with acute diverticulitis.The appropriate management of left colon acute diverticulitis remains still debated because of the vast spectrum of clinical presentations and different approaches to treatment proposed. The authors present a new simple classification system based on both CT scan results driving decisions making management of acute diverticulitis that may be universally accepted for day to day practice.

Screening for frailty among older patients with cancer that qualify for abdominal surgery

OBJECTIVE The Geriatric Assessment (GA) is an established method for evaluating and optimizing diagnostic and treatment plans. However, it requires experience and is time-consuming. Therefore, a variety of screening methods have been developed. The aim of this study was to compare their accuracy for predicting frailty among older patients with cancer qualified for abdominal surgery based on comparison to the GA. MATERIAL AND METHODS One hundred and thirty five consecutive patients ≥65years of age were prospectively enrolled. The diagnostic performance of eight screening tests was evaluated: The Vulnerable Elderly Survey (VES-13), Triage Risk Screening Tool (TRST), Geriatric 8 (G8), Groningen Frailty Index (GFI), abbreviated Comprehensive Geriatric Assessment (aCGA), Rockwood, Balducci and Fried score. RESULTS The prevalence of frailty as diagnosed by the GA was 73%. Screening methods identified frail patients in 40-75.5% of cases. The sensitivity and specificity of these tests in predicting frailty were 52%-97% (Fried score-G8) and 44-100% (G8-Rockwood score), respectively. The positive and negative predictive values were 82-100% (Balducci-Rockwood) and 43-84% (TRST-G8), respectively. Age significantly influenced the predictive value of the screening tests whereas gender and type of cancer did not. CONCLUSION At present, there is no universal screening test that adequately identifies frailty in at risk older patients. The results of this study showed that the aCGA and G8 were the best screens for older patients with cancer that qualified for elective abdominal surgery; the G8 had the highest sensitivity and negative predictive value and the aCGA was a good overall assessment tool.

Doppler guided haemorrhoidal arterial ligation with recto‐anal‐repair (RAR) for the treatment of advanced haemorrhoidal disease

Objective  A modification of Doppler guided haemorrhoidal artery ligation (DGHAL) to include the addition of recto‐anal repair is reported. Preliminary results of function and safety of third and fourth degree haemorrhoidals are given.

Six screening instruments for frailty in older patients qualified for emergency abdominal surgery.

INTRODUCTION The literature on geriatric assessment in emergency admitted patients is scarce, particularly there are no studies regarding the efficacy of frailty screening tests among patients qualified for emergency abdominal surgery. Therefore, the aim of this study was to compare the diagnostic accuracy of six screening instruments in this group of patients. MATERIAL AND METHODS The diagnostic accuracy of the Vulnerable Elderly Survey (VES-13), Triage Risk Screening Tool (TRST), Geriatric-8 (G8), Groningen Frailty Index (GFI), Rockwood, Balducci score was evaluated in a prospective group of 184 consecutive patients ≥65 years of age. Outcome measure was sensitivity, specificity, positive and negative predictive values of these tests in prediciting 30-day postoperative outcome. RESULTS Patients mean age was 76.9±5.8 (65-100) years. The prevalence of frailty, as diagnosed by screening methods, was: 50-79.9% (Balducci/Rockwood-G8). Multivariate analyses have identified all screening tests apart from Rockwood and TRST as independent factors that predict postoperative outcome. The sensitivity and negative predictive value in case of postoperative mortality were 60-91% (Rockwood-VES-13) and 30-93% (GFI-VES13). In case of postoperative morbidity they were 52-85% (Rockwood-VES-13 and G8) and 44-70% (Rockwood-VES-13), respectively. CONCLUSION Considering these results, it is possible to perform safely and efficiently screening test for frailty in older patients qualified for emergency abdominal surgery. The VES-13 was the best screening instrument; it had the highest sensitivity and negative predictive value both for the postoperative mortality and morbidity. This instrument may offer physicians additional information that can be used in the postoperative optimisation of the treatment of these high-risk group of patients.

World society of emergency surgery study group initiative on Timing of Acute Care Surgery classification (TACS)

Timing of surgical intervention is critical for outcomes of patients diagnosed with surgical emergencies. Facing the challenge of multiple patients requiring emergency surgery, or of limited resource availability, the acute care surgeon must triage patients according to their disease process and physiological state. Emergency operations from all surgical disciplines should be scheduled by an agreed time frame that is based on accumulated data of outcomes related to time elapsed from diagnosis to surgery. Although literature exists regarding the optimal timing of various surgical interventions, implementation of protocols for triage of surgical emergencies is lacking. For institutions of a repetitive triage mechanism, further discussion on optimal timing of surgery in diverse surgical emergencies should be encouraged. Standardizing timing of interventions in surgical emergencies will promote clinical investigation as well as a commitment by administrative authorities to proper operating theater provision for acute care surgery.

WSES guidelines for emergency repair of complicated abdominal wall hernias

Emergency repair of complicated abdominal hernias is associated with poor prognosis and a high rate of post-operative complications.A World Society of Emergency Surgery (WSES) Consensus Conference was held in Bergamo in July 2013, during the 2nd Congress of the World Society of Emergency Surgery with the goal of defining recommendations for emergency repair of abdominal wall hernias in adults. This document represents the executive summary of the consensus conference approved by a WSES expert panel.

Complicated intra-abdominal infections in Europe: preliminary data from the first three months of the CIAO Study

The CIAO Study is a multicenter observational study currently underway in 66 European medical institutions over the course of a six-month study period (January-June 2012).This preliminary report overviews the findings of the first half of the study, which includes all data from the first three months of the six-month study period.Patients with either community-acquired or healthcare-associated complicated intra-abdominal infections (IAIs) were included in the study.912 patients with a mean age of 54.4 years (range 4–98) were enrolled in the study during the first three-month period. 47.7% of the patients were women and 52.3% were men. Among these patients, 83.3% were affected by community-acquired IAIs while the remaining 16.7% presented with healthcare-associated infections. Intraperitoneal specimens were collected from 64.2% of the enrolled patients, and from these samples, 825 microorganisms were collectively identified.The overall mortality rate was 6.4% (58/912). According to univariate statistical analysis of the data, critical clinical condition of the patient upon hospital admission (defined by severe sepsis and septic shock) as well as healthcare-associated infections, non-appendicular origin, generalized peritonitis, and serious comorbidities such as malignancy and severe cardiovascular disease were all significant risk factors for patient mortality.White Blood Cell counts (WBCs) greater than 12,000 or less than 4,000 and core body temperatures exceeding 38°C or less than 36°C by the third post-operative day were statistically significant indicators of patient mortality.

Definition of the rectum and level of the peritoneal reflection – still a matter of debate?

Introduction Pathological lesions of the rectum are common and their management requires detailed knowledge of pelvic anatomy. There has been considerable debate as to the definition of the rectum and the variability of the level of the peritoneal reflection. The lack of a clear consensus was proven in the research by McCullen et al. regarding the current pattern of practice for the investigation of primary rectal cancer by general surgeons. Aim To carry out bibliographic research on the definition of the rectum and level of the peritoneal reflection. Material and methods A web-based published literature search of PubMed, Ovid Medline, Science Direct and Springer was made. Results The paper presents the current definitions of proximal and distal margin of the rectum and level of peritoneal reflection based not only on the results of tests on cadavers but also on living humans. Conclusions The results of tests on living humans allow more accurate qualification of patients for local excision, which is particularly important for patients with colorectal cancer.