Colopleural fistula, a rare pathological connection between the colon and the pleural cavity, is associated with high mortality and typically requires surgical management. We report the case of a 63-year-old man with colopleural fistula secondary to diverticulitis that progressed to a lung abscess. He was transferred with sepsis and metabolic acidosis in the setting of pneumonia and a left lower lobe (LLL) abscess. During intravenous antibiotic therapy at the referring hospital, he developed uncontrolled epistaxis requiring additional management. His medical history included diabetes mellitus, atrial fibrillation, and prior repair of a perforated gastric ulcer. Despite 5 days of antibiotic therapy, the infection persisted. On hospital day 6, contrast-enhanced computed tomography revealed a fistulous tract between the LLL and the splenic flexure; colonoscopy confirmed diverticulosis with a fistulous communication. Surgical management included left hemicolectomy, adhesiolysis, video-assisted thoracoscopic LLL resection, and diaphragmatic repair. Postoperatively, an intra-abdominal abscess required reoperation, and gastric ulcer bleeding was treated endoscopically. The patient was discharged without further complications. Colopleural fistula should be suspected in cases of lung abscess that are unresponsive to antibiotics; early contrast-enhanced imaging and timely surgical intervention are essential to optimize outcomes.
Purpose Post–intensive care syndrome (PICS) has traditionally been conceptualized as comprising physical, cognitive, and psychological impairments. However, emerging evidence highlights additional domains, including fatigue, sleep disturbance, pain, social participation, and self-management. This COSMIN-based scoping review aimed to map available PICS assessment instruments, evaluate their psychometric and methodological quality, and propose future directions for the development of comprehensive multidomain tools. Methods Following the COSMIN guideline, JBI methodology, and the PRISMA-ScR framework, we systematically searched PubMed, Embase, the Cochrane Library, CINAHL, and RISS for studies published between January 2012 and June 2024. Two reviewers independently screened studies and extracted data. Psychometric properties, including content validity, structural validity, internal consistency, reliability, measurement error, and responsiveness, were evaluated according to COSMIN criteria. Results Twenty-eight studies describing 20 PICS-related instruments were identified. Single-domain measures were used more frequently than multidomain instruments. Multidomain tools demonstrated acceptable internal consistency; however, evidence for confirmatory factor analysis, measurement invariance, test-retest reliability, and measurement error was limited. Several patient-experienced domains, including fatigue, sleep disturbance, pain, and social participation, were only partially represented across instruments, thereby limiting the comprehensive assessment of recovery trajectories. Conclusion Despite growing recognition of PICS, the use of validated assessment tools in clinical practice remains inconsistent, and existing instruments do not adequately capture the full spectrum of physical, cognitive, psychological, and social outcomes. Evidence supporting their psychometric robustness is also limited. A patient-centered, multidomain instrument with strong methodological foundations is urgently needed to enable accurate monitoring, guide timely interventions, and improve long-term outcomes among intensive care unit survivors.
Acute corrosive injury most commonly affects the upper aerodigestive tract and may necessitate emergency surgery in a minority of cases when transmural necrosis develops. The present case manifested with multiorgan dysfunction and subsequently deteriorated, developing acute peritoneal signs that required emergency surgical intervention. Intraoperatively, the distal thoracic esophagus and proximal stomach appeared unexpectedly viable; however, there was extensive transmural circumferential gangrene involving the distal stomach, duodenal C-loop, and proximal jejunum. A surgical decision between pancreatoduodenectomy and pancreas-sparing duodenectomy was required. Given the patient’s poor general condition and hemodynamic instability, pancreas-sparing duodenectomy with ampullo-jejunal anastomosis was performed. Although the postoperative course was complicated, the patient gradually recovered and was discharged on an oral liquid diet. This report outlines the complexities associated with such atypical presentations and emphasizes the importance of individualized surgical decision-making and multidisciplinary postoperative care in the comprehensive management of acute corrosive injuries.
