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The epidemiology and the outcomes of acute appendicitis in elderly patients are very different from the younger population. Elderly patients with acute appendicitis showed higher mortality, higher perforation rate, lower diagnostic accuracy, longer delay from symptoms onset and admission, higher postoperative complication rate and higher risk of colonic and appendiceal cancer. The aim of the present work was to investigate age-related factors that could influence a different approach, compared to the 2016 WSES Jerusalem guidelines on general population, in terms of diagnosis and management of elderly patient with acute appendicitis. During the XXIX National Congress of the Italian Society of Surgical Pathophysiology (SIFIPAC) held in Cesena (Italy) in May 2019, in collaboration with the Italian Society of Geriatric Surgery (SICG), the World Society of Emergency Surgery (WSES) and the Italian Society of Emergency Medicine (SIMEU), a panel of experts participated to a Consensus Conference where eight panelists presented a number of statements, which were developed for each of the four topics about diagnosis and management of acute appendicitis in elderly patients, formulated according to the GRADE system. The statements were then voted, eventually modified and finally approved by the participants to the Consensus Conference. The current paper is reporting the definitive guidelines statements on each of the following topics: diagnosis, non-operative management, operative management and antibiotic therapy.

The World Society of Emergency Surgery promotes training and continuing medical education in the field of emergency surgery and trauma. One of the most important activities of the society is the development of guidelines. The debate about the process of developing and updating guidelines is very active with no clear consensus and different policies among scientific societies. The present commentary provides the position of the World Society of Emergency Surgery on guideline development process and their update.

Background Substantial advancements were achieved in the management of postoperative pain, however the need for further improvement remains. This study explores the pharmacokinetics and safety of the CannaHaler, a metered dose inhaler for plant material made by Kite-Systems situated in Tel-Aviv, Israel. Methods The study was conducted on 12 healthy adult volunteers divided into four arms (each arm/group holds 3 volunteers) with the evaporated plant material being Alaska strain provided by “Tikun Olam”. This strain is a hybrid of 70% Sativa and 30% Indika strains, consisting of 20–22% THC and 0% CBD. Each arm received a single dose and groups were divided in an ascending dose fashion: Group I-IV receiving 10, 15, 20, 25 mg of THC respectively. The volunteers inhaled a single dose of THC using the CannaHaler, device. Blood samples for Δ9 – Tetrahydrocannabinol (THC) and 9-THCCOOH were taken at base line and up to 30 min after dosing. Adverse events were monitored following the inhalation. Pharmacokinetics profile was obtained for each patient in all arms. Results Ascending doses of THC produced a linear increase in the maximum concentration 10, 15, 20 and 25 mg of THC. (35.43 ± 5.97, 51.47 ± 13.79, 72.37 ± 15.93, 88.63 ± 14.75 respectively) with the same linear increase in the dimension of the AUC (441.59 ± 88.49, 624 ± 123.56, 698.35 ± 174.98, 971.36 ± 310.4 respectively) both with no change in the time needed to reach such concentration. No adverse events were recorded in all of study subjects. The CannaHaler achieved high Cmax (35.43–88.63 ng/mL) values and low coefficient of variations (16.64–26.79%) in comparison to both smoking and oral preparations, thus reaching the potential of a pharmaceutical grade device for inhaled substance. Conclusions The current study showed that the use of Kite-Systems CannaHaler as a smokeless medical cannabis inhalation device is feasible and efficient. The low coefficient of variation together with the high Cmax values, suggest the potential use of the CannaHaler device as a pharmaceutical cannabis dosing administrator.

BackgroundSurgical site infections (SSI) represent a considerable burden for healthcare systems. They are largely preventable and multiple interventions have been proposed over past years in an attempt to prevent SSI.We aim to provide a position paper on Operative Room (OR) prevention of SSI in patients presenting with intra-abdominal infection to be considered a future addendum to the well-known World Society of Emergency Surgery (WSES) Guidelines on the management of intra-abdominal infections.MethodsThe literature was searched for focused publications on SSI until March 2019. Critical analysis and grading of the literature has been performed by a working group of experts; the literature review and the statements were evaluated by a Steering Committee of the WSES.ResultsWound protectors and antibacterial sutures seem to have effective roles to prevent SSI in intra-abdominal infections. The application of negative-pressure wound therapy in preventing SSI can be useful in reducing postoperative wound complications.It is important to pursue normothermia with the available resources in the intraoperative period to decrease SSI rate.The optimal knowledge of the pharmacokinetic/pharmacodynamic characteristics of antibiotics helps to decide when additional intraoperative antibiotic doses should be administered in patients with intra-abdominal infections undergoing emergency surgery to prevent SSI.ConclusionsThe current position paper offers an extensive overview of the available evidence regarding surgical site infection control and prevention in patients having intra-abdominal infections.

