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BACKGROUND: Coronavirus disease (COVID-19) has impacted both emergency and elective surgical management owing to its highly infectious nature and the shortage of personal protective equipment. This study aimed to review the outcomes of emergency surgical conditions and trauma during the pandemic lockdown. MATERIAL AND METHODS: We retrospectively reviewed and collected data from patients who attended the Acute Care Surgery Service from 1st April to May 31st, 2020 during Thailand's COVID-19 pandemic lockdown. We separated staff and performed preoperative COVID-19 swab testing on all patients to assess the requirement for personal protective equipment. Compared with previous years of service, of 2018 and 2019. Preoperative COVID-19 testing was performed using multiplex and manual RT-PCR. Morbidity and mortality, consultation time, and waiting time to surgery were analyzed. RESULTS: A total of 61 patients were enrolled. The average age of patients was 53.8 years. The average consultation time, waiting time to surgery, and surgical duration were 10 min, 660 min, and 88.77 min, respectively. The average time taken to obtain the preoperative COVID-19 test result was 227.26 min. The morbidity and mortality rates were 9.84% and 1.64%, respectively. Compared with the same period in 2018 and 2019, consultation time was significantly faster (10 min; p = 0.033) and waiting time to surgery was significantly longer (660 min, respectively; p = 0.011). Morbidity and mortality between pandemic period and the previous year of service were not significantly different. No medical workers were infected with COVID-19. CONCLUSIONS: During the COVID-19 pandemic, optimal triage of emergency patients is key. Waiting for preoperative COVID-19 swab testing in emergency case is safe and results in good outcomes. Although the waiting time to surgery was significantly longer owing to the time required to receive preoperative COVID-19 swab results, morbidity and mortality rates were unaffected.
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BACKGROUND: Acute Care Surgery (ACS) is a rapid response system in emergency surgical conditions. The patients who over 60 year-old have numerous factors associated with high mortality and morbidity in emergency colorectal surgery. We aimed to identify potentially preventable risk factors, to improve patients' outcomes. METHODS: A retrospective review of patients age over 60 year-old undergoing emergency colorectal surgery in the ACS service from August 1, 2017 through November 30, 2019. RESULTS: Ninety-two patients were analyzed, average age 72.41 years. The most common diagnosis was complicated colorectal cancer (76, 83.52%) with locations on the right (37, 41.51%), left (35,39.33%), and rectum (17, 19.10%). Clinical presentations were obstruction without perforation (61, 67.03%), perforation (25, 27.17%), and ischemia (2, 2.17%). Overall mortality was 6.52%. Cause of death included septic shock (3, 50%); respiratory failure (3, 50%); and pulmonary embolism (1, 16.67%). Morbidity from surgical and medical complications were 41.30% and 26.08%, respectively. For all causes, operations included resection with primary anastomosis (62, 71.26%); Hartmann's operation (11, 12.64%); and loop colostomy (12, 13.79%). Average operative time was 159.86 min. In emergency colorectal surgery, pre-existing heart disease, clinical perforation, and ventilator dependency increased risk of death 7.6-, 16.5-, and 0.08-fold, respectively. CONCLUSION: Clinical perforation leads to sepsis and septic shock in older patients, this may be modifiable to improve mortality by developing an early, rapid, protocol-driven surgical sepsis fast-track process. Ventilator dependency is potentially modifiable with postoperative advanced surgical critical care. The non-modifiable risk factor of co-morbid heart disease might be improved by postoperative advanced critical care for close monitoring.
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BACKGROUND: Major pelvic fractures are often associated with intra-abdominal organ injuries. Considering patients' hemodynamic status, Focused Assessment with Sonography for Trauma (FAST) can facilitate decision-making for abdominal exploration. Non-therapeutic exploratory laparotomy from pelvic fractures should be avoided. Aim of this study is to determine the accuracy of FAST in diagnosing significant intraabdominal hemorrhage that leads to determine whether or not to pursue therapeutic abdominal exploration in patients with major pelvic fractures. MATERIAL AND METHODS: We systematically reviewed the PubMed and SCOPUS databases from 2009 to 2019 and also using a retrospective review of patients admitted to the Acute Care Surgery service from 2016 to 2019. We performed a meta-analysis by using a random effects model. RESULTS: A total 677 patients were analyzed, 28 cases from our hospital. Mean patient age was 40.8 years. Leading mechanism of injury were motor vehicle collision (44.72%), fall from height (13.41%), and motorcycle collision (13.69%). Average injury severity score (ISS) was 32.5 (range: 24.1-50), and overall mortality rate was 11.65%. The pooled sensitivity, specificity, and accuracy of FAST to identify significant intra-abdominal hemorrhage was 79%,90%, and 93%, respectively (95% confidence interval: 89%-94%). Meta-regression revealed no significant correlation between injury severity score and the accuracy of FAST. CONCLUSION: Our meta-analysis revealed that FAST in major pelvic fracture accurately detected significant intra-abdominal hemorrhage. Using FAST in the presence of unstable hemodynamics, we can decide to perform abdominal exploration with the expectation of finding significant intra-abdominal hemorrhage require surgically control.
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BACKGROUND: Blunt force injuries in patients with preexisting kidney disease account for 19% of all kidney injuries, suggesting that diseased kidneys are more vulnerable than normal kidneys. When a horseshoe kidney (a rare anomaly: prevalence of 0.2%) is injured, treatment is challenging, especially when nonoperative management is desired. In high-grade blunt force normal kidney injury, nonoperative management has high succession rate (94.8%) with kidney-related complication (13.6%). Surgical reconstruction and preservation of a damaged horseshoe kidney is difficult because of variations in its vascular anatomy. We report successful nonoperative management of a blunt horseshoe kidney injury with active bleeding and review previous outcomes and complications. Case Presentation. A 57-year-old man had a head-on collision motorcycle road traffic accident. On arrival, blood pressure was 90/60 mmHg, pulse rate 140 bpm, and clear yellow urine output 200 ml. The patient was transiently responsive to fluid and blood component. Whole body computed tomography showed a high-volume retroperitoneal hematoma and multiple-lacerated lower pole of the kidney, compatible with preexisting horseshoe kidney disease with active contrast-enhanced extravasation from the accessory right renal artery. Embolization was performed. Renal function, transiently impaired after embolization, normalized on day 3. An infected hematoma found on day 7 was successfully controlled with antibiotics. His recovery was uneventful. At the 6-month follow-up, his serum creatinine level had returned to normal. The average age of blunt force horseshoe kidney injury is 31.75 years and occurred more common in male (87.5%). CONCLUSION: Diseased horseshoe kidneys are prone to injury even with low-velocity impact such as a road traffic accident speed < 15 km/h. Embolization is considered the first choice for management, with its high clinical success rate leading to less need for surgical repair. Not removing a hematoma is likely to result in complications. If embolization fails to stop bleeding, life-saving surgical exploration should be mandated.