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Background: The aim of this study was to develop a consensus-based set of indicators of high-quality acute moderate to severe traumatic brain injury (msTBI) clinical management that can be used to measure structure, process, and outcome factors that are likely to influence patient outcomes. This is the first stage of the PRECISION-TBI program, which is a prospective cohort study that aims to identify and promote optimal clinical management of msTBI in Australia., Methods: A preliminary set of 45 quality indicators was developed based on available evidence. An advisory committee of established experts in the field refined the initial indicator set in terms of content coverage, proportional representation, contamination, and supporting evidence. The refined indicator set was then distributed to a wider Delphi panel for assessment of each indicator in terms of validity, measurement feasibility, variability, and action feasibility. Inclusion in the final indicator set was contingent on prespecified inclusion scoring., Results: The indicator set was structured according to the care pathway of msTBI and included prehospital, emergency department, neurosurgical, intensive care, and rehabilitation indicators. Measurement domains included structure indicators, logistic indicators, and clinical management indicators. The Delphi panel consisted of 44 participants (84% physician, 12% nursing, and 4% primary research) with a median of 15 years of practice. Of the 47 indicators included in the second round of the Delphi, 32 indicators were approved by the Delphi group., Conclusions: This study identified a set of 32 quality indicators that can be used to structure data collection to drive quality improvement in the clinical management of msTBI. They will also be used to guide feedback to PRECISION-TBI's participating sites., (© 2024. The Author(s).)

Objective: To compare the perioperative cumulative opioid consumption and the incidence of cardiovascular complications in dogs undergoing hemilaminectomy in which either an erector spinae plane (ESP) block or systemic opioids were administered., Study Design: Prospective randomized clinical trial., Animals: A total of 60 client-owned dogs., Methods: Dogs were randomized to one of three groups: an ESP block (group ESP), a constant rate infusion of fentanyl (group FNT, positive control) or a single dose of methadone as premedication (group MTD, negative control). Intraoperative nociceptive response was treated with fentanyl [1 μg kg -1 , intravenously (IV)] boli. Before closure of the surgical site, morphine (0.1 mg kg -1 ) was applied to the dura mater. The cumulative dose of opioids was recorded and compared between groups. The incidence of intraoperative bradycardia and/or hypotension and the time to extubation were compared between groups. The short form of the Glasgow Composite Pain Scale (SF-GCPS) was used to score nociception before anaesthetic induction and 1, 2, 6, 12,18 and 24 hours postoperatively. Methadone 0.2 mg kg -1 was administered IV if the SF-GCPS score was ≥ 5., Results: Group MTD required more intraoperative rescue analgesia than groups ESP (p = 0.008) and FNT (p = 0.001). The total cumulative intraoperative dose of fentanyl was higher in groups FNT (p < 0.0001) and MTD (p = 0.002) than in group ESP. The incidence of cardiovascular complications was similar between groups. Extubation time was longer in group MTD (p = 0.03). Postoperatively, the time to first rescue analgesia was longer in group ESP than in group MTD (p = 0.03). The cumulative postoperative opioid consumption and pain scores were similar between groups., Conclusions and Clinical Relevance: The ESP block resulted in a reduced intraoperative opioid consumption compared with the control positive and negative groups., (Copyright © 2024 Association of Veterinary Anaesthetists and American College of Veterinary Anesthesia and Analgesia. Published by Elsevier Ltd. All rights reserved.)

Background: Diaphragmatic hernia (DH) presenting acutely can be a potentially life-threatening condition. Its management continues to be debatable., Methods: A bibliographic search using major databases was performed using the terms "emergency surgery" "diaphragmatic hernia," "traumatic diaphragmatic rupture" and "congenital diaphragmatic hernia." GRADE methodology was used to evaluate the evidence and give recommendations., Results: CT scan of the chest and abdomen is the diagnostic gold standard to evaluate complicated DH. Appropriate preoperative assessment and prompt surgical intervention are important for a clinical success. Complicated DH repair is best performed via the use of biological and bioabsorbable meshes which have proven to reduce recurrence. The laparoscopic approach is the preferred technique in hemodynamically stable patients without significant comorbidities because it facilitates early diagnosis of small diaphragmatic injuries from traumatic wounds in the thoraco-abdominal area and reduces postoperative complications. Open surgery should be reserved for situations when skills and equipment for laparoscopy are not available, where exploratory laparotomy is needed, or if the patient is hemodynamically unstable. Damage Control Surgery is an option in the management of critical and unstable patients., Conclusions: Complicated diaphragmatic hernia is a rare life-threatening condition. CT scan of the chest and abdomen is the gold standard for diagnosing the diaphragmatic hernia. Laparoscopic repair is the best treatment option for stable patients with complicated diaphragmatic hernias. Open repair is considered necessary in majority of unstable patients in whom Damage Control Surgery can be life-saving., (© 2023. The Author(s).)

Intra-abdominal infections (IAI) are among the most common global healthcare challenges and they are usually precipitated by disruption to the gastrointestinal (GI) tract. Their successful management typically requires intensive resource utilization, and despite the best therapies, morbidity and mortality remain high. One of the main issues required to appropriately treat IAI that differs from the other etiologies of sepsis is the frequent requirement to provide physical source control. Fortunately, dramatic advances have been made in this aspect of treatment. Historically, source control was left to surgeons only. With new technologies non-surgical less invasive interventional procedures have been introduced. Alternatively, in addition to formal surgery open abdomen techniques have long been proposed as aiding source control in severe intra-abdominal sepsis. It is ironic that while a lack or even delay regarding source control clearly associates with death, it is a concept that remains poorly described. For example, no conclusive definition of source control technique or even adequacy has been universally accepted. Practically, source control involves a complex definition encompassing several factors including the causative event, source of infection bacteria, local bacterial flora, patient condition, and his/her eventual comorbidities. With greater understanding of the systemic pathobiology of sepsis and the profound implications of the human microbiome, adequate source control is no longer only a surgical issue but one that requires a multidisciplinary, multimodality approach. Thus, while any breach in the GI tract must be controlled, source control should also attempt to control the generation and propagation of the systemic biomediators and dysbiotic influences on the microbiome that perpetuate multi-system organ failure and death. Given these increased complexities, the present paper represents the current opinions and recommendations for future research of the World Society of Emergency Surgery, of the Global Alliance for Infections in Surgery of Surgical Infection Society Europe and Surgical Infection Society America regarding the concepts and operational adequacy of source control in intra-abdominal infections., (© 2023. The Author(s).)

Sigmoid volvulus is a common surgical emergency, especially in elderly patients. Patients can present with a wide range of clinical states: from asymptomatic, to frank peritonitis secondary to colonic perforation. These patients generally need urgent treatment, be it endoscopic decompression of the colon or an upfront colectomy. The World Society of Emergency Surgery united a worldwide group of international experts to review the current evidence and propose a consensus guidelines on the management of sigmoid volvulus., (© 2023. The Author(s).)

