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Abstract Background Patients undergoing emergency surgery for peritonitis are at increased risk of abdominal wall-related complications. In patients with peritonitis, the risk of incisional hernia (IH) is extremely elevated. The evaluation of quality of life of patients with incisional hernia showed lower mean scores on physical components of health-related quality of life and body image. Furthermore, the arise of a post-operative abdominal wall complication (i.e., wound dehiscence, evisceration and IH) greatly increases morbidity and mortality rates and prolongs the hospitalization. Methods The present study aims to evaluate the efficacy of the use of a swine dermal collagen prosthesis implanted preperitoneally as a prophylactic procedure in urgency/emergency setting against abdominal wall complications in patients operated with contaminated/infected field in peritonitis. The sample size was defined in 90 patients divided in two arms (prosthesis positioning versus normal wall abdominal closure). The follow-up will be performed at 3, 6, and 12 months after surgery. The percentage of incisional hernias, wound infections, and adverse events will be investigated by physical examination and ultrasound. Discussion The objective is to evaluate the possibility to reduce the incisional hernia rate in patients undergoing urgent/emergent laparotomy in contaminated/infected field with peritonitis by using swine dermal collagen prosthesis preperitoneal positioning as a prophylactic procedure. Trial registration ClinicalTrials.gov NCT04681326. Registered (retrospectively after first patient recruited) on 23 December 2020.

Abstract The difficult laparoscopic cholecystectomy remains a surgical challenge for surgeons who must decide between laparoscopic continuation and open conversion. The balance between the lack of open surgery training of young surgeons and the risk of maintaining the laparoscopic approach in difficult laparoscopic cholecystectomy is still an unresolved problem. Furthermore, the time that must be spent in an attempt to complete laparoscopic surgery before conversion is still controversial. The authors in this letter discuss about these and other questions that still require an answer.

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

Background: The current standard of care for mild acute biliary pancreatitis (MABP) involves early laparoscopic cholecystectomy (ELC) to reduce the risk of recurrence. The MANCTRA-1 project revealed a knowledge-to-action gap and higher recurrence rates in patients admitted to medical wards, attributable to fewer ELCs being performed. The project estimated a 35% to 70% probability of narrowing this gap by 2025. This study evaluates the safety of suboptimal ELC implementation and identifies risk factors for recurrent acute biliary pancreatitis (RAP) in patients not undergoing ELC after an MABP episode., Methods: We conducted a post-hoc analysis of the MANCTRA-1 registry, including MABP patients who did not undergo ELC during the index hospitalization, excluding those with related complications. The primary outcome was the 30-day hospital readmission rate due to RAP. We performed multivariable logistic regression to find risk factors associated with the primary outcome., Results: Between January 2019 and December 2020, 1920, MABP patients from 150 centers were included in the study. The 30-day readmission rate due to RAP was 6%. Multivariable logistic regression found the admission to a medical ward (internal medicine or gastroenterology) (OR = 1.95, p = 0.001) and a positive COVID-19 test (OR = 3.08, p = 0.029) as independent risk factors for RAP., Conclusion: Our analysis offers valuable insights into the management of MABP, particularly in centers where ELC cannot be fully implemented due to logistical and clinical constraints, worsened by the COVID-19 pandemic. Regardless of the admitting ward, prompt access to surgical care is crucial in reducing the risk of early recurrence, highlighting the need to implement surgical consultation pathways within MABP care bundles., Competing Interests: Declarations. Conflict of interest: The authors declare no conflict of interest., (© 2025. The Author(s).)

