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Background: Common bile duct (CBD) stones are found in 10% of patients who undergo elective laparoscopic surgery for gallstone disease and in 10-20% of patients who present with acute cholecystitis (AC). For the latter, the role of laparoscopic transcystic exploration of the common duct (LTCE) as part of a single-stage procedure is still unknown. Methods: This study, based on a 'laparoscopy first' policy, included 201 subjects with cholecystocholedocholithiasis: 104 underwent a scheduled laparoscopic surgery (group A), and 97 where admitted for AC and had urgent laparoscopy (group B). Group B patients were significantly older (68.4 vs. 62.1 years; P = 0.0045), had a higher proportion of women (56% vs. 41%; P = 0.0345), and included more patients in the ASA III-IV class (39% vs. 21%; P = 0.0006). LTCE was performed by using basket-wired catheters. CBD clearance, operating time, conversion rate, morbidity and mortality, postoperative hospital stay, readmission, and residual CBD stones were the main outcome measures. Results: Clearance of CBD was obtained in 84% of patients of group A and in 80% of patients of group B ( P = not significant). Time spent in the operating room was longer for group B (175 vs. 141 min; P = 0.0003). There were no significant differences for postoperative hospital stay (group A 4.9 vs. group B 5.2 days), readmission rate (3.7% vs. 3.7%), and residual CBD stones (2.8% vs. 3.1%). Need to convert and morbidity occurred more frequently in group B (11.7% vs. 4.6% and 28.7% vs. 16.8%, respectively), but differences were not significant. In group A, one patient died from MOFS. Conclusions: LTCE has proved to be a simple technique with a high yield of CBD clearance in the acute setting. Courses are comparable to those observed for the same procedure in elective surgery despite the fact that patients with AC are more at risk for drawbacks. [ABSTRACT FROM AUTHOR]

Summary: Background: The primary challenge of surgery for colon cancer (CC) presenting as an emergency is the control of the complication but a proper oncologic technique should not be missed when bowel resection is feasible. Currently, recommended oncologic criteria include en-bloc resection of invaded organs and structures, an adequate extent of the bowel resection and of the free margins and an adequate number of lymph nodes yielded. Methods: Chart-review of 499 CC patients undergone colectomy. One hundred and twenty-one (group A) presented as emergencies (obstruction n=85, perforation n=30, hemorrhage n=6) and were analyzed for tumor stage, need for enlarged resection, distal free margin, lymph node yield, mortalty and morbidity. Results were compared with those observed in the 378 patients operated electively (group B). Results: Group A patients had a more advanced cancer stage (stage III/IV 62.8% vs. 48.7%, p<.01), but the need for enlarged resection was not significantly different in the two groups. Also the length of free distal margin was similar (means, group A: 97mm; group B: 84mm, p=ns). The number of excised nodes was greater in emergency (means, group A: 26.2 nodes; group B: 20.8 nodes, p<.01). Compared with group B, emergency procedures resulted in higher morbidity (22.3% vs. 13.4%, p<.05) and mortality (8.2% vs. .8%, p<.0001). Conclusions: Recommended oncologic resection techniques may be applicable to surgery for complicated tumors of the colon and radical resection may be warranted by emergency colectomy. The worse long-term prognosis for patients with colonic cancer presenting acutely may be related to the stage of the disease rather than to the failure of surgery. [Copyright &y& Elsevier]

Background: Gastrointestinal stromal tumours (GISTs) are uncommon primary mesenchymal tumours of the gastrointestinal tract mostly observed in the adults. Duodenal GISTs are relatively rare in adults and it should be regarded as exceptional in childhood. In young patients duodenal GISTs may be a source of potentially lethal haemorrhage and this adds diagnostic and therapeutic dilemmas to the concern about the long-term outcome. Case presentation: A 14-year-old boy was referred to our hospital with severe anaemia due to recurrent episodes of upper gastrointestinal haemorrhage. Endoscopy, small bowel series, scintigraphy and video capsule endoscopy previously done elsewhere were negative. Shortly after the admission, the patient underwent emergency surgery for severe recurrence of the bleeding. At surgery, a 4 cm solid mass arising from the wall of the fourth portion of the duodenum was identified. The invasion and the erosion of the duodenal mucosa was confirmed by intra-operative pushed duodenoscopy. The mass was resected by a full-thickness duodenal wall excision with adequate grossly free margins. Immunohistochemical analysis of the specimen revealed to be positive for CD117 (c-KIT protein) consistent with a diagnosis of GIST. The number of mitoses was < 5/50 HPF. Mutational analysis for c-KIT/PDGFRA tyrosine kinase receptor genes resulted in a wildtype pattern. The patient had an uneventful course and he has remained disease-free during two years of follow-up. Conclusion: Duodenal GISTs in children are very rare and may present with massive bleeding. Cure can be achieved by complete surgical resection, but even in the low-aggressive tumours the long-term outcome may be unpredictable. [ABSTRACT FROM AUTHOR]

Background: Controversies remain on the diagnostic strategy in suspected AA, considering the different settings worldwide. Material and Methods: A prospective observational international multicentric study including patients operated for suspected AA with a definitive histopathological analysis was conducted. Three groups were analyzed: (1) No radiology; (2) Ultrasound, and (3) Computed tomography. The aim was to analyze the performance of three diagnostic schemes. Results: Three thousand and one hundred twenty three patients were enrolled; 899 in the no radiology group, 1490 in the US group, and 734 in the CT group. The sex ratio was in favor of males (p < 0.001). The mean age was lower in the no radiology group (24 years) compared to 28 and 38 years in US and CT‐scan groups, respectively (p < 0.001). Overall, the negative appendectomy rate 3.8%: no radiology group (5.1%) versus US (2.9%) and CT‐scan (4.1%) (p < 0.001). The sensitivity and specificity analysis showed the best balance in clinical evaluation + score + US. These data reach the best results in those patients with an equivocal Alvarado score (4–6). Inverse probability weighting (IPW), showed as the use of ultrasound, is significantly associated with an increased probability of formulating the correct diagnosis (p 0.004). In the case of a CT scan, this association appears weaker (p 0.08). Conclusion: The association of clinical scores and ultrasound seems the best strategy to reach a correct preoperative diagnosis in patients with clinical suspicion of AA, even in those population subgroups where the clinical score may have an equivocal result. This strategy can be especially useful in low‐resource settings worldwide. CT‐scan association may improve the detection of patients who may potentially be submitted to conservative treatment. [ABSTRACT FROM AUTHOR]

Laparotomy incisions provide easy and rapid access to the peritoneal cavity in case of emergency surgery. Incisional hernia (IH) is a late manifestation of the failure of abdominal wall closure and represents frequent complication of any abdominal incision: IHs can cause pain and discomfort to the patients but also clinical serious sequelae like bowel obstruction, incarceration, strangulation, and necessity of reoperation. Previous guidelines and indications in the literature consider elective settings and evidence about laparotomy closure in emergency settings is lacking. This paper aims to present the World Society of Emergency Surgery (WSES) project called ECLAPTE (Effective Closure of LAParoTomy in Emergency): the final manuscript includes guidelines on the closure of emergency laparotomy. [ABSTRACT FROM AUTHOR]