Background: Severe complicated intra-abdominal sepsis (SCIAS) has an increasing incidence with mortality rates over 80% in some settings. Mortality typically results from disruption of the gastrointestinal tract, progressive and self-perpetuating bio-mediator generation, systemic inflammation, and multiple organ failure. A further therapeutic option may be open abdomen (OA) management with negative peritoneal pressure therapy (NPPT) to remove inflammatory ascites and attenuate the systemic damage from SCIAS, although there are definite risks of leaving the abdomen open whenever it might possibly be closed. This potential therapeutic paradigm is the rationale being assessed in the Closed Or Open after Laparotomy (COOL trial) ( https://clinicaltrials.gov/ct2/show/NCT03163095 ). Initially, the COOL trial received Industry sponsorship; however, this funding mandated the use of a specific trademarked and expensive NPPT device in half of the patients allocated to the intervention (open) arm. In August 2022, the 3 M/Acelity Corporation without consultation but within the terms of the contract canceled the financial support of the trial. Although creating financial difficulty, there is now no restriction on specific NPPT devices and removing a cost-prohibitive intervention creates an opportunity to expand the COOL trial to a truly global basis. This document describes the evolution of the COOL trial, with a focus on future opportunities for global growth of the study., Methods: The COOL trial is the largest prospective randomized controlled trial examining the random allocation of SCIAS patients intra-operatively to either formal closure of the fascia or the use of the OA with an application of an NPPT dressing. Patients are eligible if they have free uncontained intraperitoneal contamination and physiologic derangements exemplified by septic shock OR severely adverse predicted clinical outcomes. The primary outcome is intended to definitively inform global practice by conclusively evaluating 90-day survival. Initial recruitment has been lower than hoped but satisfactory, and the COOL steering committee and trial investigators intend with increased global support to continue enrollment until recruitment ensures a definitive answer., Discussion: OA is mandated in many cases of SCIAS such as the risk of abdominal compartment syndrome associated with closure, or a planned second look as for example part of "damage control"; however, improved source control (locally and systemically) is the most uncertain indication for an OA. The COOL trial seeks to expand potential sites and proceed with the evaluation of NPPT agnostic to device, to properly examine the hypothesis that this treatment attenuates systemic damage and improves survival. This approach will not affect internal validity and should improve the external validity of any observed results of the intervention., Trial Registration: National Institutes of Health ( https://clinicaltrials.gov/ct2/show/NCT03163095 )., (© 2023. The Author(s).)

Background: There were described in veterinary literature, the possibility of pneumothorax as a complication of laparoscopic surgery in dogs undergoing laparoscopic ovariectomy associated with total laparoscopic gastropexy., Aim: To assess if spontaneous pneumothorax secondary to pneumoperitoneum is a real risk in dogs undergoing total laparoscopic gastropexy., Methods: Dogs undergoing totally laparoscopic gastropexy received chest X-rays (CXR) in lateral (left and right) and ventro-dorsal projection before and after the surgery. Two veterinary radiologists reported the x-rays and indicated the presence or not of pneumothorax., Results: Postoperative pneumothorax was not detected on postoperative CXR in the total of 76 dogs of the study., Conclusion: The odds risk of pneumothorax after total laparoscopic gastropexy surgical procedure is low., Competing Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The aim of this paper was to review the recent literature to create recommendations for the day-to-day diagnosis and surgical management of small bowel and colon injuries. Where knowledge gaps were identified, expert consensus was pursued during the 8th International Congress of the World Society of Emergency Surgery Annual (September 2021, Edinburgh). This process also aimed to guide future research., (© 2022. The Author(s).)

Multidisciplinary team (MDT) meetings are the mainstay of the decision-making process for patients presenting with complex clinical problems such as papillary thyroid carcinoma (PTC). Adherence to guidelines by MDTs has been extensively investigated; however, scarce evidence exists on MDT performance and variability where guidelines are less prescriptive. We evaluated the consistency of MDT management recommendations for T1 and T2 PTC patients and explored key variables that may influence therapeutic decision making. A retrospective review of the prospective database of all T1 and T2 PTC patients discussed by the MDT was conducted between January 2016 and May 2021. Univariate analysis (with Bonferroni correction significance calculated at p < 0.006) was performed to establish clinical variables linked to completion thyroidectomy and Radioactive iodine (RAI) recommendations. Of 468 patients presented at thyroid MDT, 144 pT1 PTC and 118 pT2 PTC met the selection criteria. Only 18% ( n = 12) of pT1 PTC patients initially managed with hemithyroidectomy were recommended completion thyroidectomy. Mean tumour diameter was the only variable differing between groups ( p = 0.003). pT2 patients were recommended completion thyroidectomy in 66% ( n = 16) of instances. No measured variable explained the difference in recommendation. pT1 patients initially managed with total thyroidectomy were not recommended RAI in 71% ( n = 55) of cases with T1a status ( p = 0.001) and diameter ( p = 0.001) as statistically different variables. For pT2 patients, 60% ( n = 41) were recommended RAI post-total thyroidectomy, with no differences observed among groups. The majority of MDT recommendations were concordant for patients with similar measurable characteristics. Discordant recommendations for a small group of patients were not explained by measured variables and may have been accounted for by individual patient factors. Further research into the MDT decision-making process is warranted.

Permanent hypoparathyroidism, a feared thyroidectomy complication, leads to significant patient morbidity, medical treatment, and monitoring. This study explores whether preoperative high-dose vitamin D loading decreases the incidence of permanent hypoparathyroidism. In a subgroup analysis, the study examines the predictive utility of day 1 parathyroid hormone (PTH) in permanent hypoparathyroidism. Patients ( n = 150) were previously recruited in the VItamin D In Thyroidectomy (VIDIT) trial, a multicentre, randomised, double blind, placebo-controlled trial evaluating the role of 300,000 IU cholecalciferol administered orally a week before total thyroidectomy. Patients were contacted postoperatively beyond six months through a telephonic questionnaire. The primary outcome was permanent hypoparathyroidism, strictly defined as the need for activated vitamin D six months postoperatively. Out of 150 patients, 130 (86.7%) were contactable. Permanent hypoparathyroidism occurred in 11/130 (8.5%) patients, with a lower incidence of 5.3% (3/57) in the cholecalciferol group compared to 11% (8/73) in the placebo group; however, this was non-significant ( p = 0.34). In a subgroup analysis, no relationship between day 1 PTH level and the incidence of permanent hypoparathyroidism was found ( p ≥ 0.99). There was a lower rate of permanent hypoparathyroidism in the cholecalciferol group, which was not significant. The predictive utility of day 1 postoperative PTH levels may be limited to transient hypoparathyroidism.

Background: Recent trauma guidelines recommend non-operative management for grade III splenic injury without contrast extravasation on computed tomography. Nevertheless, such recommendations rely on low-quality evidence, and practice variation characterizes clinical management for this type of injury. We aimed to identify the role of eleven selected clinical factors influencing the management of grade III splenic injury without contrast extravasation by expert consensus and a modified Delphi approach., Methods: A questionnaire was developed with the endorsement of the World Society of Emergency Surgery (WSES). This was delivered and answered live by acute care surgeons attending the 6 th WSES congress in Nijmegen in 2019. A dedicated mobile phone application was utilized to collect the answers. All answers were evaluated for areas of discrepancy with an 80% threshold for consensus between respondents., Results: Three factors generated discrepancy in opinion for managing this pattern of injury: the patients' injury severity, the presence of a bleeding diathesis, and an associated intra-abdominal injury. Agreement was obtained for the other eight factors., Conclusion: Researchers should focus their efforts on the identified area of discrepancy. Clinicians should use additional care in the presence of the three factors for which discordant opinions were found.