Fournier gangrene (FG) is an uncommon but life-threatening condition characterized by rapidly spreading necrotizing fasciitis of the perianal, genital, or perineal regions and accounts for less than 0.02% of hospital admissions, with a reported fatality rate of 20% to 30%. Early diagnosis and prompt multidisciplinary management are essential for achieving optimal outcomes. A 63-year-old man presented with swelling in the right scrotal region. He underwent surgical incision and drainage followed by negative pressure wound therapy. Despite the severity of the presentation, the patient’s prognosis was favorable. This case highlights the risk of misdiagnosing FG in the outpatient setting when initial symptoms resemble benign scrotal conditions and underscores the importance of rapid intervention. The involvement of a clinical pharmacist may enhance patient care by supporting the implementation of an optimized treatment strategy for FG.
Sigmoid volvulus involves the axial rotation of a distended sigmoid colon around its mesenteric axis, obstructing venous and arterial blood flow. This obstruction leads to progressive bowel ischemia, tissue necrosis, and, if not promptly addressed, an increased risk of perforation. In this case series, involving six patients with sigmoid volvulus, all were managed by exploratory laparotomy, consisting of detorsion, resection of the affected colon segment, and anastomosis. Postoperative recovery was generally uneventful, with normal bowel function restored by day 3 in all cases. Patients were discharged on day 10, and no significant complications occurred. Sigmoid volvulus is a common surgical emergency in older patients and is effectively managed by resection and primary anastomosis using GIA staplers. This surgical approach ensures excellent outcomes, minimal complications, and a low mortality rate.
Purpose Ventilator-associated pneumonia (VAP) is a frequent complication among critically ill patients with major trauma. We aimed to develop and evaluate a multi-input deep learning model that integrates early clinical data and chest radiographs to predict VAP in mechanically ventilated trauma patients. Methods We retrospectively analyzed patients aged ≥16 years with an Injury Severity Score ≥16 who were admitted to a level I trauma center intensive care unit and required mechanical ventilation for more than 2 days. VAP was defined by new or progressive infiltrates within the first week or documented pneumonia with positive microbiological findings. Selected clinical variables were processed using an artificial neural network, and early chest radiographs were analyzed using a ResNet50-based convolutional neural network with long short-term memory layers. Clinical and imaging features were integrated into a multi-input neural network and evaluated using a held-out test dataset. Results Among 491 patients, 147 (29.9%) developed VAP. In the test dataset, the integrated model achieved a sensitivity of 0.92, a negative predictive value of 0.97, and an area under the receiver operating characteristic curve of 0.84. Conclusion A multi-input deep learning model that combined early clinical variables with chest radiographs demonstrated high sensitivity and negative predictive value for predicting VAP in patients with major trauma.
Purpose Although several studies of preperitoneal pelvic packing (PPP) have reported a hemostatic effect in patients with pelvic fractures, the presence of packed surgical tapes may provoke inflammation or infection. In Korean institutions, the delta neutrophil index (DNI) is currently used as a clinical biomarker for identifying sepsis and predicting prognosis. Therefore, this study aimed to evaluate the usefulness of DNI in pelvic fracture patients who underwent PPP. Methods We retrospectively reviewed 36 hemodynamically unstable patients who underwent PPP between May 2014 and December 2018 at Wonju Severance Christian Hospital. To evaluate differences in postoperative DNI patterns between survivors and nonsurvivors, repeated-measures analysis of variance was performed. Results Eight patients died, and 16 patients developed PPP-related complications. Packed surgical tapes were maintained for a mean of 46.3 hours. Compared with survivors, nonsurvivors had significantly higher DNI values on postoperative day (POD) 2 (5.3% [range, 0%–40.2%] vs. 36.0% [range, 5.4%–70.2%], P<0.001) and POD 3 (2.6% [range, 0%–16.3%] vs. 29.9% [range, 1.2%–64.2%], P<0.001). The overall pattern of DNI change over time differed significantly between survivors and nonsurvivors (P=0.001). In addition, patients with PPP-related complications exhibited a significantly smaller decrease in DNI between POD 1 and POD 2 compared with those without complications (–1.6% [range, −7.8% to 58.9%] vs. –4.5% [−46.8% to 31.6%], P=0.048). Conclusion Postoperative DNI may serve as a clinical indicator for predicting mortality and complications in pelvic fracture patients who have undergone PPP.