The current COVID-19 pandemic underlines the importance of a mindful utilization of financial and human resources. Preserving resources and manpower is paramount in healthcare. It is important to ensure the ability of surgeons and specialized professionals to function through the pandemic. A conscious effort should be made to minimize infection in this sector. A high mortality rate within this group would be detrimental. This manuscript is the result of a collaboration between the major Italian surgical and anesthesiologic societies: ACOI, SIC, SICUT, SICO, SICG, SIFIPAC, SICE, and SIAARTI. We aim to describe recommended clinical pathways for COVID-19-positive patients requiring acute non-deferrable surgical care. All hospitals should organize dedicated protocols and workforce training as part of the effort to face the current pandemic. [ABSTRACT FROM AUTHOR]

Iatrogenic urinary tract injury (IUTI) is a severe complication of emergency digestive surgery. It can lead to increased postoperative morbidity and mortality and have a long-term impact on the quality of life. The reported incidence of IUTIs varies greatly among the studies, ranging from 0.3 to 1.5%. Given the high volume of emergency digestive surgery performed worldwide, there is a need for well-defined and effective strategies to prevent and manage IUTIs. Currently, there is a lack of consensus regarding the prevention, detection, and management of IUTIs in the emergency setting. The present guidelines, promoted by the World Society of Emergency Surgery (WSES), were developed following a systematic review of the literature and an international expert panel discussion. The primary aim of these WSES guidelines is to provide evidence-based recommendations to support clinicians and surgeons in the prevention, detection, and management of IUTIs during emergency digestive surgery. The following key aspects were considered: (1) effectiveness of preventive interventions for IUTIs during emergency digestive surgery; (2) intra-operative detection of IUTIs and appropriate management strategies; (3) postoperative detection of IUTIs and appropriate management strategies and timing; and (4) effectiveness of antibiotic therapy (including type and duration) in case of IUTIs. [ABSTRACT FROM AUTHOR]

Background: Immunocompromised patients with acute diverticulitis are at increased risk of morbidity and mortality. The aim of this study was to compare clinical presentations, types of treatment, and outcomes between immunocompromised and immunocompetent patients with acute diverticulitis. Methods: We compared the data of patients with acute diverticulitis extracted from the Web-based International Registry of Emergency Surgery and Trauma (WIRES-T) from January 2018 to December 2021. First, two groups were identified: medical therapy (A) and surgical therapy (B). Each group was divided into three subgroups: nonimmunocompromised (grade 0), mildly to moderately (grade 1), and severely immunocompromised (grade 2). Results: Data from 482 patients were analyzed—229 patients (47.5%) [M:F = 1:1; median age: 60 (24–95) years] in group A and 253 patients (52.5%) [M:F = 1:1; median age: 71 (26–94) years] in group B. There was a significant difference between the two groups in grade distribution: 69.9% versus 38.3% for grade 0, 26.6% versus 51% for grade 1, and 3.5% versus 10.7% for grade 2 (p < 0.00001). In group A, severe sepsis (p = 0.027) was more common in higher grades of immunodeficiency. Patients with grade 2 needed longer hospitalization (p = 0.005). In group B, a similar condition was found in terms of severe sepsis (p = 0.002), quick Sequential Organ Failure Assessment score > 2 (p = 0.0002), and Mannheim Peritonitis Index (p = 0.010). A Hartmann's procedure is mainly performed in grades 1–2 (p < 0.0001). Major complications increased significantly after a Hartmann's procedure (p = 0.047). Mortality was higher in the immunocompromised patients (p = 0.002). Conclusions: Immunocompromised patients with acute diverticulitis present with a more severe clinical picture. When surgery is required, immunocompromised patients mainly undergo a Hartmann's procedure. Postoperative morbidity and mortality are, however, higher in immunocompromised patients, who also require a longer hospital stay. [ABSTRACT FROM AUTHOR]

Background: This systematic review aims to investigate whether percutaneous transhepatic gallbladder biliary drainage (PTGBD) is superior to emergency cholecystectomy (EC) as a definitive treatment in high-risk patients with acute cholecystitis (AC). Material and Methods: A systematic literature search was performed until December 2022 using the Scopus, Medline/PubMed and Web of Science databases. Results: Seventeen studies have been included with a total of 783,672 patients (32,634 treated with PTGBD vs. 4663 who underwent laparoscopic cholecystectomy, 343 who had open cholecystectomy and 746,032 who had some form of cholecystectomy, but without laparoscopic or open approach being specified). An analysis of the results shows that PTGBD, despite being less invasive, is not associated with lower morbidity with respect to EC (RR 0.77 95% CI [0.44 to 1.34]; I2 = 99%; p = 0.36). A lower postoperative mortality was reported in patients who underwent EC (2.37%) with respect to the PTGBD group (13.78%) (RR 4.21; 95% CI [2.69 to 6.58]; p < 0.00001); furthermore, the risk of hospital readmission for biliary complications (RR 2.19 95% CI [1.72 to 2.79]; I2 = 48%; p < 0.00001) and hospital stay (MD 4.29 95% CI [2.40 to 6.19]; p < 0.00001) were lower in the EC group. Conclusions: In our systematic review, the majority of studies have very low-quality evidence and more RCTs are needed; furthermore, PTGBD is inferior in the treatment of AC in high-risk patients. The definition of high-risk patients is important in interpreting the results, but the methods of assessment and definitions differ between studies. The results of our systematic review and meta-analysis failed to demonstrate any advantage of using PTGBD over ER as a definitive treatment of AC in critically ill patients, which suggests that EC should be considered as the treatment of choice even in very high-risk patients. Most likely, the inferiority of PTGBD versus early LC for high-risk patients is related to an association of various patient-side factor conditions and the severity of acute cholecystitis. [ABSTRACT FROM AUTHOR]

Acute cholecystitis is one of the most common causes of acute abdomen. Early laparoscopic cholecystectomy is the gold standard treatment, still burdened by a risk of intraoperative biliary duct injury. An alternative strategy to manage patients with severe acute cholecystitis is the percutaneous gallbladder drainage (PGBD). The Italian Society of Emergency Surgery and Trauma performed a systematic review and meta-analysis with the aim to clarify controversies about the preoperative use of PGBD. We extracted 32 studies: 9 Randomized Control Trial Studies (RCTs) and 23 no RCTs. The incidence of post-operative complications was lower in the PGBD associated at LC than in the LC alone (RCTs: RR 0.28, 95% CI 0.14 to 0.56, I2 = 63%). The incidence of the post-operative biliary leakage was higher in late PGBD' group (RCTs: RR 0.18, 95% CI 0.04 to 0.80). The incidence of intraabdominal abscess, blood loss, conversion to open, subtotal cholecystectomy, operative time and wound infection was lower in PGBD' group. The total hospital stay was the same. A strong recommendation is performed to the use of the PGBD + LC than upfront LC to reduce biliary leakage (recommendation "strong positive") in high risk acute cholecystitis especially in patients with higher perioperative risks or longstanding acute cholecystitis. For post-operative complications a recommendation "positive weak" suggests that PGBD + LC could be used than upfront LC to reduce the rate of post-operative complications. • Laparoscopic cholecystectomy is still burdened by a certain risk of biliary injury. • An alternative strategy to manage acute cholecystitis is the cholecystostomy. • Lower complications in the drainage before laparoscopic cholecystectomy group. • Secondary outcomes are in favour of the drainage before the cholecystectomy. • Cholecystostomy before cholecystectomy is recommended in severe cholecystitis. [ABSTRACT FROM AUTHOR]