Purpose: Prehospital guidelines stratify and manage patients with Glasgow Coma Scale (GCS) less than nine and any sign of head injury as affected by severe traumatic brain injury (STBI). We hypothesized that this group of patients is so inhomogeneous that uniform treatment guidelines cannot be advocated., Methods: Patients (2005-2012) with prehospital GCS below nine and abbreviated injury scale head and neck above two were identified from trauma registry. Patients with acute lethal injuries, isolated neck injuries, extubated within 24 h or transferred interhospitally were excluded. Patients were dichotomized based on the worst prehospital GCS (recorded before sedatives) into two groups: GCS 3-5 and GCS 6-8. These were statistically compared using univariate analysis., Results: The GCS 3-5 group (99 patients) when compared with the GCS 6-8 group (49 patients) had shorter prehospital times (63 vs. 79 min; p < 0.05), more frequent episodes of both hypoxia (30.3% vs. 7.7%; p < 0.05) and hypotension (26.7% vs. 6.4%; p < 0.05), more often required craniectomy (15.1% vs. 4.0%; p = 0.05) and higher mortality (33.3% vs. 2%; p < 0.05). In the GCS 3-5 group, prehospital endotracheal intubation was attempted more often (57.5% vs. 28.6%, p < 0.05) and was more often successful (39.3% vs. 10.2%; p = 0.05). Length of stay in ICU did not differ., Conclusions: STBI patients are fundamentally different based on whether their initial GCS falls into 3-5 or 6-8 category. Recommendations from trials investigating trauma patients with GCS less than nine as one group should be translated with caution to clinical practice.

The trend in laparoscopy is to develop easy and rapid techniques associated with reduced intraoperative complications and decreased postoperative pain. The aim of this study was to compare combined laparoscopic ovariectomy (OIE) and laparoscopic-assisted incisional gastropexy (LAG) with combined laparoscopic OIE and total laparoscopic gastropexy (TLG) for surgical time, incidence of complications and postoperative pain. Twenty-eight female dogs were randomly assigned to the LAG group (n = 14) or the TLG group (n = 14). All laparoscopic procedures were performed using a three-port technique. The gastropexy was located 3 cm caudal to the 13th rib and 4 cm lateral to the rectus abdominis muscle. Surgical time (minutes [min]), intraoperative complications and postoperative complications were recorded. The Glasgow pain score (GPS) (short form) was calculated before surgery and at 1, 6, 12, 18 and 24 hr after extubation. Surgical time was significantly longer in the TLG group (48 ± 2 min) compared with the LAG group (39 ± 2 min). Minor postoperative complications occurred in both groups and included swelling (n = 2) and subcutaneous emphysema (n = 1). No significant differences regarding the GPS were recorded between groups. The GPS was significantly higher in both groups at 1 hr and 6 hr than before surgery. Two dogs in each group required rescue analgesia. Combined laparoscopic OIE and TLG require more time to perform than combined laparoscopic OIE and LAG. Neither procedure results in significant surgical complications. Postoperative pain for 24 hr was mild and comparable in both groups., (© 2020 The Authors. Veterinary Medicine and Science Published by John Wiley & Sons Ltd.)

The role of invasive intracranial pressure (ICP) monitoring in patients with severe traumatic brain injury (STBI) remain unclear. Perfusion computed tomography (CTP) provides crucial information about the cerebral perfusion status in these patients. We hypothesised that CTP abnormalities would be associated with the severity of intracranial hypertension (ICH). To investigate this hypothesis, twenty-eight patients with STBI and ICP monitors were investigated with CTP within 48 h from admission. Treating teams were blind to these results. Patients were divided into five groups based on increasing intervention required to control ICH and were compared. Group I required no intervention above routine sedation, group II required a single first tier intervention, group III required multiple different first-tier interventions, group IV required second-tier medical therapy and group V required second-tier surgical therapy. Analysis of the results showed demographics and injury severity did not differ among groups. In group I no patients showed CTP abnormality, while patients in all other groups had abnormal CTP ( p = 0.003). Severe ischaemia observed on CTP was associated with increasing intervention for ICH. This study, although limited by small sample size, suggests that CTP abnormalities are associated with the need to intervene for ICH. Larger scale assessment of our results is warranted to potentially avoid unnecessary invasive procedures in head injury patients.

Background and Aims: Acute appendicitis (AA) is among the most common causes of acute abdominal pain. Diagnosis of AA is still challenging and some controversies on its management are still present among different settings and practice patterns worldwide. In July 2015, the World Society of Emergency Surgery (WSES) organized in Jerusalem the first consensus conference on the diagnosis and treatment of AA in adult patients with the intention of producing evidence-based guidelines. An updated consensus conference took place in Nijemegen in June 2019 and the guidelines have now been updated in order to provide evidence-based statements and recommendations in keeping with varying clinical practice: use of clinical scores and imaging in diagnosing AA, indications and timing for surgery, use of non-operative management and antibiotics, laparoscopy and surgical techniques, intra-operative scoring, and peri-operative antibiotic therapy., Methods: This executive manuscript summarizes the WSES guidelines for the diagnosis and treatment of AA. Literature search has been updated up to 2019 and statements and recommendations have been developed according to the GRADE methodology. The statements were voted, eventually modified, and finally approved by the participants to the consensus conference and by the board of co-authors, using a Delphi methodology for voting whenever there was controversy on a statement or a recommendation. Several tables highlighting the research topics and questions, search syntaxes, and the statements and the WSES evidence-based recommendations are provided. Finally, two different practical clinical algorithms are provided in the form of a flow chart for both adults and pediatric (< 16 years old) patients., Conclusions: The 2020 WSES guidelines on AA aim to provide updated evidence-based statements and recommendations on each of the following topics: (1) diagnosis, (2) non-operative management for uncomplicated AA, (3) timing of appendectomy and in-hospital delay, (4) surgical treatment, (5) intra-operative grading of AA, (6) ,management of perforated AA with phlegmon or abscess, and (7) peri-operative antibiotic therapy.

Assessment of heart rate variability (HRV) and cardiac ectopic beats is a clinically relevant topic. The present exploratory observational study aimed to inspect the relationships of lifestyle, dietary patterns, and anthropometrics with HRV, premature ventricular complexes (PVCs), and supraventricular premature complexes (SVPCs). A cross-sectional study enrolling subjects undergoing Holter monitoring was performed. Sociodemographic and clinical characteristics, body composition (full-body bio-impedentiometry), dietary patterns (validated food frequency questionnaire and 24 h dietary recall), and quality of life were assessed. Generalized additive models were estimated to evaluate the relationships between outcomes of interest and variables collected. The study enrolled 121 consecutive patients undergoing 24 h Holter monitoring. Upon univariable analysis, HRV was found to have an inverse association with mass of body fat (MBF) ( p -value 0.015), while doing physical activity was associated with a significantly higher HRV ( p -value 0.036). Upon multivariable analysis, fruit consumption in the 24 h dietary recall was found to be directly associated with HRV ( p -value 0.044). The present findings might be useful for improving the management of patients attending cardiac rhythm labs, and to tailor ad hoc prevention strategies (modification of lifestyle and eating habits) based on Holter parameters.