Antimicrobial resistance is a critical global challenge in the 21st century, validating Sir Alexander Fleming's warning about the misuse of antibiotics leading to resistant microbes. With a dwindling arsenal of effective antibiotics, it is imperative to concentrate on alternative antimicrobial strategies. Previous studies have not comprehensively discussed the advantages and limitations of various strategies, including bacteriophage therapy, probiotics, immunotherapies, photodynamic therapy, essential oils, nanoparticles and antimicrobial peptides (AMPs) within a single review. This review addresses that gap by providing an overview of these various non-antibiotic antimicrobial strategies, highlighting their pros and cons, with a particular emphasis on antimicrobial peptides (AMPs). We explore the mechanism of action of AMPs against bacteria, viruses, fungi and parasites. While these peptides hold significant promise, their application in mainstream drug development is hindered by challenges such as low bioavailability and potential toxicity. However, advancements in peptide engineering and chemical modifications offer solutions to enhance their clinical utility. Additionally, this review presents updates on strategies aimed at improving the cost, stability and selective toxicity of AMPs through the development of peptidomimetics. These molecules have demonstrated effective activity against a broad range of pathogens, making them valuable candidates for integration into surface coatings to prevent device-associated infections. Furthermore, we discuss various approaches for attaching and functionalising these peptides on surfaces. Finally, we recommend comprehensive in vivo studies to evaluate the efficacy of AMPs and their mimetics, investigate their synergistic combinations with other molecules and assess their potential as coatings for medical devices.

Aim: This study aimed to evaluate the impact of the WSES-AAST guidelines in clinical practice and to investigate the knowledge, attitudes, and practices of emergency surgeons in managing the complications of ulcerative colitis (UC) and Crohn's disease (CD)., Methods: The MIBODI survey is a cross-sectional study among WSES members designed as an international web-based survey, according to the Checklist for Reporting Results of Internet E-Surveys, to collect data on emergency surgeons' knowledge, attitudes, and practices concerning the management of patients presenting with acute complications of CD and UC. The questionnaire was composed of 30 questions divided into five sections: (1) demographic data, (2) primary evaluation, (3) non-operative management, (4) operative management, and (5) perianal sepsis management., Results: Two hundred and forty-two surgeons from 48 countries agreed to participate in the survey. The response rate was 24.2% (242/1000 members on WSES mail list). Emergency surgeons showed high adherence to recommendations for 6 of the 21 assessed items, with a "correct" response rate greater than or equal to 60%, according to WSES-AAST recommendations. Nine critical issues were highlighted, with correct answers at a rate of less than 50%., Conclusions: Inflammatory bowel disease is a complex disease that requires a multidisciplinary approach with close collaboration between gastroenterologists and surgeons. Emergency surgeons play a crucial role in managing complications related to IBD. One year after publication, the MIBODI study showed significant global implementation of the WSES-AAST guidelines in clinical practice, offering an imperative tool in the improved management of IBD in emergency and urgent settings., Competing Interests: Declarations. Ethics approval and consent to participate: Not required. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

Background: The quality of Big Data analysis in medicine and surgery heavily depends on the methods used for clinical data collection, organization, and storage. The Knowledge Graph (KG) represents knowledge through a semantic model, enhancing connections between diverse and complex information. While it can improve the quality of health data collection, it has limitations that can be addressed by the Decentralized (blockchain-powered) Knowledge Graph (DKG). We report our experience in developing a DKG to organize data and knowledge in the field of emergency surgery., Methods and Results: The authors leveraged the cyb.ai protocol, a decentralized protocol within the Cosmos network, to develop the Emergency Surgery DKG. They populated the DKG with relevant information using publications from the World Society of Emergency Surgery (WSES) featured in the World Journal of Emergency Surgery (WJES). The result was the Decentralized Knowledge Graph (DKG) for the WSES-WJES bibliography., Conclusions: Utilizing a DKG enables more effective structuring and organization of medical knowledge. This facilitates a deeper understanding of the interrelationships between various aspects of medicine and surgery, ultimately enhancing the diagnosis and treatment of different diseases. The system's design aims to be inclusive and user-friendly, providing access to high-quality surgical knowledge for healthcare providers worldwide, regardless of their technological capabilities or geographical location. As the DKG evolves, ongoing attention to user feedback, regulatory frameworks, and ethical considerations will be critical to its long-term success and global impact in the surgical field., Competing Interests: Declarations. Ethics approval and consent to participate: Not applicable. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)