Laparotomy incisions provide easy and rapid access to the peritoneal cavity in case of emergency surgery. Incisional hernia (IH) is a late manifestation of the failure of abdominal wall closure and represents frequent complication of any abdominal incision: IHs can cause pain and discomfort to the patients but also clinical serious sequelae like bowel obstruction, incarceration, strangulation, and necessity of reoperation. Previous guidelines and indications in the literature consider elective settings and evidence about laparotomy closure in emergency settings is lacking. This paper aims to present the World Society of Emergency Surgery (WSES) project called ECLAPTE (Effective Closure of LAParoTomy in Emergency): the final manuscript includes guidelines on the closure of emergency laparotomy. [ABSTRACT FROM AUTHOR]

Introduction: ERAS pathway has been proposed as the standard of care in elective abdominal surgery. Guidelines on ERAS in emergency surgery have been recently published; however, few evidences are still available in the literature. The aim of this study was to evaluate the feasibility of an enhanced recovery protocol in a large cohort of patients undergoing emergency surgery and to identify possible factors impacting postoperative protocol compliance. Methods: This is a prospective multicenter observational study including patients who underwent major emergency general surgery for either intra-abdominal infection or intestinal obstruction. The primary endpoint of the study is the adherence to ERAS postoperative protocol. Secondary endpoints are 30-day mortality and morbidity rates, and length of hospital stay. Results: A total of 589 patients were enrolled in the study, 256 (43.5%) of them underwent intestinal resection with anastomosis. Major complications occurred in 92 (15.6%) patients and 30-day mortality was 6.3%. Median adherence occurred on postoperative day (POD) 1 for naso-gastric tube removal, on POD 2 for mobilization and urinary catheter removal, and on POD 3 for oral intake and i.v. fluid suspension. Laparoscopy was significantly associated with adherence to postoperative protocol, whereas operative fluid infusion > 12 mL/Kg/h, preoperative hyperglycemia, presence of a drain, duration of surgery and major complications showed a negative association. Conclusions: The present study supports that an enhanced recovery protocol in emergency surgery is feasible and safe. Laparoscopy was associated with an earlier recovery, whereas preoperative hyperglycemia, fluid overload, and abdominal drain were associated with a delayed recovery. [ABSTRACT FROM AUTHOR]

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). [ABSTRACT FROM AUTHOR]

Background: The risk of conversion to open surgery is inevitably present during any minimally invasive colorectal surgical procedure. Conversions have been associated with adverse postoperative and oncologic outcomes. No previous study has evaluated the specific causes and consequences of conversion during a minimally invasive right colectomy (MIS-RC). Materials and Methods: We analyzed the Minimally invasivE surgery for oncologic Right ColectomY (MERCY) study database including patients who underwent laparoscopic or robotic RC because of colon cancer between 2014 and 2020. Descriptive analyses were performed to determine the different reasons for conversion. Uni- and multivariate logistic regressions were run to identify potential variables associated with this outcome. Cox regression analyses were used to evaluate the impact of conversion on tumor recurrence. Results: Over a total of 1574 MIS-RC, 120 (7.6%) were converted to open surgery. The main reasons for conversion were procedural difficulties related to adherences from previous abdominal surgical procedures (39.2%), or owing to large tumor size or infiltration of adjacent structures (26.7%). Only 16.7% of the conversions were caused by intraoperative medical or surgical complications. Converted patients required longer operative times and developed more postoperative complications, both overall (39.2% versus 27.5%; P = .006) and severe ones (13.3% versus 8.3%; P = .061). Male gender (odds ratio [OR] = 1.89 [95% confidence interval: 1.31–2.71]), obesity (OR = 1.99 [1.4–2.83]), prior abdominal surgery (OR = 1.68 [1.19–2.37]), and pT4 cancers (OR = 4.04 [2.86–5.69]) were independently associated with conversion. Conversion to open surgery was not significantly associated with tumor recurrence (hazard ratios = 1.395 [0.724–2.687]). Conclusions: Although conversion to open surgery during MIS-RC for cancer is associated with worsened postoperative outcomes, it seems not to impact on the oncologic prognosis. [ABSTRACT FROM AUTHOR]

As we walk through a period of uncertainty, it becomes essential to obtain clear, prompt, and evidence-based indications to guide surgeons and protect OR staff. The SARS-CoV-2 pandemic profoundly modified the patients' case load of most surgical units, affecting both the volume and the quality of care: different behaviors have been suggested to regulate surgical and endoscopic activity during the emergency [[1]-[6]] and a significant concern has been raised about the possibility of contagion from patients affected by COVID-19 infection during interventional procedures. A low cost, safe and effective method for smoke evacuation in laparoscopic surgery for suspected coronavirus patients. [Extracted from the article]

BACKGROUND: The American College of Surgeons NSQIP surgical risk calculator provides an estimation of 30-day postoperative adverse outcomes. It is useful in the identification of high-risk patients needing clinical optimization and supports the informed consent process. The purpose of this study is to validate its predictive value in the Italian emergency setting. STUDY DESIGN: Six Italian institutions were included. Inclusion diagnoses were acute cholecystitis, appendicitis, gastrointestinal perforation or obstruction. Areas under the receiving operating characteristic curves, Brier score, Hosmer-Lemeshow index, and observed-to-expected event ratio were measured to assess both discrimination and calibration. Effect of the Surgeon Adjustment Score on calibration was then tested. A patient's personal risk ratio was obtained, and a cutoff was chosen to predict mortality with a high negative predicted value. RESULTS: A total of 2,749 emergency procedures were considered for the analysis. The areas under the receiving operating characteristic curve were 0.932 for death (0.921 to 0.941, p < 0.0001; Brier 0.041) and 0.918 for discharge to nursing or rehabilitation facility (0.907 to 0.929, p < 0.0001; 0.070). Discrimination was also strong (area under the receiving operating characteristic curve >0.8) for renal failure, cardiac complication, pneumonia, venous thromboembolism, serious complication, and any complication. Brier score was informative (<0.25) for all the presented variables. The observed-to-expected event ratios were 1.0 for death and 0.8 for discharge to facility. For almost all other variables, there was a general risk underestimation, but the use of the Surgeon Adjustment Score permitted a better calibration of the model. A risk ratio >3.00 predicted the onset of death with sensitivity = 86%, specificity = 77%, and negative predicted value = 99%. CONCLUSIONS: The American College of Surgeons NSQIP surgical risk calculator has proved to be a reliable predictor of adverse postoperative outcomes also in Italian emergency settings, with particular regard to mortality. We therefore recommend the use of the surgical risk calculator in the multidisciplinary care of patients undergoing emergency abdominal surgery. The American College of Surgeons NSQIP Surgical Risk Calculator was not validated in emergency surgery outside the US. External validation on 2,749 emergency procedures was performed at 6 Italian institutions. The analysis showed that the calculator is a reliable predictor of adverse postoperative outcomes, particularly mortality. [ABSTRACT FROM AUTHOR]