A 66-year-old man presented with diabetic ketoacidosis due to new-onset type 1 diabetes mellitus following recent immunotherapy with durvalumab for lung cancer. Imaging revealed incidental pneumatosis intestinalis and elevated lactate levels in the setting of a benign abdominal examination. Mesenteric ischemia was later confirmed during surgical exploration, necessitating multiple operations and repeat bowel resections. The bowel was left in discontinuity with temporary abdominal closure, and the patient was admitted to the intensive care unit. Ultimately, the course was fatal due to insufficient viable bowel length to sustain life. This case highlights two rare but critical immune-mediated adverse effects likely associated with the recent initiation of durvalumab, a programmed death ligand 1 (PD-L1) inhibitor, for lung cancer treatment. The development of new autoimmunity or coagulopathy in patients recently treated with PD-L1 immunotherapy for cancer should prompt consideration of a potential causal relationship and early multidisciplinary discussion involving surgery and hematology-oncology.
Purpose: Pathologic pneumatosis intestinalis (PI) generally requires surgery, but diagnostic uncertainty risks negative laparotomy. This study aimed to determine its incidence, identify distinguishing variables, assess radiographic accuracy, and validate a five-factor algorithm.Methods: This multihospital, single health system retrospective cohort study analyzed electronic health record encounters with radiographic pneumatosis to assess incidence, imaging concordance, and five-factor score performance. Secondary outcomes included differences at presentation, operative management, time to surgery, and mortality. Pearson chi-square, Fisher exact, and Wilcoxon rank sum tests compared categorical and continuous variables; confusion matrices assessed imaging concordance. Statistical significance was defined as P<0.05.Results: Of 252 cases, 90 (35.7%) involved pathologic PI. Compared with benign PI, pathologic PI was associated with abdominal pain (76.7% vs. 58.0%, P=0.003), tenderness (70.0% vs. 52.5%, P=0.008), vasopressor use (21.1% vs. 5.6%, P<0.001), lactate ≥2.0 mmol/L (P=0.011), portal venous gas (48.9% vs. 32.1%, P=0.009), in-hospital mortality among operative cases (42.2% vs. 17.4%, P=0.004), and higher median aspartate aminotransferase level (36 U/L vs. 29 U/L, P=0.044), white blood cell count (13.8×103/µL vs. 11.7×103/µL, P=0.024), and neutrophil to lymphocyte ratio (13.6 vs. 8.5, P<0.001). Negative laparotomy occurred in 46 benign cases (28.4%). Computed tomography (CT) correctly localized 97.9% of cases with and 83.7% without small bowel involvement, and 76.4% of cases with and 97.1% without colonic involvement. Corresponding positive and negative predictive values were 87% and 97% for the small bowel and 98% and 72% for the colon, respectively. Among 198 complete cases, 89 (44.9%), 49 (24.7%), 33 (16.7%), and 27 (13.6%) were classified as low, intermediate, high, and very high risk, with observed pathologic PI rates of 26%, 47%, 39%, and 56%, respectively.Conclusion: Pathologic PI and negative laparotomy were common. Several clinical, laboratory, and CT findings distinguished pathologic from benign PI. CT localization was generally more concordant with operative findings in the small bowel than in the colon. The five-factor score poorly predicted pathologic PI.