Background: Rib fractures are one of the most common traumatic injuries and may result in significant morbidity and mortality. Despite growing evidence, technological advances and increasing acceptance, surgical stabilization of rib fractures (SSRF) remains not uniformly considered in trauma centers. Indications, contraindications, appropriate timing, surgical approaches and utilized implants are part of an ongoing debate. The present position paper, which is endorsed by the World Society of Emergency Surgery (WSES), and supported by the Chest Wall Injury Society, aims to provide a review of the literature investigating the use of SSRF in rib fracture management to develop graded position statements, providing an updated guide and reference for SSRF., Methods: This position paper was developed according to the WSES methodology. A steering committee performed the literature review and drafted the position paper. An international panel of experts then critically revised the manuscript and discussed it in detail, to develop a consensus on the position statements., Results: A total of 287 studies (systematic reviews, randomized clinical trial, prospective and retrospective comparative studies, case series, original articles) have been selected from an initial pool of 9928 studies. Thirty-nine graded position statements were put forward to address eight crucial aspects of SSRF: surgical indications, contraindications, optimal timing of surgery, preoperative imaging evaluation, rib fracture sites for surgical fixation, management of concurrent thoracic injuries, surgical approach, stabilization methods and material selection., Conclusion: This consensus document addresses the key focus questions on surgical treatment of rib fractures. The expert recommendations clarify current evidences on SSRF indications, timing, operative planning, approaches and techniques, with the aim to guide clinicians in optimizing the management of rib fractures, to improve patient outcomes and direct future research., (© 2024. The Author(s).)

Antimicrobial resistance (AMR) is one of the main public health global burdens of the 21st century, responsible for over a million deaths every year. Hospital programs aimed at improving antibiotic use, referred to as antimicrobial stewardship programs (ASPs), can both optimize the treatment of infections and minimize adverse antibiotics events including the development and spread of AMR. The challenge of AMR is closely linked to the development and spread of healthcare-associated infection (HAIs). In fact, the management of patients with HAIs frequently requires the administration of broader-spectrum antibiotic regimens due to the higher risk of acquiring multidrug-resistant organisms, which, in turn, promotes resistance. For this reason, even before using antibiotics correctly, it is necessary to prevent and control the spread of HAIs in our hospitals. In this narrative review, we present seven measures that healthcare workers, even if not directly involved in the tasks of infection prevention and control, must know, support, and embrace. We hope that this review may raise awareness among all healthcare professionals about the issues with the increasing rate of AMR and the ongoing efforts towards minimizing its rise.

Background: Recent studies suggest that low-molecular-weight heparin (LMWH) may play a role in mitigating the severity of acute pancreatitis (AP). This systematic review and meta-analysis aims to synthesise existing evidence on the effectiveness and safety of LMWH in the treatment of moderately-severe and severe AP., Methods: This systematic review and meta-analysis was conducted in accordance with the 2020 update of the PRISMA guidelines and the Cochrane Handbook for Systematic Reviews of Interventions. The systematic search was conducted in MEDLINE, the Cochrane Central Register of Controlled Trials, Scopus, and EMBASE, covering studies published up to February 2024. Randomised controlled trials (RCTs) and observational studies (n-RCTs) that reported the differences in the outcomes of AP for patients receiving LMWH in addition to the standard treatment (Intervention), compared to patients managed by standard treatment without LMWH (Control) were eligible. A random-effects model was used to calculate the pooled relative risk (RR) and mean differences (MD) with the corresponding 95% CI., Results: Thirteen studies were included in the meta-analysis, all published between 2004 and 2022. Eight studies were RCTs, and five were n-RCTs. Data from 13,709 patients (6.971 Interventions and 6.738 Controls) were analysed. The comparison of Intervention and Control groups showed the superiority of LMWH to standard treatments in terms of overall mortality (RR = 0.44, 95% CI = 0.31; 0.64, P < 0.0001, I 2  = 51%), acute necrotic collections (RR = 0.24, 95% CI = 0.09; 0.62, P = 0.003, I 2  = 0%), and organ failure (RR = 0.67, 95% CI = 0.48; 0.93, P = 0.02, I 2  = 78%). The Intervention group showed superior outcomes compared with the Control group for gastrointestinal bleeding (RR = 0.64, 95% CI = 0.44; 0.94, P = 0.02, I 2  = 0%), length of hospital stay (MD= - 6.08, 95% CI = - 10.08; - 2.07, P = 0.003, I 2  = 98%), need for operative interventions (RR = 0.50, 95% CI = 0.29; 0.87, P = 0.01, I 2  = 61%), and vascular thrombosis (RR = 0.43, 95% CI = 0.31; 0.61, P < 0.00001, I 2  = 0%)., Conclusions: Moderate to high-quality evidence suggests that early intervention with LMWH could improve the prognosis of non-mild AP in terms of mortality, organ failure, and decreased incidence of vascular thrombosis. In light of our findings, integrating LMWH into the treatment regimen for moderate-severe to severe AP is advocated., (© 2024. The Author(s).)