Numerous innovations have been aided by abdominal wall surgical repair. Abdominal wall surgery was drastically altered by synthetic materials. Tissue engineering was unquestionably first applied to biomaterials. The purpose of the present study is to compare different repeating approaches with rising tissue engineering complexity in repairing complex incisional hernia in emergency setting. Patients with complicated incisional hernia were prospectively included in the study and divided into 4 groups: DR (Direct Repair) group underwent direct reconstruction of the abdominal wall, BR (Biological mesh Repair) group underwent reconstruction of the abdominal wall with biological mesh (retro-muscular), BPR [Biological mesh and Platelet Enriched Plasma (PEP), gel] group underwent reconstruction of the abdominal wall with Biological mesh (retro-muscular) and PEP, BPSR (biological mesh, PEP gel and Bone Marrow Stem Cells) group underwent reconstruction of the abdominal wall with biological mesh (retromuscular), PEP and Bone Marrow Stem cells (BMSc). Forty patients were enrolled. Patients in the DR group experienced a higher rate of severe complication (p<0.05). Recurrence rates were 60% for DR patients, 20% for BM patients and 10% for the BM+PEP group (p<0.05). Median follow-up period was 64.6, 55.7 and 55.8 months (p<0.05). 7- and 30-days abdominal wall thickness is progressively increased by different techniques: BP, BP+PEP and BP+PEP+BMSc (p<0.05). No mortality was registered. Tissue engineering techniques in abdominal wall reconstruction showed promising results. They seem to reduce the recurrence rate without increasing complication one in complicated incisional abdominal wall hernia. Although many aspects are yet to be determined and standardized, it seems extremely important to continue research and experimentation in this field. [ABSTRACT FROM AUTHOR]

Background: International register of open abdomen (IROA) enrolls patients from several centers in American, European, and Asiatic continent. The aim of our study is to compare the characteristics, management and clinical outcome of adult patients treated with OA in the three continents. Material and methods: A prospective analysis of adult patients enrolled in the international register of open abdomen (IROA). Trial registration: NCT02382770. Results: 1183 patients were enrolled from American, European and Asiatic Continent. Median age was 63 years (IQR 49–74) and was higher in the European continent (65 years, p < 0.001); 57% were male. The main indication for OA was peritonitis (50.6%) followed by trauma (15.4%) and vascular emergency (13.5%) with differences among the continents (p < 0.001). Commercial NPWT was preferred in America and Europe (77.4% and 52.3% of cases) while Barker vacuum pack (48.2%) was the preferred temporary abdominal closure technique in Asia (p < 0.001). Definitive abdominal closure was achieved in 82.3% of cases in America (fascial closure in 90.2% of cases) and in 56.4% of cases in Asia (p < 0.001). Prosthesis were mostly used in Europe (17.3%, p < 0.001). The overall entero-atmospheric fistula rate 2.5%. Median open abdomen duration was 4 days (IQR 2–7). The overall intensive care unit and hospital length-of-stay were, respectively, 8 and 11 days (no differences between continents). The overall morbidity and mortality rates for America, Europe, and Asia were, respectively, 75.8%, 75.3%, 91.8% (p = 0.001) and 31.9%, 51.6%, 56.9% (p < 0.001). Conclusion: There is no uniformity in OA management in the different continents. Heterogeneous adherence to international guidelines application is evident. Different temporary abdominal closure techniques in relation to indications led to different outcomes across the continents. Adherence to guidelines, combined with more consistent data, will ultimately allow to improving knowledge and outcome. [ABSTRACT FROM AUTHOR]

Aim: Operation time (OT) is a key operational factor influencing surgical outcomes. The present study aimed to analyse whether OT impacts on short‐term outcomes of minimally‐invasive right colectomies by assessing the role of surgical approach (robotic [RRC] or laparoscopic right colectomy [LRC]), and type of ileocolic anastomosis (i.e., intracorporal [IA] or extra‐corporal anastomosis [EA]). Methods: This was a retrospective analysis of the Minimally‐invasivE surgery for oncological Right ColectomY (MERCY) Study Group database, which included adult patients with nonmetastatic right colon adenocarcinoma operated on by oncological RRC or LRC between January 2014 and December 2020. Univariate and multivariate analyses were used. Results: The study sample was composed of 1549 patients who were divided into three groups according to the OT quartiles: (1) First quartile, <135 min (n = 386); (2) Second and third quartiles, 135–199 min (n = 731); and (3) Fourth quartile ≥200 min (n = 432). The majority (62.7%) were LRC‐EA, followed by LRC‐IA (24.3%), RRC‐IA (11.1%), and RRC‐EA (1.9%). Independent predictors of an OT ≥ 200 min included male gender, age, obesity, diabetes, use of indocyanine green fluorescence, and IA confection. An OT ≥ 200 min was significantly associated with an increased risk of postoperative noninfective complications (AOR: 1.56; 95% CI: 1.15–2.13; p = 0.004), whereas the surgical approach and the type of anastomosis had no impact on postoperative morbidity. Conclusion: Prolonged OT is independently associated with increased odds of postoperative noninfective complications in oncological minimally‐invasive right colectomy. [ABSTRACT FROM AUTHOR]

Acute mesenteric ischemia (AMI) is a group of diseases characterized by an interruption of the blood supply to varying portions of the intestine, leading to ischemia and secondary inflammatory changes. If untreated, this process may progress to life-threatening intestinal necrosis. The incidence is low, estimated at 0.09–0.2% of all acute surgical admissions, but increases with age. Although the entity is an uncommon cause of abdominal pain, diligence is required because if untreated, mortality remains in the range of 50%. Early diagnosis and timely surgical intervention are the cornerstones of modern treatment to reduce the high mortality associated with this entity. The advent of endovascular approaches in parallel with modern imaging techniques is evolving and provides new treatment options. Lastly, a focused multidisciplinary approach based on early diagnosis and individualized treatment is essential. Thus, we believe that updated guidelines from World Society of Emergency Surgery are warranted, in order to provide the most recent and practical recommendations for diagnosis and treatment of AMI. [ABSTRACT FROM AUTHOR]

Abstract: The case of a 70-year-old patient with a leiomyosarcoma of the right ovarian vein is presented. For this rare entity, complete surgical excision is believed to offer the best chance of cure. [Copyright &y& Elsevier]