Purpose: Delirium is common among mechanically ventilated intensive care unit (ICU) patients and is associated with adverse outcomes. Although opioid analgesia is central to sedation management, its effect on delirium remains uncertain. This study compared delirium outcomes between sufentanil- and fentanyl-based analgesia in mechanically ventilated surgical ICU patients.Methods: In this prospective, multicenter, randomized exploratory trial conducted at three tertiary hospitals, adults requiring invasive mechanical ventilation and continuous opioid-based analgesia were randomized at enrollment in a 1:1 ratio to receive sufentanil or fentanyl. Delirium was assessed at least twice daily using the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). The primary outcome was delirium incidence during the ICU stay. Secondary outcomes included delirium duration, prolonged delirium (≥3 days), and other clinical outcomes. Delirium-related analyses were performed in a modified intention-to-treat population.Results: A total of 252 patients were screened for eligibility: 217 were randomized to sufentanil (n=120) or fentanyl (n=97), and 199 were evaluable for delirium outcomes. Delirium occurred in 53 of 113 patients (46.9%) in the sufentanil group and 51 of 86 patients (59.3%) in the fentanyl group (relative risk for fentanyl vs. sufentanil, 1.26; 95% confidence interval [CI], 0.97–1.64; P=0.083). Delirium duration was shorter in the sufentanil group than in the fentanyl group (1.9±3.2 days vs. 2.9±3.9 days, P=0.034), and prolonged delirium (≥3 days) was less frequent (20.4% vs. 34.9%, P=0.022). In an exploratory multivariable analysis, opioid type was not significantly associated with delirium occurrence (adjusted odds ratio [aOR], 1.65; 95% CI, 0.88–3.09; P=0.118). Among patients who developed delirium, fentanyl use was associated with prolonged delirium (aOR, 2.35; 95% CI, 1.00–5.48; P=0.049). Other major clinical outcomes were comparable between the groups.Conclusion: Overall delirium incidence did not differ significantly between sufentanil- and fentanyl-based analgesia. However, secondary analyses suggested that delirium duration may be shorter with sufentanil.Trial Registration: Registered in the Clinical Research Information Service (CRIS No. PRE20260212-006).
Postoperative pneumoperitoneum after intraperitoneal procedures, such as laparoscopic surgery, is common and often clinically insignificant because it usually reflects residual free air. In contrast, benign pneumoperitoneum after cardiac surgery is extremely rare and may lead to unnecessary abdominal exploration if it is misinterpreted. We report the case of a 50-year-old woman who developed massive pneumoperitoneum 48 hours after drain removal following uncomplicated coronary artery bypass grafting (CABG). Despite concerning radiographic findings, she remained hemodynamically stable and had a benign abdominal examination. Contrast-enhanced abdominal computed tomography showed no evidence of gastrointestinal perforation. The pneumoperitoneum was attributed to air entry through the drain tract and was managed conservatively, with gradual resolution. Delayed pneumoperitoneum after CABG can occur in the absence of gastrointestinal perforation. Awareness of this rare but benign entity is important to avoid unnecessary surgical intervention.
The Heimlich maneuver is a useful technique for rescuing patients with airway obstruction, but improper application can cause serious complications. We report a case of a 70-year-old man who underwent the Heimlich maneuver after a food bolus became lodged in his throat while he was eating. Because inappropriate sternal compressions were performed, the obstructing foreign body was not removed at the scene; instead, it was extracted during endotracheal intubation in the emergency department. The patient also developed flail chest as a result of the chest compressions and required conservative management with hospitalization for more than 60 days. This case highlights that caregivers may know of the Heimlich maneuver but may not clearly understand the proper technique. Proper education and training in this lifesaving procedure are therefore essential.
A 78-year-old man developed lower abdominal pain during antibiotic treatment for pneumonia and was admitted to the intensive care unit because of hemodynamic instability. Contrast-enhanced computed tomography revealed edematous changes extending from the ascending colon to the rectum, ascites, and increased density of the surrounding mesenteric fat. Blood tests showed a severe inflammatory response, acute renal failure, and metabolic acidosis, and the patient required continuous vasopressor administration for hemodynamic instability. Clostridioides difficile (CD) antigen and toxin were also detected, leading to a diagnosis of fulminant CD enterocolitis. Because colonic necrosis was suspected, exploratory laparotomy was performed. Operative findings showed no ischemic changes or wall thinning. The colon was preserved, and diverting loop ileostomy with colonic lavage was performed. Although total colectomy is the standard surgical treatment for fulminant CD enterocolitis, this case was successfully managed with ileostomy and colonic lavage.