Fluorescence imaging is a real-time intraoperative navigation modality to enhance surgical vision and it can guide emergency surgeons while performing difficult, high-risk surgical procedures. The aim of this study is to assess current knowledge, attitudes, and practices of emergency surgeons in the use of indocyanine green (ICG) in emergency settings. Between March 08, 2023 and April 10, 2023, a questionnaire composed of 27 multiple choice and open-ended questions was sent to 200 emergency surgeons who had previously joined the ARtificial Intelligence in Emergency and trauma Surgery (ARIES) project promoted by the WSES. The questionnaire was developed by an emergency surgeon with an interest in advanced technologies and artificial intelligence. The response rate was 96% (192/200). Responders affirmed that ICG fluorescence can support the performance of difficult surgical procedures in the emergency setting, particularly in the presence of severe inflammation and in evaluating bowel viability. Nevertheless, there were concerns regarding accessibility and availability of fluorescence imaging in emergency settings. Eighty-seven out of 192 (45.3%) respondents have a fluorescence imaging system of vision for both elective and emergency surgical procedures; 32.3% of respondents have this system solely for elective procedures; 21.4% of respondents do not have this system, 15% do not have experience with it, and 38% do not use this imaging in emergency surgery. Less than 1% (2/192) affirmed that ICG fluorescence changed always their intraoperative decision-making. Precision surgery effectively tailors surgical interventions to individual patient characteristics using advanced technology, data analysis and artificial intelligence. ICG fluorescence can serve as a valid and safe tool to guide emergency surgery in different scenarios, such as intestinal ischemia and severe acute cholecystitis. Due to the lack of high-level evidence within this field, a consensus of expert emergency surgeons is needed to encourage stakeholders to increase the availability of fluorescence imaging systems and to support emergency surgeons in implementing ICG fluorescence in their daily practice., (© 2024. Italian Society of Surgery (SIC).)

Wars destroy human rights, promoting violence as a means to resolve conflicts and cause profound direct and indirect health consequences for people. As important as it is that healthcare does not enter into the merits of the responsibilities for wars, it is equally important that healthcare places itself, in principle, in opposition to war. Despite the enormous impacts of wars and armed conflicts, global public health is poorly prepared to mitigate the threats of wars and armed conflicts. The tragedies, challenges and public health consequences of war are often overlooked and do not receive adequate attention from the international community. Healthcare should globally recognize wars and armed conflicts as a public health emergency and provide the required level of attention. Public health professionals should be aware of the impacts of wars, represent a single voice and coordinate in concerted efforts globally to stand in solidarity, without any discrimination, with conflict-affected communities by understanding their critical needs. Together we can be the voice that says "stop", striving to build a safer world for all.