Introduction: Colon cancer (CC) and epithelial ovarian cancer (EOC) are common and severe neoplasms frequently sharing a massive inflammatory involvement of peritoneum. A detailed molecular characterization of such carcinomatosis has not been performed, so far. Methods: Omental adipocytes were isolated from thirty-three adult women who underwent primary surgery for CC or EOC. Expression of several pro-inflammatory genes was determined by real-time PCR and immunofluorescence. Data were related to the clinical phenotype of the patients. Results: CD68, FGFR1, and IL-6 were significantly more expressed in adipocytes from CC patients and VEGF in adipocytes from EOC. TNFα, TGFβ, or MCP-1, as well as the pro-inflammatory platform P2X7R-NLRP3, did not differ between the 2 cancers. White blood cell count, mirroring systemic inflammation, was related to adipocyte P2X7R (R = 0.508, p = 0.003), NLRP3 (R = 0.405; p = 0.02), and MCP-1 (R = 0.448; p = 0.009). P2X7R and NLRP3 were the only inflammatory factors significantly more expressed in patients carrying both omental and peritoneal carcinosis, who were also characterized by a higher leukocytosis. None of the tested inflammatory markers was associated with tumor grading for both neoplasms; however, the presence of metastases was associated with a higher adipocyte expression of FGFR1 and TGFβ. Conclusion: We show here that rarely measured molecules seem to specifically characterize omental carcinomatosis of CC or EOC, while more common inflammatory agents like TNFα, TGFβ, or MCP-1 do not; the P2X7R-NLRP3 complex marks omental and peritoneal carcinosis and is related to circulating white blood cells and MCP-1, involved in monocyte-macrophage tissue infiltration; increased TGFβ and FGFR1 characterize the tumoral dissemination. [ABSTRACT FROM AUTHOR]

The article presents the correction for a article titled "World Journal of Emergency Surgery (2023)" published in World Journal of Emergency Surgery 2023 edition.

Background: The objectives of the study were to investigate the organizational characteristics of acute care facilities worldwide in preventing and managing infections in surgery; assess participants' perception regarding infection prevention and control (IPC) measures, antibiotic prescribing practices, and source control; describe awareness about the global burden of antimicrobial resistance (AMR) and IPC measures; and determine the role of the Coronavirus Disease 2019 pandemic on said awareness. Methods: A cross-sectional web-based survey was conducted contacting 1432 health care workers (HCWs) belonging to a mailing list provided by the Global Alliance for Infections in Surgery. The self-administered questionnaire was developed by a multidisciplinary team. The survey was open from May 22, 2021, and June 22, 2021. Three reminders were sent, after 7, 14, and 21 days. Results: Three hundred four respondents from 72 countries returned a questionnaire, with an overall response rate of 21.2%. Respectively, 90.4% and 68.8% of participants stated their hospital had a multidisciplinary IPC team or a multidisciplinary antimicrobial stewardship team. Local protocols for antimicrobial therapy of surgical infections and protocols for surgical antibiotic prophylaxis were present in 76.6% and 90.8% of hospitals, respectively. In 23.4% and 24.0% of hospitals no surveillance systems for surgical site infections and no monitoring systems of used antimicrobials were implemented. Patient and family involvement in IPC management was considered to be slightly or not important in their hospital by the majority of respondents (65.1%). Awareness of the global burden of AMR among HCWs was considered very important or important by 54.6% of participants. The COVID-19 pandemic was considered by 80.3% of respondents as a very important or important factor in raising HCWs awareness of the IPC programs in their hospital. Based on the survey results, the authors developed 15 statements for several questions regarding the prevention and management of infections in surgery. The statements may be the starting point for designing future evidence-based recommendations. Conclusion: Adequacy of prevention and management of infections in acute care facilities depends on HCWs behaviours and on the organizational characteristics of acute health care facilities to support best practices and promote behavioural change. Patient involvement in the implementation of IPC is still little considered. A debate on how operationalising a fundamental change to IPC, from being solely the HCWs responsibility to one that involves a collaborative relationship between HCWs and patients, should be opened. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

• Sarcina Ventriculi is mainly isolated in the gastrointestinal tract. • Upper endoscopy could lead to SV diagnosis and rule out gastric perforations • Antibiotic therapy may eradicate the infection and prevent complications. • Emergency surgery is required in case of source control. This study is aimed to report a case of SV -related gastritis and the results of a systematic literature review of SV infections. Following a case presentation, we systematically searched different databases (MEDLINE, PubMed, Scopus, Web of Science, EMBASE, google scholar) for the items " sarcina, " " ventriculi, " " clostridium " with AND/OR. A total of 55 articles reporting 65 cases of Sarcina Ventriculi were found. Thus, 66 patients, including our case, were reviewed. The median age was 51 years (IQR: 0-87 years). Females accounted for 51% of cases. 68% of patients had one or more comorbidities. SV was isolated in the gastrointestinal tract (88%), respiratory (5%), urine (4%), and bloodstream (3%) systems. Upper endoscopy was performed in 52 patients (79%). Biopsies were obtained in all 52 cases and were normal in 23%. Surgery was warranted in 15 patients (23%), and specific antimicrobial therapy was delivered in 34 (52%) patients. Mortality was 14%. At follow-up, 88% of patients showed complete eradication of the SV infection. Upper gastrointestinal biopsy positive for SV should prompt an evaluation of the clinical conditions, considering the risk of gastric perforation is not negligible. Antibiotic therapy may eradicate the infection and prevent complications. Emergency surgery is required in case of source control. [ABSTRACT FROM AUTHOR]

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. Together, the World Society of Emergency Surgery, the Global Alliance for Infections in Surgery, the Surgical Infection Society-Europe, The World Surgical Infection Society, and the American Association for the Surgery of Trauma have jointly completed an international multi-society document to promote global standards of care in SSTIs guiding clinicians by describing reasonable approaches to the management of SSTIs. An extensive non-systematic review was conducted using the PubMed and MEDLINE databases, limited to the English language. The resulting evidence was shared by an international task force with different clinical backgrounds. [ABSTRACT FROM AUTHOR]

Spleen injuries are among the most frequent trauma-related injuries. The approach for diagnosis and management of Blunt Splenic Injury (BSI) has been considerably shifted towards Non-Operative Management (NOM) in the last few decades. NOM of blunt splenic injuries includes Splenic Angio-Embolization (SAE). Aim of this study was to analyze Pisa Level 1 trauma center (Italy) last 10-years-experience in the management of Blunt Splenic Trauma (BST), and more specifically to evaluate NOM rate and failure. Retrospective analysis of all patients admitted with blunt splenic trauma was done. They were divided into two groups according to the treatment: hemodynamically unstable patients treated operatively (OM group) and patients underwent a non-operative management (NOM group). The CT scan performed in all NOM group patients. Univariate analysis was performed to identify differences between the two groups. Multivariate analysis adjusting for factors with a p value < 0.05 or with clinical relevance was used to identify possible risk factors for NOM failure. 193 consecutive patients with blunt splenic trauma were admitted. Emergency splenectomies were performed in 53 patients (OM group); 140 were managed non-operatively with or without SAE (NOM group). NOM rate in high grade injuries is 57%. Overall NOM failure rate is 9%, and success rate in high grade splenic injuries is 48%; multivariate analysis showed AAST score ≥3 as a risk factor for NOM failure. Non-operative management currently represents the gold standard management for hemodynamically stable patient with blunt splenic trauma even in high grade splenic injuries. AAST ≥3 spleen lesion is a failure risk factor but not a contraindication to for non-operative management. [ABSTRACT FROM AUTHOR]