Background Early laparoscopic cholecystectomy has been adopted as the treatment of choice for acute cholecystitis due to a shorter hospital length of stay and no increased morbidity when compared to delayed cholecystectomy. However, randomised studies and meta-analysis report a wide array of timings of early cholecystectomy, most of them set at 72 h following admission. Setting early cholecystectomy at 72 h or even later may influence analysis due to a shift towards a more balanced comparison. At this time, the rate of resolving acute cholecystitis and the rate of ongoing acute process because of failed conservative treatment could be not so different when compared to those operated with a delayed timing of 6–12 weeks. As a result, randomised comparison with such timing for early cholecystectomy and meta-analysis including such studies may have missed a possible advantage of an early cholecystectomy performed within 24 h of the admission, when conservative treatment failure has less potential effects on morbidity. This review will explore pooled data focused on randomised studies with a set timing of early cholecystectomy as a maximum of 24 h following admission, with the aim of verifying the hypothesis that cholecystectomy within 24 h may report a lower post-operative complication rate compared to a delayed intervention. Methods A systematic review of the literature will identify randomised clinical studies that compared early and delayed cholecystectomy. Pooled data from studies that settled the early intervention within 24 h from admission will be explored and compared in a sub-group analysis with pooled data of studies that settled early intervention as more than 24 h. Discussion This paper will not provide evidence strong enough to change the clinical practice, but in case the hypothesis is verified, it will invite to re-consider the timing of early cholecystectomy and might promote future clinical research focusing on an accurate definition of timing for early cholecystectomy for acute cholecystitis.

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.

Since December 2019, the world is potentially facing one of the most difficult infectious situations of the last decades. COVID-19 epidemic warrants consideration as a mass casualty incident (MCI) of the highest nature. An optimal MCI/disaster management should consider all four phases of the so-called disaster cycle: mitigation, planning, response, and recovery. COVID-19 outbreak has demonstrated the worldwide unpreparedness to face a global MCI.This present paper thus represents a call for action to solicitate governments and the Global Community to actively start effective plans to promote and improve MCI management preparedness in general, and with an obvious current focus on COVID-19.

Emergency surgeons have a crucial role in bridging the gap of skills resulting from the well-known general surgery fragmentation. The multi-specialist general surgery approach is still necessary to define proper diagnosis and therapy priorities in an emergency. Governments have to find effective organizational solutions to maintain emergency general surgery standards of care and to improve them further.

Background Analyzing the data of the International Register of Open Abdomen (IROA), the feasibility of open abdomen treatment has been demonstrated at every age. This new analysis on the IROA database investigates the risk factors for mortality in elderly patients treated with open abdomen for intra-abdominal infection. Methods Data were derived from the IROA, a prospective observational international cohort study that enrolled patients treated with open abdomen worldwide. A univariate analysis of potential risk factors was performed. Inclusion criteria were patients older than 65 years and treated with open abdomen for intra-abdominal infection. End point was overall mortality, calculated within 30 days after open abdomen management, after 1-month and 1-year follow-up. Results A total of 116 patients was analyzed with mean age of 76 ± 7 years. Definitive closure was achieved in 93 patients (93/116, 80.2%) for a mean open abdomen duration of 5.0 ± 5.0 days. Complicated patients were 101 (101/116, 87.1%) for a total of 201 complications. Overall, 62 out of 116 patients (53.4%) died: 23 patients (23/62, 37.1%) during open abdomen management, 29 patients (46.8%) within 30 days after abdominal closure, 9 patients (14.5%) after 1-month follow-up, and 1 patient (1.6%) after 1-year follow-up. Age did not affect mortality (75 ± 6 years in alive patients versus 77 ± 7 years in dead patients, p = 0.773). Definitive abdominal closure was the most important factor to prevent mortality. Conclusions This study confirmed that age alone cannot be considered a determinant for death, even in elderly patients managed with open abdomen for severe intra-abdominal infection.