Background: Nerves and neurotrophic growth factors are emerging promoters of cancer growth. The precursor for Nerve Growth Factor (proNGF) is overexpressed in thyroid cancer, but its potential role as a clinical biomarker has not been reported. Here we have examined the value of proNGF as a serum and biopsy-rinse biomarker for thyroid cancer diagnosis., Methods: Patients presenting for thyroid surgery or biopsy were enrolled in separate cohorts examining serum (n = 204, including 46 cases of thyroid cancer) and biopsy-rinse specimens (n = 188, including 26 cases of thyroid cancer). ProNGF levels in clinical samples were analysed by ELISA. Univariate and multivariate statistical analyses were used to compare proNGF levels with malignancy status and clinicopathological parameters., Results: ProNGF was not detected in the majority of serum samples (176/204, 86%) and the detection of proNGF was not associated with thyroid cancer diagnosis. In the few cases where proNGF was detected in the serum, thyroidectomy did not affect proNGF concentration, demonstrating that the thyroid was not the source of serum proNGF. Intriguingly, an association between hyperthyroidism and serum proNGF was observed (OR 3.3, 95% CI 1.6-8.7 p = 0.02). In biopsy-rinse, proNGF was detected in 73/188 (39%) cases, with no association between proNGF and thyroid cancer. However, a significant positive association between follicular lesions and biopsy-rinse proNGF was found (OR 3.3, 95% CI 1.2-8.7, p = 0.02)., Conclusions: ProNGF levels in serum and biopsy-rinse are not increased in thyroid cancer and therefore proNGF is not a clinical biomarker for this condition.

Background: Hungry bone syndrome (HBS) is one of the most serious complications following parathyroidectomy for severe hyperparathyroidism. There is a lack of literature informing the treatment and risk factors for this condition and the ideal pre-operative strategy for prevention., Aims: The primary aims were to examine the incidence of HBS with pre-operative calcitriol loading for 10 days and to determine the risk factors for HBS. The secondary aims were to determine the rate of intravenous calcium replacement in those with HBS and to assess whether cinacalcet removal has increased rates of parathyroidectomy in the end-stage kidney disease population., Methods: We performed a retrospective study from 2011 to 2018 on 45 patients with end-stage kidney disease undergoing total parathyroidectomy with autotransplantation for severe hyperparathyroidism. This was based at the John Hunter and Newcastle Private Hospitals in New South Wales., Results: 28.3% of patients with calcitriol loading undergoing parathyroidectomy fulfilled criteria for HBS. Pre-operative variables that were associated with HBS were elevated parathyroid hormone (P = 0.028) and longer duration of renal replacement therapy (P = 0.033). Rates of total parathyroidectomy were higher after the removal of calcimimetics from the Pharmaceutical Benefits Scheme (P = 0.0024)., Conclusions: HBS remains a common complication of parathyroidectomy, even with prolonged high-dose calcitriol loading. This emphasises the need for further trials investigating other targeted therapies, such as bisphosphonates, to prevent HBS. Those most at risk of HBS are patients with high bone turnover and prolonged renal replacement therapy., (© 2019 Royal Australasian College of Physicians.)

Introduction: Cerebral perfusion computed tomography (PCT) provides crucial information in acute stroke and has an increasing role in traumatic brain injury (TBI) management. Most studies on TBI patients utilize 64-slice scanners, which are limited to four brain slices (limited-brain PCT, LBPCT). Newer 320-slice scanners depict the whole brain perfusion status (WBPCT). We aimed to identify the additional information gained with WBPCT when compared to LBPCT., Patients and Methods: Forty-nine patients with severe TBI were investigated within 48 h from admission with WBPCT. Findings from LBPCT were compared with findings from WBPCT., Results: A perfusion abnormality was identified in 39 (80%) and 37 (76%) patients by WBPCT and LBPCT, respectively ( p = 0.8). There were 90 and 68 perfusion abnormalities identified by WBPCT and LBPCT, respectively ( p < 0.001). In the 39 patients with a perfusion abnormality detected by WBPCT, 15 (38%) had further perfusion abnormalities outside the LBPCT area of coverage. Thirty-six (92%) patients had a larger perfusion abnormality upon WBPCT compared with LBPCT. Additional information gained showed some statistically significant correlation with clinical outcome., Conclusions: In severe TBI patients, WBPCT provides extra information compared to LBPC. The limitations of LBPCT should be considered when evaluating studies reporting on PCT findings and their association with outcomes.

Objective: To compare meloxicam and robenacoxib for short-term postoperative pain management after combined laparoscopic ovariectomy and laparoscopic-assisted gastropexy., Study Design: Double-blind, prospective, randomised clinical trial., Animals: Twenty-six client-owned female dogs., Methods: Dogs undergoing combined laparoscopic ovariectomy and laparoscopic-assisted gastropexy were randomly divided into 2 groups. Before induction of anesthesia, 13 dogs received meloxicam (0.2 mg/kg subcutaneously), and 13 dogs received robenacoxib (2 mg/kg subcutaneously). Pain was scored with the Glasgow Composite Pain Scale (short form) before surgery and at 1, 6, 12, 18, and 24 hours after extubation. Rescue analgesia (tramadol, 3 mg/kg) was provided to dogs with a Glasgow pain score (GPS) ≥5. Glasgow pain scores were analyzed by ANOVA with treatment, age, and surgical time as fixed factors., Results: Glasgow pain scores were higher at 24 hours postsurgery in dogs treated with robenacoxib (2.18 ± 0.29) compared with those treated with meloxicam (0.68 ± 0.41, P = .04). Two dogs treated with meloxicam and 7 dogs treated with robenacoxib required rescue analgesia. Regardless of the treatment, the overall GPS was lower at 18 and 24 hours postsurgery when the surgical time was >40 minutes compared with surgical times ≤40 minutes, but surgical site inflammation was likely a confounding factor in this finding. Glasgow pain score was not affected by patient age., Conclusion: Meloxicam was more effective than robenacoxib at controlling pain in the population of dogs reported here., Clinical Significance: Preoperative administration of meloxicam effectively controls pain for 24 hours after combined laparoscopic ovariectomy and laparoscopic-assisted gastropexy, but rescue analgesia may be required., (© 2019 The American College of Veterinary Surgeons.)

Two dogs underwent a combined laparoscopic ovariectomy and total laparoscopic gastropexy. The intra-abdominal pressure and pulmonary compliance decreased, but the peak airway pressure increased at 20 min after the start of gastropexy with intracorporeal suturing. Right chest auscultation and percussion revealed reduced breath sounds and hyper-resonance. No abnormalities in the functioning of the instruments or diaphragmatic defects were detected. The tidal volume was reduced and a positive end-expiratory pressure of 5 cmH₂O was applied. The right chest of the two dogs was drained off: 950 mL (case 1) and 250 mL (case 2) of gas. After thoracentesis, the pulmonary compliance improved and surgery was completed successfully. The postoperative chest radiographs highlighted the residual right pneumothorax., Competing Interests: The authors declare no conflicts of interest., (© 2019 The Korean Society of Veterinary Science.)