Background: The diagnosis of penetrating isolated diaphragmatic injuries can be challenging because they are usually asymptomatic. Diagnosis by chest X-ray (CXR) is unreliable, while CT scan is reported to be more valuable. This study evaluated the diagnostic ability of CXR and CT in patients with proven DI.Methods: Single center retrospective study (2009-2019), including all patients with penetrating diaphragmatic injuries (pDI) documented at laparotomy or laparoscopy with preoperative CXR and/or CT evaluation. Imaging findings included hemo/pneumothorax, hemoperitoneum, pneumoperitoneum, elevated diaphragm, definitive DI, diaphragmatic hernia, and associated abdominal injuries.Results: 230 patients were included, 62 (27%) of which had isolated pDI, while 168 (73%) had associated abdominal or chest trauma. Of the 221 patients with proven DI and preoperative CXR, the CXR showed hemo/pneumothorax in 99 (45%), elevated diaphragm in 51 (23%), and diaphragmatic hernia in 4 (1.8%). In 86 (39%) patients, the CXR was normal. In 126 patients with pDI and preoperative CT, imaging showed hemo/pneumothorax in 95 (75%), hemoperitoneum in 66 (52%), pneumoperitoneum in 35 (28%), definitive DI in 56 (44%), suspected DI in 26 (21%), and no abnormality in 3 (2%). Of the 57 patients with isolated pDI the CXR showed a hemo/pneumothorax in 24 (42%), elevated diaphragm in 14 (25%) and was normal in 24 (42%).Conclusions: Radiologic diagnosis of DI is unreliable. CT scan is much more sensitive than CXR. Laparoscopic evaluation should be considered liberally, irrespective of radiological findings. [ABSTRACT FROM AUTHOR]

Objective Smoking is a recognized cardiovascular risk factor. Perivascular visceral adipose tissue ( PVAT) is a source of inflammatory molecules, thus contributing to atherosclerosis progression. The P2 X7 receptor ( P2 X7 R)-inflammasome complex, crucial in determining IL-1β and IL-18 release, participates in this scenario. We evaluated whether smoking might affect the PVAT inflammatory phenotype and explored the putative role of the axis P2 X7 R-inflammasome in this picture. Subjects and Methods TNFα, IL-6, RBP4, MCP-1, as well as P2 X7 R and inflammasome components NLRP3, ASC, caspase-1 and IL-1β and IL-18 expression was determined in adipocytes isolated by PVAT of healthy smokers ( Smok) and nonsmokers ( No- Smok) subjects. Plasma and culture medium levels of these cytokines were also determined. Results Perivascular adipose tissue of Smok had a higher expression of P2 X7 R and inflammasome components; via P2 X7 R activation, it released more IL-1β and IL-18, whose serum levels were also higher in Smok than in No- Smok. Linear correlations of NLRP3 with P2 X7 R and IL-18 expression and release emerged. Smok also had a higher PVAT expression of the chemotactic factor MCP-1. However, no difference was observed in the PVAT expression of genes more strictly related to insulin resistance, like TNFα, RBP4, IL-6; this was coupled with similar plasma levels of TNFα and RBP4 in the two groups. Conclusion Smoking contributes to the pro-inflammatory status of the PVAT by enhancing expression and activity of the P2 X7 R-inflammasome complex; the effect on adipocytokines more related to insulin resistance and metabolic abnormalities appears trivial. [ABSTRACT FROM AUTHOR]

Abstract: Objective: P2X7 receptor (P2X7R), upon its stimulation with extracellular ATP, modulates several inflammatory responses in different cell types. No information is available on its presence in human adipocytes and its potential involvement in the chronic inflammation associated with metabolic syndrome (MS). Therefore, we evaluated P2X7R presence and functional activity in adipocytes from visceral (VAT) and subcutaneous (SAT) adipose tissue of patients with MS and controls (CTL). Methods: Adipocyte gene expression of TNFα, IL-6 and PAI-1 (by realtime-PCR) and their plasma concentrations (ELISA); P2X7R expression (realtime-PCR, Western blot and immunofluorescence); P2X7R functional activity (intracellular calcium fluxes by fluorimetry); cytokine release from adipocytes (ELISA). The inflammasome components were also determined. Results: In VAT, TNFα, IL-6 and PAI-1 were more expressed in MS than in CTL. These differences were confirmed in SAT for IL-6 and PAI-1. Plasma IL-6, PAI-1 and TNFα levels were higher in MS. P2X7R mRNA and protein, identified in both VAT and SAT, were more abundant in MS than in CTL. Immunofluoresce confirmed the typical “ring-like” arrangement of P2X7R at the plasma membrane. Benzoyl-benzoyl-ATP raised intracellular calcium both in VAT and SAT, and induced IL-6, TNFα and PAI-1 release in both MS and CTL cells. This effect was partially inhibited by KN62, specific human P2X7R blocker, or by P2X7R gene silencing. The inflammasome was more activated in MS than in CTL adipocytes. Conclusion: Human adipocytes express functionally active P2X7R, which modulate the release of inflammatory cytokines, at least in part via inflammasome activation. Adipocytes from MS patients show an enhanced P2X7R expression, which might contribute to the subclinical inflammatory status characterizing these patients and conferring them an increased CV risk. [Copyright &y& Elsevier]

Intra-abdominal infections (IAIs) are common surgical emergencies and have been reported as major contributors to non-trauma deaths in hospitals worldwide. The cornerstones of effective treatment of IAIs include early recognition, adequate source control, appropriate antimicrobial therapy, and prompt physiologic stabilization using a critical care environment, combined with an optimal surgical approach. Together, the World Society of Emergency Surgery (WSES), the Global Alliance for Infections in Surgery (GAIS), the Surgical Infection Society-Europe (SIS-E), the World Surgical Infection Society (WSIS), and the American Association for the Surgery of Trauma (AAST) have jointly completed an international multi-society document in order to facilitate clinical management of patients with IAIs worldwide building evidence-based clinical pathways for the most common IAIs. An extensive non-systematic review was conducted using the PubMed and MEDLINE databases, limited to the English language. The resulting information was shared by an international task force from 46 countries with different clinical backgrounds. The aim of the document is to promote global standards of care in IAIs providing guidance to clinicians by describing reasonable approaches to the management of IAIs. [ABSTRACT FROM AUTHOR]

Immunocompromised patients are a heterogeneous and diffuse category frequently presenting to the emergency department with acute surgical diseases. Diagnosis and treatment in immunocompromised patients are often complex and must be multidisciplinary. Misdiagnosis of an acute surgical disease may be followed by increased morbidity and mortality. Delayed diagnosis and treatment of surgical disease occur; these patients may seek medical assistance late because their symptoms are often ambiguous. Also, they develop unique surgical problems that do not affect the general population. Management of this population must be multidisciplinary. This paper presents the World Society of Emergency Surgery (WSES), Surgical Infection Society Europe (SIS-E), World Surgical Infection Society (WSIS), American Association for the Surgery of Trauma (AAST), and Global Alliance for Infection in Surgery (GAIS) joined guidelines about the management of acute abdomen in immunocompromised patients. [ABSTRACT FROM AUTHOR]