Background Peptic ulcer disease is common with a lifetime prevalence in the general population of 5–10% and an incidence of 0.1–0.3% per year. Despite a sharp reduction in incidence and rates of hospital admission and mortality over the past 30 years, complications are still encountered in 10–20% of these patients. Peptic ulcer disease remains a significant healthcare problem, which can consume considerable financial resources. Management may involve various subspecialties including surgeons, gastroenterologists, and radiologists. Successful management of patients with complicated peptic ulcer (CPU) involves prompt recognition, resuscitation when required, appropriate antibiotic therapy, and timely surgical/radiological treatment. Methods The present guidelines have been developed according to the GRADE methodology. To create these guidelines, a panel of experts was designed and charged by the board of the WSES to perform a systematic review of the available literature and to provide evidence-based statements with immediate practical application. All the statements were presented and discussed during the 5th WSES Congress, and for each statement, a consensus among the WSES panel of experts was reached. Conclusions The population considered in these guidelines is adult patients with suspected complicated peptic ulcer disease. These guidelines present evidence-based international consensus statements on the management of complicated peptic ulcer from a collaboration of a panel of experts and are intended to improve the knowledge and the awareness of physicians around the world on this specific topic. We divided our work into the two main topics, bleeding and perforated peptic ulcer, and structured it into six main topics that cover the entire management process of patients with complicated peptic ulcer, from diagnosis at ED arrival to post-discharge antimicrobial therapy, to provide an up-to-date, easy-to-use tool that can help physicians and surgeons during the decision-making process.

Background Ischemic colitis remains a challenge for the surgeon, both in its diagnosis and treatment. Data from a single tertiary center, of patients diagnosed with ischemic colitis, was collected. An attempt was made to delineate the patients requiring surgical intervention. Methods A retrospective study was undertaken in patients diagnosed with ischemic colitis admitted to Rambam Health Care Campus between 2011 and 2016. The primary outcome was defined as mortality. Secondary outcomes were defined as complications during conservative treatment and postoperative course. Results Sixty-three patients were diagnosed with ischemic colitis during the study period. The mean age at presentation was 72.5 years, with a female predominance (62%). The overall mortality rate was 29% (18/63). Six patients (50%) of those operated died. An older age, comorbidities and higher lactate levels present risk factors for a worse outcome. Conclusions Ischemic colitis continues to present a challenge in its management. A better understanding of the disease process is required. And one needs to adhere to sound surgical principles for a timely diagnosis and treatment, especially in older patients with worrisome clinical, laboratory, and imaging features.

Ingestion of foreign bodies (FBs) is a common misfortune worldwide. Fishbone migration from the gastrointestinal tract into the liver is an unusual cause of liver abscess. We present a 66-year-old woman who presented to the emergency department with epigastric pain, with no other relevant anamnestic details. Computed tomography scan revealed a liver abscess, secondary to stomach perforation from a long, sharp object. Diagnostic laparoscopy revealed a fishbone protruding from the left lobe of the liver. The FB was extracted and the liver abscess incised and drained laparoscopically with no operative and post-operative complications. Migration of FB into the liver is a rare occurrence. Treatment of such liver abscess must include the extraction of the FB. Laparoscopy in these cases is feasible and safe and may prevent unnecessary exploratory laparotomy.

Iatrogenic colonoscopy perforation (ICP) is a severe complication that can occur during both diagnostic and therapeutic procedures. Although 45–60% of ICPs are diagnosed by the endoscopist while performing the colonoscopy, many ICPs are not immediately recognized but are instead suspected on the basis of clinical signs and symptoms that occur after the endoscopic procedure. There are three main therapeutic options for ICPs: endoscopic repair, conservative therapy, and surgery. The therapeutic approach must vary based on the setting of the diagnosis (intra- or post-colonoscopy), the type of ICP, the characteristics and general status of the patient, the operator’s level of experience, and surgical device availability. Although ICPs have been the focus of numerous publications, no guidelines have been created to standardize the management of ICPs. The aim of this article is to present the World Society of Emergency Surgery (WSES) guidelines for the management of ICP, which are intended to be used as a tool to promote global standards of care in case of ICP. These guidelines are not meant to substitute providers’ clinical judgment for individual patients, and they may need to be modified based on the medical team’s level of experience and the availability of local resources.