Objective: Post-thyroidectomy hypocalcaemia is a significant cause of morbidity and prolonged hospitalization, usually due to transient parathyroid gland damage, treated with calcium and vitamin D supplementation. We present a randomized, double-blinded placebo-controlled trial of preoperative loading with high-dose cholecalciferol (300 000 IU) to reduce post-thyroidectomy hypocalcaemia., Patients and Measurements: Patients (n = 160) presenting for thyroidectomy at tertiary hospitals were randomized 1:1 to cholecalciferol (300 000 IU) or placebo 7 days prior to thyroidectomy. Ten patients withdrew prior to surgery. The primary outcome was post-operative hypocalcaemia (corrected calcium <2.1 mmol/L in first 180 days)., Results: The study included 150 patients undergoing thyroidectomy for Graves' disease (31%), malignancy (20%) and goitre (49%). Mean pre-enrolment vitamin D was 72 ± 26 nmol/L. Postoperative hypocalcaemia occurred in 21/72 (29%) assigned to cholecalciferol and 30/78 (38%) participants assigned to placebo (P = 0.23). There were no differences in secondary end-points between groups. In pre-specified stratification, baseline vitamin D status did not predict hypocalcaemia, although most individuals were vitamin D replete at baseline. Post-hoc stratification by day 1 parathyroid hormone (PTH) (<10 pg/mL, low vs ≥10 pg/mL, normal) was explored due to highly divergent rates of hypocalcaemia in these groups. Using a Cox regression model, the hazard ratio for hypocalcaemia in the cholecalciferol group was 0.56 (95%CI 0.32-0.98, P = 0.04) after stratification for Day 1 PTH. Further clinical benefits were observed in these subgroups., Conclusions: Pre-thyroidectomy treatment with high-dose cholecalciferol did not reduce the overall rate of hypocalcaemia following thyroidectomy. In subgroups stratified by day 1 PTH status, improved clinical outcomes were noted., (© 2018 John Wiley & Sons Ltd.)

Introduction: The occurrence of thyroid cancer is increasing throughout the developed world and since the 1990s has become the fastest increasing malignancy. In 2014, a total of 2693 Australians and 302 New Zealanders were diagnosed with thyroid cancer, with this number projected to rise to 3650 in 2018. The purpose of this protocol is to establish a binational population-based clinical quality registry with the aim of monitoring and improving the quality of care provided to patients diagnosed with thyroid cancer in Australia and New Zealand., Methods and Analysis: The Australian and New Zealand Thyroid Cancer Registry (ANZTCR) aims to capture clinical data for all patients over the age of 16 years with thyroid cancer, confirmed by histopathology report, who have been diagnosed, assessed or treated at a contributing hospital. A multidisciplinary steering committee was formed which, with operational support from Monash University, established the ANZTCR in early 2017. The pilot phase of the registry is currently operating in Victoria, New South Wales, Queensland, Western Australia and South Australia, with over 20 sites expected to come on board across Australia in 2018. A modified Delphi process was undertaken to determine the clinical quality indicators to be reported by the registry, and a minimum data set was developed comprising information regarding thyroid cancer diagnosis, pathology, surgery and 90-day follow-up., Future Plans: The establishment of the ANZTCR provides the opportunity for Australia and New Zealand to further understand current practice in the treatment of thyroid cancer and identify variation in outcomes. The engagement of endocrine surgeons in supporting this initiative is crucial. While the pilot registry has a focus on early clinical outcomes, it is anticipated that future collection of longer term outcome data particularly for patients with poor prognostic disease will add significant further value to the registry., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Adhesive small bowel obstruction (ASBO) is a common surgical emergency, causing high morbidity and even some mortality. The adhesions causing such bowel obstructions are typically the footprints of previous abdominal surgical procedures. The present paper presents a revised version of the Bologna guidelines to evidence-based diagnosis and treatment of ASBO. The working group has added paragraphs on prevention of ASBO and special patient groups., Methods: The guideline was written under the auspices of the World Society of Emergency Surgery by the ASBO working group. A systematic literature search was performed prior to the update of the guidelines to identify relevant new papers on epidemiology, diagnosis, and treatment of ASBO. Literature was critically appraised according to an evidence-based guideline development method. Final recommendations were approved by the workgroup, taking into account the level of evidence of the conclusion., Recommendations: Adhesion formation might be reduced by minimally invasive surgical techniques and the use of adhesion barriers. Non-operative treatment is effective in most patients with ASBO. Contraindications for non-operative treatment include peritonitis, strangulation, and ischemia. When the adhesive etiology of obstruction is unsure, or when contraindications for non-operative management might be present, CT is the diagnostic technique of choice. The principles of non-operative treatment are nil per os, naso-gastric, or long-tube decompression, and intravenous supplementation with fluids and electrolytes. When operative treatment is required, a laparoscopic approach may be beneficial for selected cases of simple ASBO.Younger patients have a higher lifetime risk for recurrent ASBO and might therefore benefit from application of adhesion barriers as both primary and secondary prevention., Discussion: This guideline presents recommendations that can be used by surgeons who treat patients with ASBO. Scientific evidence for some aspects of ASBO management is scarce, in particular aspects relating to special patient groups. Results of a randomized trial of laparoscopic versus open surgery for ASBO are awaited., Competing Interests: Not applicableThe authors declare that they have no competing interests.Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Background: The role of prehospital endotracheal intubation (PETI) for traumatic brain injury is unclear. In Victoria, paramedics use rapid sequence induction (RSI) drugs to facilitate PETI, while in New South Wales (NSW) they do not have access to paralysing agents. We hypothesized that RSI would both increase PETI rates and improve mortality., Methods: Retrospective comparison of adult primary admissions (Glasgow Coma Scale <9 and abbreviated injury scale head and neck >2) to either Victorian or NSW trauma centre, which were compared with univariate and logistic regression analysis to estimate odds ratio for mortality and intensive care unit (ICU) length of stay., Results: One hundred and ninety-two Victorian and 91 NSW patients did not differ in: demographics (males: 77% versus 79%; P = 0.7 and age: 34 (18-88) versus 33 (18-85); P = 0.7), Glasgow Coma Scale (3 (3-8) versus 5 (3-8); P = 0.07), and injury severity score (38 (26-75) versus 35 (18-75); P = 0.09), prehospital hypotension (15.4% versus 11.7%; P = 0.5) and desaturation (14.6% versus 17.5%; P = 0.5). Victorians had higher abbreviated injury scale head and neck (5 (4-5) versus 5 (3-6); P = 0.04) and more often successful PETI (85% versus 22%; P < 0.05). On logistic regression analysis, mortality did not differ among groups (31.7% versus 26.3%; P = 0.34; OR = 0.84; 95% CI: 0.38-1.86; P = 0.67). Among survivors, Victorians had longer stay in ICU (364 (231-486) versus 144 (60-336) h), a difference that persisted on gamma regression (effect = 1.58; 95% CI: 1.30-1.92; P < 0.05)., Conclusion: Paramedics using RSI to obtain PETI in patients with traumatic brain injury had a higher success rate. This increase in successful PETI rate was not associated with an improvement in either mortality rate or ICU length of stay., (© 2018 Royal Australasian College of Surgeons.)