Background: Immunocompromised patients are at higher risk of surgical site infection and wound complications. However, optimal management in the perioperative period is not well established. Present systematic review aims to analyse existing strategies and interventions to prevent and manage surgical site infections and other wound complications in immunocompromised patients. Methods: A systematic review of the literature was conducted. Results: Literature review shows that partial skin closure is effective to reduce SSI in this population. There is not sufficient evidence to definitively suggest in favour of prophylactic negative pressure wound therapy. The use of mammalian target of rapamycin (mTOR) and calcineurin inhibitors (CNI) in transplanted patient needing ad emergent or undeferrable abdominal surgical procedure must be carefully and multidisciplinary evaluated. The role of antibiotic prophylaxis in transplanted patients needs to be assessed. Conclusion: Strict adherence to SSI infection preventing bundles must be implemented worldwide especially in immunocompromised patients. Lastly, it is necessary to elaborate a more widely approved definition of immunocompromised state. Without such shared definition, it will be hard to elaborate the needed methodologically correct studies for this fragile population. [ABSTRACT FROM AUTHOR]

Background: Laparoscopic cholecystectomy (LC) is considered to be the gold standard in the early management of acute cholecystitis however, recommendations for routine drain insertion in the acute setting are unavailable.Study Design: A systematic review of literature review and metanalysis was conducted. All studies comparing drain versus no drain after LC for acute cholecystitis were included.Results: Seven studies, with 1274 patients, were included. Postoperative wound infection rates (relative risk (RR) 0.30, 95% confidence interval (CI) 0.10 to 0.88; I2 = 0%) and postoperative abdominal collection requiring drainage (RR 1.20, 95% CI 0.35 to 4.12; I 2 = 0%) were lower in the no-drain group, but this was only significant for wounded infections on subgroup analysis of RCTs. Length of stay hospital (mean difference (MD) -0.49, 95% CI -0.89 to -0.09; I 2 = 69%) and operative time (MD -8.13, 95% CI -13.87 to -2.38; I 2 = 92%) were significantly shorter in the no drain group however this was in the context of significant heterogeneity.Conclusion: The available data suggests that acute cholecystitis is not an indication for routine drain placement after LC. However, these results must be interpreted with caution due to the limitations of the included studies. In effect, the main issue of this meta-analysis lies on the limitations of the included studies themselves, because of a considerable heterogeneity among the included works, particularly for the inclusion criteria of patients and reported severity of acute cholecystitis. Further work is required to produce evidence which will definitively alter clinical practice.Level Of Evidence: Level 2a (systematic review of cohort studies). Oxford CEBM levels of evidence. [ABSTRACT FROM AUTHOR]

Background: Despite the current therapeutic options for the treatment of inflammatory bowel disease, surgery is still frequently required in the emergency setting, although the number of cases performed seems to have decreased in recent years. The World Society of Emergency Surgery decided to debate in a consensus conference of experts, the main pertinent issues around the management of inflammatory bowel disease in the emergent situation, with the need to provide focused guidelines for acute care and emergency surgeons. Method: A group of experienced surgeons and gastroenterologists were nominated to develop the topics assigned and answer the questions addressed by the Steering Committee of the project. Each expert followed a precise analysis and grading of the studies selected for review. Statements and recommendations were discussed and voted at the Consensus Conference of the 6th World Society of Emergency Surgery held in Nijmegen (The Netherlands) in June 2019. Conclusions: Complicated inflammatory bowel disease requires a multidisciplinary approach because of the complexity of this patient group and disease spectrum in the emergency setting, with the aim of obtaining safe surgery with good functional outcomes and a decreasing stoma rate where appropriate. [ABSTRACT FROM AUTHOR]

Introduction: Damage control surgery (DCS) is the classic approach to manage severe trauma and has recently also been considered an appropriate approach to the treatment of critically ill patients with severe intra-abdominal sepsis. The purpose of the present review is to evaluate the outcomes following DCS for Hinchey II–IV complicated acute diverticulitis (CAD). Methods: A comprehensive systematic search was undertaken to identify all randomized clinical trials (RCTs) and observational studies, irrespectively of their size, publication status, and language. Adults who have undergone DCS for CAD Hinchey II, III, or IV were included in this review. DCS is compared with the immediate and definitive surgical treatment in the form of HP, colonic resection, and primary anastomosis (RPA) with or without covering stoma or laparoscopic lavage. We searched the following electronic databases: PubMed MEDLINE, Scopus, and ISI Web of Knowledge. The protocol of this systematic review and meta-analysis was published on Prospero (CRD42020144953). Results: Nine studies with 318 patients, undergoing DCS, were included. The presence of septic shock at the presentation in the emergency department was heterogeneous, and the weighted mean rate of septic shock across the studies was shown to be 35.1% [95% CI 8.4 to 78.6%]. The majority of the patients had Hinchey III (68.3%) disease. The remainder had either Hinchey IV (28.9%) or Hinchey II (2.8%). Phase I is similarly described in most of the studies as lavage, limited resection with closed blind colonic ends. In a few studies, resection and anastomosis (9.1%) or suture of the perforation site (0.9%) were performed in phase I of DCS. In those patients who underwent DCS, the most common method of temporary abdominal closure (TAC) was the negative pressure wound therapy (NPWT) (97.8%). The RPA was performed in 62.1% [95% CI 40.8 to 83.3%] and the 22.7% [95% CI 15.1 to 30.3%]: 12.8% during phase I and 87.2% during phase III. A covering ileostomy was performed in 6.9% [95% CI 1.5 to 12.2%]. In patients with RPA, the overall leak was 7.3% [95% CI 4.3 to 10.4%] and the major anastomotic leaks were 4.7% [95% CI 2.0 to 7.4%]; the rate of postoperative mortality was estimated to be 9.2% [95% CI 6.0 to 12.4%]. Conclusions: The present meta-analysis revealed an approximately 62.1% weighted rate of achieving GI continuity with the DCS approach to generalized peritonitis in Hinchey III and IV with major leaks of 4.7% and overall mortality of 9.2%. Despite the promising results, we are aware of the limitations related to the significant heterogeneity of inclusion criteria. Importantly, the low rate of reported septic shock may point toward selection bias. Further studies are needed to evaluate the clinical advantages and cost-effectiveness of the DCS approach. [ABSTRACT FROM AUTHOR]

Introduction: Quality in medical care must be measured in order to be improved. Trauma management is part of health care, and by definition, it must be checked constantly. The only way to measure quality and outcomes is to systematically accrue data and analyze them. Material and methods: A systematic revision of the literature about quality indicators in trauma associated to an international consensus conference Results: An internationally approved base core set of 82 trauma quality indicators was obtained: Indicators were divided into 6 fields: prevention, structure, process, outcome, post-traumatic management, and society integrational effects. Conclusion: Present trauma quality indicator core set represents the result of an international effort aiming to provide a useful tool in quality evaluation and improvement. Further improvement may only be possible through international trauma registry development. This will allow for huge international data accrual permitting to evaluate results and compare outcomes. [ABSTRACT FROM AUTHOR]

Comment on: SARS-Cov-2 in peritoneal fluid: an important finding in the Covid-19 pandemic I Editor i We read with great interest the article recently published by Barberi I et al i , in which the authors identified the presence of a positive swab for SARS-Cov-2 from the abdominal fluid in a 71-year-old COVID-19 positive woman who underwent a subtotal colectomy with terminal ileostomy. A potential SARS-CoV-2 positivity of the peritoneal fluid may dramatically influence the grade of exposure of the operating team to COVID-19-contaminated aerosol during laparoscopy or open surgery. [Extracted from the article]