Objective: We compared outcomes of elective inguinal hernia repair performed at one institution by three approaches: robotic-assistance, laparoscopic, and open. Methods: Characteristics of the patients, the hernia and the procedures performed during 2014–2016 were accessed from patient electronic medical files of 137 elective inguinal hernia repairs. 24 surgeries were robotic-assisted, 16 laparoscopic and 97 open repairs. Results: Distributions of age, sex and BMI did not differ between the groups. Bilateral repair was more common in the robotic (70.8%) than the laparoscopic (50.0%) and open groups (12.4%) (p

Background: Open abdomen is the cornerstone of damage control strategies in acute care and trauma surgery. The role of BMI has not been well investigated. The aim of the study was to assess the role of BMI in determining outcomes after open abdomen. Methods: This is an analysis of patients recorded into the International Register of Open Abdomen; patients were classified in two groups according to BMI using a cutoff of 30 kg/m2. The primary outcome was in-hospital mortality; secondary outcomes were primary fascia closure rate, length of treatment, complication rate, entero-atmospheric fistula rate and length of ICU stay. Results: A total of 591 patients were enrolled from 57 centers, and obese patients were 127 (21.5%). There was no difference in mortality between the two groups; complications developed during the open treatment were higher in obese patients (63.8% vs. 53.4%, p = 0.038) while post-closure complications rate was similar. Obese patients had a significantly longer duration of the open treatment (9.1 ± 11.5 days vs. 6.3 ± 7.5 days; p = 0,002) and lower primary fascia closure rate (75.5% vs. 89.5%; p < 0,001). No differences in fistula rate were found. There was a linear correlation between the duration of open abdomen and the BMI (Pearson’s linear correlation coefficient = 0,201; p < 0,001). Conclusions: Open abdomen in obese patients seems to be safe as in non-obese patients with similar mortality; however, in obese patients the length of open abdomen is significantly higher with higher complication rate, longer ICU length of stay and lower primary fascia closure rate. Trial registration number: ClinicalTrials.gov, Identifier: NCT02382770.

During mass casualty events, a larger portion of victims need emergency surgery compared with victims of conventional trauma. For example, bombing resulted in significantly enhanced use of intensive care, prolonged hospital stay, more surgical interventions, and increased hospital mortality compared to conventional trauma [1]. In this contest, an adequate Operating Room (OR) setup is crucial in order to face a mass casualty event.

Background For many years total pancreatectomy (TP) had a notorious reputation due to the resulting brittle diabetes and pancreatic exocrine insufficiency, recent evidence suggests otherwise. The purpose of the current study is to evaluate the comparative perioperative results of TP and pancreatico-duodenectomy (PD).Methods The current study is a single center retrospective, case control study comparing the peri-operative outcomes of TP and PD over a period of 7 years for malignant and benign diseases of the pancreas. Primary and secondary measures of outcome were peri-operative mortality and morbidity respectively.Results 214 patients underwent pancreatic resection during the study period of which 35 patients underwent TP and 179 patients underwent PD. The two groups were homogenous in terms of demographics and clinical presentation. Mortality was not different between TP and PD and stands on 2.9% and 5% respectively (p-0.58). Overall complication rate was significantly lower in the TP group (17.1% vs. 55%, p3) was lower but did not reach statistical significance (2.9% vs. 11.2%, p-0.13).Conclusions Our study suggests that total pancreatectomy is not only feasible and safe, it might have better perioperative outcomes than PD with same mortality and reduced overall complication rate.

Post-cholecystectomy bile leak is relatively a well-known surgical complication. Several potential treatment modalities for such leaks are used. The early use of ERCP to exclude significant bile duct injury and to treat the leak by various endoscopic means is supported by a large bulk of data. However, there is no consensus as to the optimal endoscopic intervention.A retrospective review of ERCP database was done to identify all cases of bile leak related to cholecystectomy. Patient records including surgical and endoscopic reports were reviewed, and telephone interviews were conducted to collect data.During the period 2004-2016, 100 patients (53 men, 47 women; mean age, 55 years) with post-cholecystectomy bile leak were referred for ERCP. Cholecystectomy was done laparoscopically in 82 patients (with an open conversion rate of 13%). In the majority of cases (77%), the leak was diagnosed by ongoing bile flow from the drains. The most common symptoms were pain (17%) and fever (4%). The most common site of the leak was the cystic duct stump (79%) followed by subvesical ducts (7%). Low grade leaks were seen in 84% of cases. Treatment included stent insertion alone (9%), sphincterotomy alone (11%), combination stent/sphincterotomy (76%) and others (1%). Failed ERCP was encountered in 3%. Endoscopic therapy was successful in 90 patients (90%). In subgroup analysis, success rate of procedures with stent insertion (with or without sphincterotomy) is significantly higher compared to procedures without stent insertion (95.3% vs 72.7%, p 0.05). The failure rate of sphincterotomy alone procedures (3/11, 27%) is much higher compared to procedures with stent insertion (4/85, 5%) with p 0.05. Four patients (4%) developed post-ERCP pancreatitis (mild to moderate) and one patient (1%) suffered from retroperitoneal perforation.The optimal endoscopic intervention for post-cholecystectomy bile leak should include temporary insertion of a biliary stent.