Background: In patients with primary hyperparathyroidism (PHPT) and preoperative imaging suggesting a solitary parathyroid adenoma (SPA), focused parathyroidectomy is most often curative. Even so, large studies show up to 3% of patients experience persistent or recurrent PHPT. Unilateral neck exploration (UNE) aiming to identify the SPA and the other ipsilateral parathyroid may reduce this failure rate. We hypothesized that: (i) minimally invasive video-assisted (MIVA) approach would facilitate UNE and (ii) this would be a clinically relevant strategy., Methods: Prospective case series of a consecutive cohort of PHPT patients (with preoperative diagnosis of SPA), who underwent MIVA-UNE. A 15 mm collar incision and endoscopic magnification were utilized to both excise the SPA and seek the ipsilateral parathyroid gland., Results: From 2009 to 2014, 132 patients were offered MIVA-UNE (age: 63.0 (interquartile range: 11.2); females: 94 (71.2%); symptomatic: 89 (67.4%); mean serum corrected calcium: 2.7 (standard deviation: 0.9) mmol/L; mean serum parathyroid hormone: 16.8 (standard deviation: 11.8) pmol/L). Conversion from MIVA-UNE to open UNE was required in 14 (10.6%) patients (excluded from subsequent analysis). MIVA-UNE was concluded in 118 patients. The second ipsilateral parathyroid was identified in 62 (52.5%) patients and in 13 (11.0%) it appeared enlarged and was excised. Histopathology confirmed five (4.2%) of these glands to be hyperplastic., Conclusion: MIVA-UNE allows identification of the second ipsilateral parathyroid in about half the patients. This approach helped to diagnose and treat unexpected multigland disease in almost 5% of patients., (© 2017 Royal Australasian College of Surgeons.)

Background: Lower GI hemorrhage is a common source of morbidity and mortality. Tranexamic acid is an antifibrinolytic that has been shown to reduce blood loss in a variety of clinical conditions. Information regarding the use of tranexamic acid in treating lower GI hemorrhage is lacking., Objective: The aim of this trial was to determine the clinical efficacy of tranexamic acid when used for lower GI hemorrhage., Design: This was a prospective, double-blind, placebo-controlled, randomized clinical trial., Settings: The study was conducted at a tertiary referral university hospital in Australia., Patients: Consecutive patients aged >18 years with lower GI hemorrhage requiring hospital admission from November 2011 to January 2014 were screened for trial eligibility (N = 265)., Interventions: A total of 100 patients were recruited after exclusions and were randomly assigned 1:1 to either tranexamic acid or placebo., Main Outcome Measures: The primary outcome was blood loss as determined by reduction in hemoglobin levels. The secondary outcomes were transfusion rates, transfusion volume, intervention rates for bleeding, length of hospital stay, readmission, and complication rates., Results: There was no difference between groups with respect to hemoglobin drop (11 g/L of tranexamic acid vs 13 g/L of placebo; p = 0.9445). There was no difference with respect to transfusion rates (14/49 tranexamic acid vs 16/47 placebo; p = 0.661), mean transfusion volume (1.27 vs 1.93 units; p = 0.355), intervention rates (7/49 vs 13/47; p = 0.134), length of hospital stay (4.67 vs 4.74 d; p = 0.934), readmission, or complication rates. No complications occurred as a direct result of tranexamic acid use., Limitations: A larger multicenter trial may be required to determine whether there are more subtle advantages with tranexamic acid use in some of the secondary outcomes., Conclusions: Tranexamic acid does not appear to decrease blood loss or improve clinical outcomes in patients presenting with lower GI hemorrhage in the context of this trial. see Video Abstract at http://links.lww.com/DCR/A453.

Background: Opportunities to improve emergency surgery outcomes exist through guided better practice and reduced variability. Few attempts have been made to define optimal care in emergency surgery, and few clinically derived key performance indicators (KPIs) have been published. A summit was therefore convened to look at resources for optimal care of emergency surgery. The aim of the Donegal Summit was to set a platform in place to develop guidelines and KPIs in emergency surgery., Methods: The project had multidisciplinary global involvement in producing consensus statements regarding emergency surgery care in key areas, and to assess feasibility of producing KPIs that could be used to monitor process and outcome of care in the future., Results: Forty-four key opinion leaders in emergency surgery, across 7 disciplines from 17 countries, composed evidence-based position papers on 14 key areas of emergency surgery and 112 KPIs in 20 acute conditions or emergency systems., Conclusions: The summit was successful in achieving position papers and KPIs in emergency surgery. While position papers were limited by non-graded evidence and non-validated KPIs, the process set a foundation for the future advancement of emergency surgery.

Background: In patients with severe traumatic brain injury (TBI), early CT perfusion (CTP) provides additional information beyond the non-contrast CT (NCCT) and may alter clinical management. We hypothesized that this information may prognosticate functional outcome., Methods: Five-year prospective observational study was performed in a level-1 trauma centre on consecutive severe TBI patients. CTP (obtained in conjunction with first routine NCCT) was interpreted as: abnormal, area of altered perfusion more extensive than on NCCT, and the presence of ischaemia. Six months Glasgow Outcome Scale-Extended of four or less was considered an unfavourable outcome. Logistic regression analysis of CTP findings and core variables [preintubation Glasgow Coma Scale (GCS), Rotterdam score, base deficit, age] was conducted using Bayesian model averaging to identify the best predicting model for unfavourable outcome., Results: Fifty patients were investigated with CTP (one excluded for the absence of TBI) [male: 80%, median age: 35 (23-55), prehospital intubation: 7 (14.2%); median GCS: 5 (3-7); median injury severity score: 29 (20-36); median head and neck abbreviated injury scale: 4 (4-5); median days in ICU: 10 (5-15)]. Thirty (50.8%) patients had an unfavourable outcome. GCS was a moderate predictor of unfavourable outcome (AUC = 0.74), while CTP variables showed greater predictive ability (AUC for abnormal CTP = 0.92; AUC for area of altered perfusion more extensive than NCCT = 0.83; AUC for the presence of ischaemia = 0.81)., Conclusion: Following severe TBI, CTP performed at the time of the first follow-up NCCT, is a non-invasive and extremely valuable tool for early outcome prediction. The potential impact on management and its cost effectiveness deserves to be evaluated in large-scale studies., Level of Evidence Iii: Prospective study.