Purpose This study aimed to examine the associations of resilience and social support with multidimensional quality of life (QoL) among family caregivers of patients with traumatic brain injury (TBI). Methods This single-center, cross-sectional descriptive study used questionnaire data collected at a regional trauma center in Korea. Family caregivers of patients with TBI (n=122) were recruited by convenience sampling. The questionnaires assessed participants’ general characteristics, resilience, perceived social support, and QoL. Results Multiple regression analysis showed that higher resilience was associated with greater QoL burden in the vigilance, emotional suppression, and feeling trapped domains. In contrast, higher social support was associated with lower QoL burden in the strain, anxiety, emotional suppression, feeling trapped, feeling of loss–self, and family disruption domains, but with greater QoL burden in the feeling of loss–person with TBI domain. Conclusion Resilience and social support were associated with multidimensional QoL among family caregivers of patients with TBI. Strategies to improve caregiver well-being should include targeted psychological support and interventions that strengthen resilience within existing social support systems.
Purpose Acute appendicitis is the most common abdominal surgical emergency worldwide, but hospital-based surgical case volume and disease severity continue to vary over time. Regional differences, the COVID-19 pandemic, and changes in surgical management indicate the need for updated local data. Methods We conducted a retrospective study of all patients who underwent appendectomy for acute appendicitis at Nhan dan Gia Dinh Hospital, a tertiary referral hospital in Ho Chi Minh City, Vietnam, between January 2019 and July 2025. Data were extracted from electronic medical records and included demographic characteristics, disease severity, operative approach, and operative time. Temporal patterns were analyzed by year, month, and time of day. Results A total of 7,768 patients were included. Uncomplicated appendicitis accounted for most cases, and patients with complicated appendicitis were older than those with uncomplicated disease. Female patients constituted a slight majority. Overall case numbers declined markedly in 2021, coinciding with the peak of the COVID-19 pandemic, and then stabilized. Seasonal variation was observed. Laparoscopy was the predominant operative approach, accounting for 99% of cases. The mean operative time was 76 minutes. Nighttime operations were associated with slightly longer operative times overall than daytime operations (77.1 minutes vs. 74.5 minutes), including among patients with peritonitis. Conclusion Over 7 years, hospital-based surgical case volume for acute appendicitis declined, whereas the proportion of complicated cases remained stable. Temporal fluctuations indicate dynamic changes in case numbers. Laparoscopy remained the predominant approach, reflecting sustained use of minimally invasive surgery.
This case report describes the diagnosis and treatment of a 75-year-old woman who presented to the emergency department with acute abdomen. Preoperative diagnostic evaluation suggested acute acalculous cholecystitis. Because the differential diagnosis included cholecystitis, pancreatitis, gastritis, duodenal ulcer, and other causes of acute abdomen, and because the patient did not respond to conservative management, exploratory laparoscopy was performed. Intraoperatively, gallbladder volvulus with necrosis was identified. Prompt laparoscopic cholecystectomy resolved the patient’s condition and prevented complications such as perforation. This case highlights the importance of timely surgical evaluation and treatment to prevent serious complications, including gangrene and diffuse peritonitis.