Intra-abdominal infections (IAIs) account for a major cause of morbidity and mortality, representing the second most common sepsis-related death with a hospital mortality of 23-38%. Prompt identification of sepsis source, appropriate resuscitation, and early treatment with the shortest delay possible are the cornerstones of management of IAIs and are associated with a more favorable clinical outcome. The aim of source control is to reduce microbial load by removing the infection source and it is achievable by using a wide range of procedures, such as definitive surgical removal of anatomic infectious foci, percutaneous drainage and toilette of infected collections, decompression, and debridement of infected and necrotic tissue or device removal, providing for the restoration of anatomy and function. Damage control surgery may be an option in selected septic patients. Intra-abdominal infections can be classified as uncomplicated or complicated causing localized or diffuse peritonitis. Early clinical evaluation is mandatory in order to optimize diagnostic testing and establish a therapeutic plan. Prognostic scores could serve as helpful tools in medical settings for evaluating both the seriousness and future outlook of a condition. The patient's conditions and the potential progression of the disease determine when to initiate source control. Patients can be classified into three groups based on disease severity, the origin of infection, and the patient's overall physical health, as well as any existing comorbidities. In recent decades, antibiotic resistance has become a global health threat caused by inappropriate antibiotic regimens, inadequate control measures, and infection prevention. The sepsis prevention and infection control protocols combined with optimizing antibiotic administration are crucial to improve outcome and should be encouraged in surgical departments. Antibiotic and antifungal regimens in patients with IAIs should be based on the resistance epidemiology, clinical conditions, and risk for multidrug resistance (MDR) and Candida spp. infections. Several challenges still exist regarding the effectiveness, timing, and patient stratification, as well as the procedures for source control. Antibiotic choice, optimal dosing, and duration of therapy are essential to achieve the best treatment. Promoting standard of care in the management of IAIs improves clinical outcomes worldwide. Further trials and stronger evidence are required to achieve optimal management with the least morbidity in the clinical care of critically ill patients with intra-abdominal sepsis.

Introduction: Fluorescence imaging with indocyanine green (ICG) has been extensively utilized to assess bowel perfusion in oncologic surgery. In the emergency setting, there are many situations in which bowel perfusion assessment is required. Large prospective studies or RCTs evaluating feasibility, safety and utility of ICG in the emergency setting are lacking. The primary aim is to assess the usefulness of ICG for evaluation of bowel perfusion in the emergency setting., Materials and Methods: The manuscript was drafted following the recommendations of Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement (PRISMA). A systematic literature search was carried out through Pubmed, Scopus, and the ISI Web of Science. Assessment of included study using the methodological index for nonrandomized studies (MINORS) was calculated. The meta-analysis was carried out in line with recommendations from the Cochrane Collaboration and Meta-analysis of Observational Studies in Epidemiology guidelines, and the Mantel-Haenszel random effects model was used to calculate effect sizes., Results: 10 093 papers were identified. Eighty-four were reviewed in full-text, and 78 were excluded: 64 were case reports; 10 were reviews without original data; 2 were letters to the editor; and 2 contained unextractable data. Finally, six studies 22-27 were available for quality assessment and quantitative synthesis. The probability of reoperation using ICG fluorescence angiography resulted similar to the traditional assessment of bowel perfusion with a RD was -0.04 (95% CI: -0.147 to 0.060). The results were statistically significant P =0.029, although the heterogeneity was not negligible with a 59.9% of the I2 index. No small study effect or publication bias were found., Conclusions: This first metanalysis on the use of IGC fluorescence for ischemic bowel disease showed that this methodology is a safe and feasible tool in the assessment of bowel perfusion in the emergency setting. This topic should be further investigated in high-quality studies., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

Emergency general surgeons often provide care to severely ill patients requiring surgical interventions and intensive support. One of the primary drivers of morbidity and mortality is perioperative bleeding. In general, when addressing life threatening haemorrhage, blood transfusion can become an essential part of overall resuscitation. However, under all circumstances, indications for blood transfusion must be accurately evaluated. When patients decline blood transfusions, regardless of the reason, surgeons should aim to provide optimal care and respect and accommodate each patient's values and target the best outcome possible given the patient's desires and his/her clinical condition. The aim of this position paper was to perform a review of the existing literature and to provide comprehensive recommendations on organizational, surgical, anaesthetic, and haemostatic strategies that can be used to provide optimal peri-operative blood management, reduce, or avoid blood transfusions and ultimately improve patient outcomes., (© 2024. The Author(s).)