Background: Endocrine surgeon localizes solitary adenoma (SA) in preoperative time by cervical ultrasound (c-US) and/or 99mTc Sesta MIBI scintigraphy (MIBI-S), but in clinical practice they often show discordant results. The aim of our study is to verify if c-US and MIBI-S have different sensitivity in preoperative localization of SA, depending on its localization, in planning minimally invasive video-assisted parathyroidectomy (MIVAP)., Methods: This is a retrospective analysis of data (demographics data, preoperative localization of SA by US and MIBI-S, presence of associated thyroid disease, preoperative calcemia, preoperative serum PTH, surgical time, intraoperative PTH values, day 1 postoperative calcemia, definitive histological report) about patients consecutively submitted to MIVAP because of SA between January 2011 and January 2014 in the department of endocrine and general surgery of the University Hospital of Parma (Italy). The data, expressed as percentages (%) and means (±SD), were analyzed with SPSS Statistics 22.0 program., Results: The c-US detected 56.25% of the superior SA (9/16 patients) and it failed to identify 7 superior adenomas (43.75%); MIBI-S identified 6/16 superior SA (37.5%) and failed in the identification of 10 superior adenomas (62.5%). For inferior SA, c-US was positive in 39/45 patients (86.66%) and falsely negative in 6/45 patients (13.33%); MIBI-S correctly showed 31/45 inferior adenomas (68.88%) and it was falsely negative in 14/45 patients (31.11%). MIBI-S showed decreased sensitivity in the identification of superior SA (P=0.0383). C-US had a high sensitivity in the identification of the inferior SA (P=0.0280)., Conclusions: C-US and MIBI-S are the best diagnostic tools for preoperative localization of SA, but both have decreased sensitivity in the presence of a concomitant thyroid diseases. In our experience c-US showed high sensitivity in the identification of inferior SA and MIBI-S showed a decreased sensitivity in the identification of superior SA. Discordant results in the identification of SA did not contraindicate MIVAP. Intraoperative parathormone dosage is fundamental to guide the endocrine surgeon and to verify the completeness of surgical resection.

Recent advances in the arena of theranostics have necessitated a re-examining of previously established fields. The existing paradigm of therapeutic thyroid-stimulating hormone receptor (TSHR) targeting in the post-surgical management of differentiated thyroid cancer using levothyroxine and recombinant human thyroid-stimulating hormone (TSH) is well understood. However, in an era of personalized medicine, and with an increasing awareness of the risk profile of longstanding pharmacological hyperthyroidism, it is imperative clinicians understand the molecular basis and magnitude of benefit for individual patients. Furthermore, TSHR has been recently re-conceived as a selective target for residual metastatic thyroid cancer, with pilot data demonstrating effective targeting of nanoparticles to thyroid cancers using this receptor as a target. This review examines the evidence for TSHR signaling as an oncogenic pathway and assesses the evidence for ongoing TSHR expression in thyroid cancer metastases. Priorities for further research are highlighted., (© 2017 Society for Endocrinology.)

[This corrects the article DOI: 10.1186/s13017-016-0082-5.].

Medullary thyroid cancer (MTC) is an uncommon thyroid cancer that requires a high index of suspicion to facilitate diagnosis of early-stage disease amenable to surgical cure. The challenges of diagnosis, as well as management in the setting of persistent disease, are explored in the context of a case presenting with the incidental finding of elevated carcinoembryonic antigen (CEA) and an (18) F-fluorodeoxyglucose positron emission tomography ((18) F-FDG-PET)-positive thyroid incidentaloma detected following treatment of colorectal cancer. Strategies to individualize prognosis, and emerging PET-based imaging modalities, particularly the potential role of (18) F-DOPA-PET in staging, are reviewed., (© 2016 John Wiley & Sons Ltd.)

Acute appendicitis (AA) is among the most common cause of acute abdominal pain. Diagnosis of AA is challenging; a variable combination of clinical signs and symptoms has been used together with laboratory findings in several scoring systems proposed for suggesting the probability of AA and the possible subsequent management pathway. The role of imaging in the diagnosis of AA is still debated, with variable use of US, CT and MRI in different settings worldwide. Up to date, comprehensive clinical guidelines for diagnosis and management of AA have never been issued. In July 2015, during the 3rd World Congress of the WSES, held in Jerusalem (Israel), a panel of experts including an Organizational Committee and Scientific Committee and Scientific Secretariat, participated to a Consensus Conference where eight panelists presented a number of statements developed for each of the eight main questions about diagnosis and management of AA. The statements were then voted, eventually modified and finally approved by the participants to The Consensus Conference and lately by the board of co-authors. The current paper is reporting the definitive Guidelines Statements on each of the following topics: 1) Diagnostic efficiency of clinical scoring systems, 2) Role of Imaging, 3) Non-operative treatment for uncomplicated appendicitis, 4) Timing of appendectomy and in-hospital delay, 5) Surgical treatment 6) Scoring systems for intra-operative grading of appendicitis and their clinical usefulness 7) Non-surgical treatment for complicated appendicitis: abscess or phlegmon 8) Pre-operative and post-operative antibiotics.

Acute calculus cholecystitis is a very common disease with several area of uncertainty. The World Society of Emergency Surgery developed extensive guidelines in order to cover grey areas. The diagnostic criteria, the antimicrobial therapy, the evaluation of associated common bile duct stones, the identification of "high risk" patients, the surgical timing, the type of surgery, and the alternatives to surgery are discussed. Moreover the algorithm is proposed: as soon as diagnosis is made and after the evaluation of choledocholitiasis risk, laparoscopic cholecystectomy should be offered to all patients exception of those with high risk of morbidity or mortality. These Guidelines must be considered as an adjunctive tool for decision but they are not substitute of the clinical judgement for the individual patient.

Trauma, both blunt and penetrating, is extremely common worldwide, as trauma to major vessels. The management of these patients requires specialized surgical skills and techniques of the trauma surgeon. Furthermore few other surgical emergencies require immediate diagnosis and treatment like a ruptured abdominal aortic aneurysm (rAAA). Mortality of patients with a rAAA reaches 85 %, with more than half dying before reaching the hospital. These are acute events demanding immediate intervention to save life and limb and precluding any attempt at transfer or referral. It is the purpose of this position paper to discuss neck, chest, extremities and abdominal trauma, bringing to light recent evidence based data as well as expert opinions; besides, in this paper we present a review of the recent literature on rAAA and we discuss the rationale for transfer to referral center, the role of preoperative imaging and the pros and cons of Endoluminal repair of rAAA (REVAR) versus Open Repair (OR).

The CIAOW study (Complicated intra-abdominal infections worldwide observational study) is a multicenter observational study underwent in 68 medical institutions worldwide during a six-month study period (October 2012-March 2013). The study included patients older than 18 years undergoing surgery or interventional drainage to address complicated intra-abdominal infections (IAIs). 1898 patients with a mean age of 51.6 years (range 18-99) were enrolled in the study. 777 patients (41%) were women and 1,121 (59%) were men. Among these patients, 1,645 (86.7%) were affected by community-acquired IAIs while the remaining 253 (13.3%) suffered from healthcare-associated infections. Intraperitoneal specimens were collected from 1,190 (62.7%) of the enrolled patients. 827 patients (43.6%) were affected by generalized peritonitis while 1071 (56.4%) suffered from localized peritonitis or abscesses. The overall mortality rate was 10.5% (199/1898). According to stepwise multivariate analysis (PR = 0.005 and PE = 0.001), several criteria were found to be independent variables predictive of mortality, including patient age (OR = 1.1; 95%CI = 1.0-1.1; p < 0.0001), the presence of small bowel perforation (OR = 2.8; 95%CI = 1.5-5.3; p < 0.0001), a delayed initial intervention (a delay exceeding 24 hours) (OR = 1.8; 95%CI = 1.5-3.7; p < 0.0001), ICU admission (OR = 5.9; 95%CI = 3.6-9.5; p < 0.0001) and patient immunosuppression (OR = 3.8; 95%CI = 2.1-6.7; p < 0.0001).