Contains fulltext : 215316.pdf (Publisher’s version ) (Open Access) Although most patients with acute pancreatitis have the mild form of the disease, about 20-30% develops a severe form, often associated with single or multiple organ dysfunction requiring intensive care. Identifying the severe form early is one of the major challenges in managing severe acute pancreatitis. Infection of the pancreatic and peripancreatic necrosis occurs in about 20-40% of patients with severe acute pancreatitis, and is associated with worsening organ dysfunctions. While most patients with sterile necrosis can be managed nonoperatively, patients with infected necrosis usually require an intervention that can be percutaneous, endoscopic, or open surgical. These guidelines present evidence-based international consensus statements on the management of severe acute pancreatitis from collaboration of a panel of experts meeting during the World Congress of Emergency Surgery in June 27-30, 2018 in Bertinoro, Italy. The main topics of these guidelines fall under the following topics: Diagnosis, Antibiotic treatment, Management in the Intensive Care Unit, Surgical and operative management, and Open abdomen.

Over the last decade the General Surgery Residency Program in Israel has changed tremendously. Residency settings have changed significantly - Residents time and exposure to the surgical ward and especially the time spent in the operating theater have dropped dramatically. This situation has evolved, while concurrently, their range of responsibilities expanded. The Israeli General Surgery Residents Association (ISRA) was founded in 2017 by residents as part of the Israeli Surgical Association in order to maintain and improve surgical training and allow equal access to all residents. The elected member of the ISRA serves as a delegate on the Israeli Surgical Association Board of Directors. The current review outlines the history of general surgery residency, describes surgical residency programs from around the world with special attention to measures to improve training amid medical workforce changes. In addition, The Israeli General Surgery Residents Association (ISRA) and its work will be presented as an example for residents taking an active and influential part in establishing new horizons in surgical training.

The Israeli Surgical Association (ISA) is celebrating its 60th anniversary. The current edition of the journal includes papers on surgical oncology, intraoperative radiotherapy and emergency surgery, as well as surgical education. The outstanding range of topics represents the academic achievements of Israeli general surgeons and highlights clinical and surgical research accomplishments. ISA is currently advancing changes in surgical education as well as promoting the use of flexible endoscopy among the relevant surgeons. These two topics are presented in articles in this current issue. A retrospective review of the past 60 years since the establishment of ISA celebrates its members' achievements with pride and gazes with excitement at the future as emergent technology will change future surgery and new horizons in surgical education will model the new professional and knowledgeable general surgeons.

Background Traumatic brain injury (TBI) is a global health problem. Extracranial hemorrhagic lesions needing emergency surgery adversely affect the outcome of TBI. We conducted an international survey regarding the acute phase management practices in TBI polytrauma patients. Methods A questionnaire was available on the World Society of Emergency Surgery website between December 2017 and February 2018. The main endpoints were the evaluation of (1) intracranial pressure (ICP) monitoring during extracranial emergency surgery (EES), (2) hemodynamic management without ICP monitoring during EES, (3) coagulation management, and (4) utilization of simultaneous multisystem surgery (SMS). Results The respondents were 122 representing 105 trauma centers worldwide. ICP monitoring was utilized in 10–30% of patients at risk of intracranial hypertension (IH) undergoing EES from about a third of the respondents [n = 35 (29%)]. The respondents reported that the safest values of systolic blood pressure during EES in patients at risk of IH were 90–100 mmHg [n = 35 (29%)] and 100–110 mmHg [n = 35 (29%)]. The safest values of mean arterial pressure during EES in patients at risk of IH were > 70 mmHg [n = 44 (36%)] and > 80 mmHg [n = 32 (26%)]. Regarding ICP placement, a large percentage of respondents considered a platelet (PLT) count > 50,000/mm3 [n = 57 (47%)] and a prothrombin time (PT)/activated partial thromboplastin time (aPTT) 100,000/mm3 [n = 67 (55%)] and a PT/aPTT