Intra-abdominal infections (IAIs) are common surgical emergencies and are an important cause of morbidity and mortality in hospital settings, particularly if poorly managed. The cornerstones of effective IAIs management include early diagnosis, adequate source control, appropriate antimicrobial therapy, and early physiologic stabilization using intravenous fluids and vasopressor agents in critically ill patients. Adequate empiric antimicrobial therapy in patients with IAIs is of paramount importance because inappropriate antimicrobial therapy is associated with poor outcomes. Optimizing antimicrobial prescriptions improves treatment effectiveness, increases patients' safety, and minimizes the risk of opportunistic infections (such as Clostridioides difficile) and antimicrobial resistance selection. The growing emergence of multi-drug resistant organisms has caused an impending crisis with alarming implications, especially regarding Gram-negative bacteria. The Multidisciplinary and Intersociety Italian Council for the Optimization of Antimicrobial Use promoted a consensus conference on the antimicrobial management of IAIs, including emergency medicine specialists, radiologists, surgeons, intensivists, infectious disease specialists, clinical pharmacologists, hospital pharmacists, microbiologists and public health specialists. Relevant clinical questions were constructed by the Organizational Committee in order to investigate the topic. The expert panel produced recommendation statements based on the best scientific evidence from PubMed and EMBASE Library and experts' opinions. The statements were planned and graded according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) hierarchy of evidence. On November 10, 2023, the experts met in Mestre (Italy) to debate the statements. After the approval of the statements, the expert panel met via email and virtual meetings to prepare and revise the definitive document. This document represents the executive summary of the consensus conference and comprises three sections. The first section focuses on the general principles of diagnosis and treatment of IAIs. The second section provides twenty-three evidence-based recommendations for the antimicrobial therapy of IAIs. The third section presents eight clinical diagnostic-therapeutic pathways for the most common IAIs. The document has been endorsed by the Italian Society of Surgery., (© 2024. The Author(s).)

Intra-abdominal infections (IAIs) are an important cause of morbidity and mortality in hospital settings worldwide. The cornerstones of IAI management include rapid, accurate diagnostics; timely, adequate source control; appropriate, short-duration antimicrobial therapy administered according to the principles of pharmacokinetics/pharmacodynamics and antimicrobial stewardship; and hemodynamic and organ functional support with intravenous fluid and adjunctive vasopressor agents for critical illness (sepsis/organ dysfunction or septic shock after correction of hypovolemia). In patients with IAIs, a personalized approach is crucial to optimize outcomes and should be based on multiple aspects that require careful clinical assessment. The anatomic extent of infection, the presumed pathogens involved and risk factors for antimicrobial resistance, the origin and extent of the infection, the patient's clinical condition, and the host's immune status should be assessed continuously to optimize the management of patients with complicated IAIs., (© 2024. The Author(s).)