Background: Open abdomen (OA) is a surgical option that can be used in patients with severe peritonitis. Few evidences exist to recommend the use of intraperitoneal fluid instillation associated with OA in managing septic abdomen. Materials and methods: A prospective analysis of adult patients enrolled in the International Register of Open Abdomen (trial registration: NCT02382770) was performed. Results: A total of 387 patients were enrolled in two groups: 84 with peritoneal fluid instillation (FI) and 303 without (NFI). The groups were homogeneous for baseline characteristics. Overall complications were 92.9% in FI and 86.3% in NFI (p = 0.106). Complications during OA were 72.6% in FI and 59.9% in NFI (p = 0.034). Complications after definitive closure were 70.8% in FI and 61.1% in NFI (p = 0.133). Entero-atmospheric fistula was 13.1% in FI and 12% in NFI (p = 0.828). Fascial closure was 78.6% in FI and 63.7% in NFI (p = 0.02). Analysis of FI in negative pressure wound therapy (NPWT) showed: Overall morbidity in NPWT was 94% and in non-NPWT 91.2% (p = 0.622) and morbidity during OA was 68% and 79.4% (p = 0.25), respectively. Definitive fascial closure in NPWT was 87.8% and 96.8% in non-NPWT (p = 0.173). Overall mortality was 40% in NPWT and 29.4% in non-NPWT (p = 0.32) and morality during OA period was 18% and 8.8% (p = 0.238), respectively. Conclusion: We found intraperitoneal fluid instillation during open abdomen in peritonitic patients to increase the complication rate during the open abdomen period, with no impact on mortality, entero-atmospheric fistula rate and opening time. Fascial closure rate is increased by instillation. Fluid instillation is feasible even when associated with nonnegative pressure temporary abdominal closure techniques. [ABSTRACT FROM AUTHOR]

Background: The aim of this study was to assess the indication for surgical treatment of incidentally discovered Meckel's diverticulum (MD) on the basis of clinical and histological features. Methods: The charts of patients undergoing surgery for MD were analysed. Two groups were identified: (1) patients who had incidentally discovered MD resected (incidental MD, IMD) and (2) patients who received first‐line surgery for a complicated MD (CMD). Demographics and intraoperative and post‐operative outcomes were compared. Histological findings were also analysed and compared. Results: Sixty‐five patients were included in the study. IMD was observed in 39 patients (60%), while CMD was observed in 26 (40%). Male gender was significantly more frequent in CMD (P = 0.020), and mean age was significantly higher in IMD (P = 0.025). Body mass index and the American Society of Anesthesiologists score >2 were similar in both groups. Laparoscopy was carried out in 36% of IMD and in 50% of CMD patients (P = 0.309). A tangential resection was performed in 92% of IMD and 73% of CMD patients (P = 0.07). No complications related to diverticular resection were found in IMD, while they occurred in 8% of CMD patients (P = 0.931). Meanly, diverticula were longer when complicated (P = 0.001). CMD showed significant histological differences and more frequent gastric ectopic mucosa (P = 0.039). A malignant tumour was incidentally found in IMD. Conclusion: As surgery is mandatory in CMD, the optimal management of IMD remains uncertain. Mucosal abnormalities may favour complications, but these cannot be identified before excision. Stapled diverticulectomy is safe and effective. A surgical approach to IMD may prevent complications at a very low cost. [ABSTRACT FROM AUTHOR]

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 6th 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. [ABSTRACT FROM AUTHOR]

Background: Small bowel diverticula are a rare condition occurring mainly in the elderly. They can be isolated or multiple and can involve the duodenum, jejunum and ileum. Acute complications are extremely rare, with an aspecific pattern of symptoms. The aim of the study is to report the different patterns of presentation of patients with complicated jejunoileal diverticula. Methods: This is a retrospective descriptive study on a consecutive series of patients admitted for complicated jejunoileal diverticula in four Italian surgical departments between 2012 and 2019. Complications included acute diverticulitis, bleeding, perforation and intestinal obstruction. Patients presenting with complicated duodenal or Meckel's diverticula were not included. Results: Twenty‐six patients were enrolled. The median age was 77 (46–94) years. Abdominal pain, fever and nausea/vomiting were the most frequent symptoms at presentation. Abdominal computed tomography (CT) was diagnostic in 35% of patients. Ten (38%) patients had bowel perforation, nine (35%) acute diverticulitis, five (19%) bowel obstruction and two (8%) had intestinal bleeding. Twenty‐one (81%) patients underwent surgery, two (8%) were managed by CT‐guided drainage of collections and three (11%) were treated with antibiotics. One patient died post‐operatively. The median hospital stay was 9 (5–62) days. Conclusion: Acutely complicated jejunoileal diverticula are infrequent, but a strong suspect should be raised whenever elderly patients are admitted for unspecific abdominal pain with a non‐diagnostic CT scan. Conservative management may be offered in very selected cases if a diagnosis is obtained, but in most instances, surgery is both diagnostic and therapeutic. [ABSTRACT FROM AUTHOR]

Acute colonic diverticulitis is one of the most common clinical conditions encountered by surgeons in the acute setting. An international multidisciplinary panel of experts from the World Society of Emergency Surgery (WSES) updated its guidelines for management of acute left-sided colonic diverticulitis (ALCD) according to the most recent available literature. The update includes recent changes introduced in the management of ALCD. The new update has been further integrated with advances in acute right-sided colonic diverticulitis (ARCD) that is more common than ALCD in select regions of the world. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: Surgical 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. Methods: The 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. Results: Wound 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. Conclusions: The current position paper offers an extensive overview of the available evidence regarding surgical site infection control and prevention in patients having intra-abdominal infections. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Purpose: Laparoscopic peritoneal lavage (LPL) is feasible in selected patients with pelvic abscess and generalized purulent peritonitis caused by acute diverticulitis. We aimed to compare LPL and laparoscopic sigmoidectomy (LS) in complicated acute diverticulitis. Methods: This prospective, observational, multicenter study included patients with a pelvic abscess not amenable to conservative management and patients with Hinchey III acute diverticulitis, from 2015 to 2018. Sixty-six patients were enrolled: 28 (42%) underwent LPL and 38 (58%) underwent LS. In LS, patients had a primary anastomosis, with or without ileostomy, or an end colostomy (HA). Major outcomes were mortality, morbidity, failure of source control, reoperation, length of stay, and diverticulitis recurrence. Results: Patient demographics were similar in the two groups. In LPL, ASA score > 2 and Mannheim Peritonitis Index were significantly higher (p = 0.05 and 0.004). In LS, 24 patients (63%) had a PA and 14 (37%) an HA. No death was recorded. Overall, morbidity was 33% in LPL and 18% in LS (p = 0.169). However, failure to achieve source control of the peritoneal infection and the need to return to the operating room were more frequent in LPL (p = 0.002 and p = 0.006). Mean postoperative length of stay was comparable (p = 0.08). Diverticular recurrence was significantly higher in LPL (p = 0.003). Conclusion: LPL is related to a higher reoperation rate, more frequent postoperative ongoing sepsis, and higher recurrence rates. Therefore, laparoscopic lavage for perforated diverticulitis carries a high risk of failure in daily practice. [ABSTRACT FROM AUTHOR]