Background: Damage control surgery is a management sequence initiated to reduce the risk of death in severely injured patients presenting with physiological derangement. Damage control principles have emerged as an approach in non-trauma abdominal emergencies in order to reduce mortality compared with primary definitive surgery., Methods: A PubMed/MEDLINE literature review was conducted of data available over the past decade (up to August 2013) to gain information on current understanding of damage control surgery for abdominal surgical emergencies. Future directions for research are discussed., Results: Damage control surgery facilitates a strategy for life-saving intervention for critically ill patients by abbreviated laparotomy with subsequent reoperation for delayed definitive repair after physiological resuscitation. The six-phase strategy (including damage control resuscitation in phase 0) is similar to that for severely injured patients, although non-trauma indications include shock from uncontrolled haemorrhage or sepsis. Minimal evidence exists to validate the benefit of damage control surgery in general surgical abdominal emergencies. The collective published experience over the past decade is limited to 16 studies including a total of 455 (range 3-99) patients, of which the majority are retrospective case series. However, the concept has widespread acceptance by emergency surgeons, and appears a logical extension from pathophysiological principles in trauma to haemorrhage and sepsis. The benefits of this strategy depend on careful patient selection. Damage control surgery has been performed for a wide range of indications, but most frequently for uncontrolled bleeding during elective surgery, haemorrhage from complicated gastroduodenal ulcer disease, generalized peritonitis, acute mesenteric ischaemia and other sources of intra-abdominal sepsis., Conclusion: Damage control surgery is employed in a wide range of abdominal emergencies and is an increasingly recognized life-saving tactic in emergency surgery performed on physiologically deranged patients., (© 2013 BJS Society Ltd. Published by John Wiley & Sons Ltd.)

Background: In 2013 Guidelines on diagnosis and management of ASBO have been revised and updated by the WSES Working Group on ASBO to develop current evidence-based algorithms and focus indications and safety of conservative treatment, timing of surgery and indications for laparoscopy., Recommendations: In absence of signs of strangulation and history of persistent vomiting or combined CT-scan signs (free fluid, mesenteric edema, small-bowel feces sign, devascularization) patients with partial ASBO can be managed safely with NOM and tube decompression should be attempted. These patients are good candidates for Water-Soluble-Contrast-Medium (WSCM) with both diagnostic and therapeutic purposes. The radiologic appearance of WSCM in the colon within 24 hours from administration predicts resolution. WSCM maybe administered either orally or via NGT both immediately at admission or after failed conservative treatment for 48 hours. The use of WSCM is safe and reduces need for surgery, time to resolution and hospital stay.NOM, in absence of signs of strangulation or peritonitis, can be prolonged up to 72 hours. After 72 hours of NOM without resolution, surgery is recommended.Patients treated non-operatively have shorter hospital stay, but higher recurrence rate and shorter time to re-admission, although the risk of new surgically treated episodes of ASBO is unchanged. Risk factors for recurrences are age <40 years and matted adhesions. WSCM does not decrease recurrence rates or recurrences needing surgery.Open surgery is often used for strangulating ASBO as well as after failed conservative management. In selected patients and with appropriate skills, laparoscopic approach is advisable using open access technique. Access in left upper quadrant or left flank is the safest and only completely obstructing adhesions should be identified and lysed with cold scissors. Laparoscopic adhesiolysis should be attempted preferably if first episode of SBO and/or anticipated single band. A low threshold for open conversion should be maintained.Peritoneal adhesions should be prevented. Hyaluronic acid-carboxycellulose membrane and icodextrin decrease incidence of adhesions. Icodextrin may reduce the risk of re-obstruction. HA cannot reduce need of surgery.Adhesions quantification and scoring maybe useful for achieving standardized assessment of adhesions severity and for further research in diagnosis and treatment of ASBO.

Background: The role of brain CT perfusion (CTP) imaging in severe traumatic brain injury (STBI) is unclear. We hypothesised that in STBI early CTP may provide additional information beyond the non contrast CT (NCCT)., Methods: Subset analysis of an ongoing prospective observational study on trauma patients with STBI who did not require craniectomy and deteriorated or failed to improve neurologically during the first 48h from trauma. Subsequently to follow-up NCCT, a CTP was obtained. Additional findings were defined as an area of altered perfusion on CTP larger than the abnormal area detected by the simultaneous NCCT. Patients who had additional finding (A-CTP) were compared with patients who did not have additional findings (NA-CTP)., Results: Study population was 30 patients [male: 90%, mean age: 38.6 (SD 16.9), blunt trauma: 100%; prehospital intubation: 6 (20%); lowest GCS before intubation: 5.1 (SD 2.0); mean ISS: 30.5 (SD 8.3); mean head and neck AIS: 4.4 (SD 0.8). Days in ICU: 10.2 (SD 6.3). Intracranial pressure (ICP) monitored in 12 (40%). Mean highest ICP in mmHg: 30.1 (SD14.1). There were five (17%) deaths. Findings of NCCT: primarily diffuse axonal injury (DAI) pattern in seven (23%), primarily haematoma in ten (33%), and primarily intracerebral contusion in nine (30%). CTP was performed 24.9 (SD 13) hours from trauma. There were 18 (60%) patients in the A-CTP group and 12 (40.0%) in NA-CTP. The A-CTP group was older (41.7 (SD16.9) vs 27.7 (SD 12.8): P<0.02) and showed on admission NCCT presence of cerebral contusion and absence of DAI. The degree of hypoperfusion was found to be severe enough to be in the ischaemic range in eight patients (27%). CTP altered clinical management in three patients (10%), who were diagnosed with massive and unsurvivable strokes despite minimal changes on NCCT., Conclusion: When compared to NCCT, CTP provided additional diagnostic information in 60% of patients with STBI. CTP altered clinical management in 10% of patients., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Background: Gestational primary hyperparathyroidism is associated with serious maternal and neonatal complications, which require prompt surgical treatment. Minimally invasive parathyroidectomy reduces pain, improves cosmesis and may achieve cure rates comparable to traditional open bilateral neck exploration. We report the clinical course of a woman with newly diagnosed gestational primary hyperparathyroidism and discuss the decision making behind the choice of video-assisted minimally invasive parathyroidectomy, amongst the other minimally invasive parathyroidectomy techniques available., Case Presentation: A 38-years-old pregnant woman at 9 weeks of gestation, with severe hyperemesis and hypercalcaemia secondary to gestational primary hyperparathyroidism (ionised calcium 1.28 mmol/l) was referred for surgery. Ultrasound examination of her neck identified 2 suspicious parathyroid enlargements. In view of pregnancy, a radioisotope Sestamibi parathyroid scan was not performed. Bilateral four-gland exploration was therefore deemed necessary to guarantee cure. This was performed with video-assisted minimally invasive parathyroidectomy, which relies on a single 15 mm central incision with external retraction and endoscopic magnification, allowing bilateral neck exploration., Conclusion: Video-assisted minimally invasive parathyroidectomy allows bilateral four-gland exploration, and is an optimal technique to treat gestational primary hyperparathyroidism. This procedure removes the need for radiation exposure, reduces pain, improves cosmesis and may achieve cure rates comparable to traditional open bilateral neck exploration.