Establishing a definitive airway in a trauma patient is a primary essential of early management. Any flaw in airway management may lead to grave morbidity or mortality. Occasionally, the caregiver may encounter difficulties in intubating the patient for anatomical or technical reasons, especially if the trauma involves the face and neck regions. In addition, trauma patient is generally regarded as having a “full stomach” and often has not been cleared of a C-spine injury. These may complicate airway management furthermore. The time available to accomplish airway control is short, and the patient’s condition may deteriorate rapidly. Both decision-making and performance are impaired in such circumstances. In order to improve airway management capability, the physician has to understand the complexity of the situation, be familiar with various airway devices and alternative ventilation techniques, and have experience in several emergency airway skills.

Background The World Society of Emergency Surgery (WSES) spleen trauma classification meets the need of an evolution of the current anatomical spleen injury scale considering both the anatomical lesions and their physiologic effect. The aim of the present study is to evaluate the efficacy and trustfulness of the WSES classification as a tool in the decision-making process during spleen trauma management. Methods Multicenter prospective observational study on adult patients with blunt splenic trauma managed between 2014 and 2016 in two Italian trauma centers (ASST Papa Giovanni XXIII in Bergamo and Sant’Anna University Hospital in Ferrara). Risk factors for operative management at the arrival of the patient and as a definitive treatment were analyzed. Moreover, the association between the different WSES grades of injury and the definitive management was analyzed. Results One hundred twenty-four patients were included. At multivariate analysis, a WSES splenic injury grade IV is a risk factor for the operative management both at the arrival of the patients and as a definitive treatment. WSES splenic injury grade III is a risk factor for angioembolization. Conclusions The WSES classification is a good and reliable tool in the decision-making process in splenic trauma management.

Introduction: No definitive data exist regarding epidemiology and outcomes of patients treated with open abdomen (OA) linked to age. Methods: This is a prospective, observational, cohort study that includes patients treated with OA. Patients were divided into 4 age groups: group 1: 16–40 y.o.; group 2: 41–60 y.o.; group 3:61–80 y.o.; group 4:> 80 y.o. Results: 760 patients were enrolled. Average age was 60 ± 18aa; 57.2% were males. Most frequent indication was peritonitis (50.9%). Mean open duration of open abdomen was8±18 days. Definitive closure was reached in 81.1% of patients. Complications were recorded in 84.8% of patients with significant differences between groups (p = 0.001). Overall mortality was41.2% with significant differences between groups (p < 0.001) (group 1 25.6%, group 2 36.1%, group 3 44.5%, group 4 67.1%) 1 month follow-up mortality post-OA was 9.2% and 1 year follow-up mortality was 11.6%; Conclusions: Open abdomen treatment is feasible at every age. Diseases requiring treatment with OA are differently distributed in relation to the different age groups. Advanced age has negative effect on complications and mortality rate.

The role of radiotherapy in the treatment of rectal cancer patients both in the neoadjuvant and adjuvant settings has grown tremendously in recent decades.

The esophagus traverses three body compartments (neck, thorax, and abdomen) and is surrounded at each level by vital organs. Injuries to the esophagus may be classified as foreign body ingestion, caustic ingestion, esophageal perforation, and esophageal trauma. These lesions can be life-threatening either by digestive contamination of surrounding structures in case of esophageal wall breach or concomitant damage of surrounding organs. Early diagnosis and timely therapeutic intervention are the keys of successful management.