Robotic surgery is an emerging modality in acute care surgery, which encompasses emergency general surgery (EGS), trauma, and critical care. Interest in robotic approaches has increased amid rising demand for timely, efficient surgical care. This narrative review summarizes current evidence on robotic EGS, with a focus on perioperative outcomes, feasibility, and future directions. A broad review of recent systematic reviews, large-scale cohort studies, and institutional experiences was conducted to assess the use of robotic surgery in emergency general surgical procedures, including cholecystectomy, gastrointestinal emergencies, hernia repair, and appendectomy. Available retrospective evidence suggests that robotic EGS is generally feasible and is associated with perioperative outcomes comparable to those of laparoscopic surgery. Some studies have reported shorter hospital stays or lower conversion rates; however, operative times and costs tend to be higher. Safety concerns, including a potential increase in bile duct injury during acute cholecystectomy, require further evaluation. Most existing studies are retrospective and based in the United States, which limits generalizability. Robotic approaches in EGS show potential but remain insufficiently validated. High-quality prospective and randomized studies are needed to assess clinical effectiveness, cost-effectiveness, and appropriate indications across diverse healthcare settings. Broader adoption will depend on rigorous evaluation, lower costs, and effective integration into existing emergency surgical workflows.
Penetrating neck trauma involving the aerodigestive tract is a life-threatening emergency. We report a case of an 18-year-old male patient with a zone II cervical wound that caused complete hypopharyngeal transection and a thyroid cartilage fracture. Initial airway control was achieved by direct translaryngeal intubation through the wound, followed by bilateral chest tube placement for pneumothoraces that developed after positive pressure ventilation. Surgical management included tracheostomy, primary hypopharyngeal and laryngeal reconstruction, and vascular control. The postoperative course was complicated by aspiration pneumonia, a strap muscle abscess requiring drainage, opioid withdrawal, and neuroleptic malignant syndrome. Despite these complications, the patient survived and was discharged after approximately 1 month with a gastrostomy tube because of persistent severe dysphagia. This case illustrates the need for flexible airway management, definitive surgical repair, and close postoperative surveillance for complex systemic complications in severe penetrating neck trauma.
Spontaneous intramural small bowel hematoma is a rare complication of anticoagulant therapy that can mimic acute abdomen or mechanical bowel obstruction. This report describes a 66-year-old man with valvular heart disease who was receiving long-term warfarin therapy after surgical aortic valve replacement and presented with diffuse abdominal pain. Computed tomography revealed long-segment bowel wall thickening of the distal jejunum with submucosal edema, findings consistent with an intramural hematoma. During hospitalization, the patient developed a marked hemoglobin decrease, from 13.0 to 6.0 g/dL, along with radiological progression of the hematoma and hemoperitoneum. However, he remained hemodynamically stable and was successfully managed conservatively with bowel rest, intravenous vitamin K, and transfusion of fresh frozen plasma and packed red blood cells. This case suggests that spontaneous intramural small bowel hematoma should be considered in the differential diagnosis of acute abdomen in anticoagulated patients. Even in the presence of severe anemia and hemoperitoneum, conservative management may be safe and effective in hemodynamically stable patients and may help avoid unnecessary surgical intervention.
Purpose: Several studies have reported venous thromboembolism after COVID-19. This association raises the possibility that the incidence of ischemic enterocolitis (IE) may have increased during the COVID-19 pandemic. This study aimed to identify changes in the incidence of IE using the National Health Insurance Service (NHIS) database in Korea and to assess the clinical impact of COVID-19.Methods: Using the NHIS data from 2016 to 2022, we identified 2,637 patients who underwent surgery after a diagnosis of IE. The primary endpoint was the annual incidence of IE and whether this incidence changed during the COVID-19 period.Results: The incidence per million population was calculated using the total population of Korea as the denominator. The annual incidences of IE from 2016 to 2022 were 6.56, 6.76, 6.98, 7.73, 7.35, 8.08, and 7.65 per million population, respectively. Poisson regression showed an annual increase in IE incidence (incidence rate ratio [IRR], 1.044; 95% confidence interval [CI], 1.004–1.085; P=0.029), whereas the COVID-19 period was not associated with a significant change in IE incidence (IRR, 0.945; 95% CI, 0.811–1.103; P=0.475).Conclusion: The incidence of IE increased significantly over time, but no significant increase was observed during the COVID-19 period.