Background Gallstone disease is very common afflicting 20 million people in the USA. In Europe, the overall incidence of gallstone disease is 18.8% in women and 9.5% in men. The frequency of gallstones related disease increases by age. The elderly population is increasing worldwide. Aim The present guidelines aims to report the results of the World Society of Emergency Surgery (WSES) and Italian Surgical Society for Elderly (SICG) consensus conference on acute calcolous cholecystitis (ACC) focused on elderly population. Material and methods The 2016 WSES guidelines on ACC were used as baseline; six questions have been used to investigate the particularities in elderly population; the answers have been developed in terms of differences compared to the general population and to statements of the 2016 WSES Guidelines. The Consensus Conference discusses, voted, and modified the statements. International experts contributed in the elaboration of final statements and evaluation of the level of scientific evidences. Results The quality of the studies available decreases when we approach ACC in elderly. Same admission laparoscopic cholecystectomy should be suggested for elderly people with ACC; frailty scores as well as clinical and surgical risk scores could be adopted but no general consensus exist. The role of cholecystostomy is uncertain. Discussion and conclusions The evaluation of pro and cons for surgery or for alternative treatments in elderly suffering of ACC is more complex than in young people; also, the oldest old age is not a contraindication for surgery; however, a larger use of frailty and surgical risk scores could contribute to reach the best clinical judgment by the surgeon. The present guidelines offer the opportunity to share with the scientific community a baseline for future researches and discussion.

Foreign body ingestion is common in mentally impaired adults. Fortunately, the vast majority of all swallowed objects pass through the gastrointestinal tract uneventfully. For patients in whom conservative treatment fails, early endoscopic intervention is required. Surgery is seldom indicated and reports of perforation or penetration of the GI tract are anecdotal. We present a case of a 32 years old mentally impaired patient with a trans-colonic penetration of a foreign body into the retro-hepatic vena cava. Keywords: Injury, Vena cava, Foreign body

Enlarged lymph nodes (ELN) pose a great diagnostic challenge. They may represent the first clinical finding of a hematologic disease or other malignancy and may be an indication of a wide range of infectious and non-infectious diseases. Because many patients undergo percutaneous biopsy, surgical excisional biopsy is not often considered.To analyze indications for a patient's referral for surgical biopsy of ELN and diagnostic steps to follow until referral, and to determine the number of ELN.A retrospective study was conducted of prospectively collected data of patients who underwent surgical biopsy of ELN from January 2004 to December 2013.Of 118 patients who underwent surgical biopsy of ELN, only 52 (44%) had needle biopsy (NB) before referral. Lymphoma was diagnosed by NB in 24 (46%) of the referred patients. In patients with a previous diagnosis of lymphoma, NB of ELN yielded a sensitivity of 67% and specificity of 79%. In patients with lymphadenopathy but with no previous history of malignancy, sensitivity for lymphoma was 68% and specificity was 71%. The investigative time period until final diagnosis was 3 months in patients who had NB but only 1.25 months in patients who were referred directly for surgery (P0.0001).Surgical biopsy of ELN still has a place in the clinical evaluation of patients with ELN. Surgery may significantly reduce the length of investigation and prevent unnecessary diagnostics, especially in patients with suspected lymphoma recurrence.

Introduction Prompt appendectomy has long been the standard of care for acute appendicitis in order to prevent complications such as perforation, abscess formation, and diffuse purulent or fecal peritonitis, all resulting in increased morbidity and even mortality. Our study was designed to examine whether the time from the beginning of symptoms to operation correlates with the pathological degree of appendicitis, incidence of postoperative complications, or increased length of hospital stay. Methods A prospective study of 171 patients who underwent emergent appendectomy for acute appendicitis in the course of 2 years was conducted in a single tertiary medical center. The following parameters were monitored and correlated: demographics, time from the onset of symptoms until the arrival to the emergency department (patient interval (PI)), time from arrival to the emergency department (ED) until appendectomy (hospital interval (HI)), time from the onset of symptoms until appendectomy (total interval (TI)), physical examination, preoperative physical findings, laboratory data, pathologic findings, complications, and length of hospital stay. Results The degree of pathology and complications were analyzed according to the time intervals. The time elapsed from the onset of symptoms to surgery was associated with higher pathology grade (p = 0.01). We found that longer time from the onset of symptoms to hospital arrival correlates with higher pathology grade (p = 0.04), while there was no correlation between the hospital interval and pathology grade (p = 0.68). A significant correlation was found between the pathology grade and the incidence of postoperative complications as well as with increased length of hospital stay (p = 0.000). Conclusion Time elapsed from the symptom onset to appendectomy correlates with increased pathology grade and complication rate. This correlation was not related to the HI. Since the HI in our study was short, we recommend an early appendectomy in adults in order to shorten the TI and the resulting complications.

Damage control resuscitation may lead to postoperative intra-abdominal hypertension or abdominal compartment syndrome. These conditions may result in a vicious, self-perpetuating cycle leading to severe physiologic derangements and multiorgan failure unless interrupted by abdominal (surgical or other) decompression. Further, in some clinical situations, the abdomen cannot be closed due to the visceral edema, the inability to control the compelling source of infection or the necessity to re-explore (as a "planned second-look" laparotomy) or complete previously initiated damage control procedures or in cases of abdominal wall disruption. The open abdomen in trauma and non-trauma patients has been proposed to be effective in preventing or treating deranged physiology in patients with severe injuries or critical illness when no other perceived options exist. Its use, however, remains controversial as it is resource consuming and represents a non-anatomic situation with the potential for severe adverse effects. Its use, therefore, should only be considered in patients who would most benefit from it. Abdominal fascia-to-fascia closure should be done as soon as the patient can physiologically tolerate it. All precautions to minimize complications should be implemented.

The Global Alliance for Infections in Surgery appreciates the great effort of the task force who derived and validated the Sepsis-3 definitions and considers the new definitions an important step forward in the evolution of our understanding of sepsis. Nevertheless, more than a year after their publication, we have a few concerns regarding the use of the Sepsis-3 definitions.

A position paper (PP) should establish a unified voice in areas where controversy occurs based upon multiple practices and/or therapeutic choices. Typically, a position paper should elucidate the knowledge gap, followed by an evidence-based review of options, leading to an “endorsed position.” A position paper should represent more than the opinion or consensus of the authors but should present current opinions and practices supported by the World Society of Emergency Surgery (WSES). Accordingly, position papers should require the approval of an expert group of WSES and in parallel be presented at an annual meeting prior to submission for publication. It is important that a unified approach for drafting of position papers be established and endorsed by WSES in order to establish credibility and prevent misunderstandings during a smooth transition to publication. The purpose of this article is to suggest a uniform process for the development of WSES guidelines.

Optimal management of emergency surgical patients represents one of the major health challenges worldwide. Emergency general surgery (EGS) was identified as multidisciplinary surgery performed for traumatic and non-traumatic acute conditions during the same admission in the hospital. EGS represents the easiest viable way to provide affordable and high-quality level of care to emergency surgical and trauma patients. It may result from the association of different physicians with other specialties in a cooperative model. The World Society of Emergency Surgery (WSES) has been working on the EGS organization and implementation since its foundation believing in the need of common benchmarks for training and educational programs throughout the world. This is a plea in different languages to all World Prime Ministers and Presidents to support the creation in all nations of an organized hub-spoke system for emergency general surgery to improve standards of care and to save lives.

Abdominopelvic trauma has been for decades classified with the AAST-OIS (American Association for the Surgery of Trauma—Organ Injury Scale) classification. It has represented a milestone. At present, the medical evolutions in trauma management allowed an incredible progress in trauma decision-making and treatment. Non-operative trauma management has been widely applied. The interventional radiological procedures and the modern conception of Hybrid and Endovascular Trauma and Bleeding Management (EVTM) led to good results in increasing the rate of patients managed non-operatively, opening new scenarios and options. Even severe anatomical lesions in hemodynamically stable patients can be safely managed non-operatively. The driving issue in deciding for the best treatment is anatomy, as well as physiology, for the patient physiological derangement grade is even more important. The emergency general surgeon must be prepared in those pathophysiological issues that play the pivotal role in the team management of trauma patients. Moreover, the classification of trauma patients cannot only remain anchored to anatomical lesions. The necessity to follow the modern possibilities of treatment imposes addressing trauma using a classification based on anatomical lesions and on the physiological status of the patient.

Skin and soft-tissue infections (SSTIs) encompass a variety of pathological conditions that involve the skin and underlying subcutaneous tissue, fascia, or muscle, ranging from simple superficial infections to severe necrotizing infections. SSTIs are a frequent clinical problem in surgical departments. In order to clarify key issues in the management of SSTIs, a task force of experts met in Bertinoro, Italy, on June 28, 2018, for a specialist multidisciplinary consensus conference under the auspices of the World Society of Emergency Surgery (WSES) and the Surgical Infection Society Europe (SIS-E). The multifaceted nature of these infections has led to a collaboration among general and emergency surgeons, intensivists, and infectious disease specialists, who have shared these clinical practice recommendations.