Background: Robotic surgery has gained widespread acceptance in elective interventions, yet its role in emergency procedures remains underexplored. While the 2021 WSES position paper discussed limited studies on the application of robotics in emergency general surgery, it recommended strict patient selection, adequate training, and improved platform accessibility. This prospective study aims to define the role of robotic surgery in emergency settings, evaluating intraoperative and postoperative outcomes and assessing its feasibility and safety., Methods: The ROEM study is an observational, prospective, multicentre, international analysis of clinically stable adult patients undergoing robotic surgery for emergency treatment of acute pathologies including diverticulitis, cholecystitis, and obstructed hernias. Data collection includes patient demographics and intervention details. Furthermore, data relating to the operating theatre team and the surgical instruments used will be collected in order to conduct a cost analysis. The study plans to enrol at least 500 patients from 50 participating centres, with each centre having a local lead and collaborators. All data will be collected and stored online through a secure server running the Research Electronic Data Capture (REDCap) web application. Ethical considerations and data governance will be paramount, requiring local ethical committee approvals from participating centres., Discussion: Current literature and expert consensus suggest the feasibility of robotic surgery in emergencies with proper support. However, challenges include staff training, scheduling conflicts with elective surgeries, and increased costs. The ROEM study seeks to contribute valuable data on the safety, feasibility, and cost-effectiveness of robotic surgery in emergency settings, focusing on specific pathologies. Previous studies on cholecystitis, abdominal hernias, and diverticulitis provide insights into the benefits and challenges of robotic approaches. It is necessary to identify patient populations that benefit most from robotic emergency surgery to optimize outcomes and justify costs., (© 2024. The Author(s).)

Background: Colorectal (CRC) cancer is becoming a disease of the elderly. Ageing is the most significant risk factor for presenting CRC. Early diagnosis of CRC and management is the best way in achieving good outcomes and longer survival but patients aged ≥75 years are usually not screened for CRC. This group of patients is often required to be managed when they are symptomatic in the emergency setting with high morbidity and mortality rates. Our main aim is to provide clinical data about the management of elderly patients presenting complicated colorectal cancer who required emergency surgical management to improve their care., Methods: The management of complicated COlorectal cancer in OLDER patients (CO-OLDER; ClinicalTrials.gov ID: NCT05788224; evaluated by the local ethical committee CPP EST III-France with the national number 2023-A01094-41) in the emergency setting project provides carrying out an observational multicenter international cohort study aimed to collect data about patients aged ≥75 years to assess modifiable risk factors for negative outcomes and mortality correlated to the emergency surgical management of this group of patients at risk admitted with a complicated (obstructed and perforated) CRC. The CO-OLDER protocol was approved by Institutional Review Board and released. Each CO-OLDER collaborator is asked to enroll ≥25 patients over a study period from 1st January 2018 to 30th October 2023. Data will be analyzed comparing two periods of study: before and after the COVID-19 pandemic. A sample size of 240 prospectively enrolled patients with obstructed colorectal cancer in a 5-month period was calculated. The secured database for entering anonymized data will be available for the period necessary to achieve the highest possible participation., Results: One hundred eighty hospitals asked to be a CO-OLDER collaborator, with 36 potentially involved countries over the world., Conclusions: The CO-OLDER project aims to improve the management of elderly people presenting with a complicated colorectal cancer in the emergency setting. Our observational global study can provide valuable data on the effectiveness of different management strategies in improving primary assessment, management and outcomes for elderly patients with obstructed or perforated colorectal cancer in the emergency setting, guiding clinical decision-making. This information can help healthcare providers make informed decisions about the best course of action for these patients.

Background: This multicentre case-control study aimed to identify risk factors associated with non-operative treatment failure for patients with CT scan Hinchey Ib-IIb and WSES Ib-IIa diverticular abscesses., Methods: This study included a cohort of adult patients experiencing their first episode of CT-diagnosed diverticular abscess, all of whom underwent initial non-operative treatment comprising either antibiotics alone or in combination with percutaneous drainage. The cohort was stratified based on the outcome of non-operative treatment, specifically identifying those who required emergency surgical intervention as cases of treatment failure. Multivariable logistic regression analysis to identify independent risk factors associated with the failure of non-operative treatment was employed., Results: Failure of conservative treatment occurred for 116 patients (27.04%). CT scan Hinchey classification IIb (aOR 2.54, 95%CI 1.61;4.01, P < 0.01), tobacco smoking (aOR 2.01, 95%CI 1.24;3.25, P < 0.01), and presence of air bubbles inside the abscess (aOR 1.59, 95%CI 1.00;2.52, P = 0.04) were independent predictors of failure. In the subgroup of patients with abscesses > 5 cm, percutaneous drainage was not associated with the risk of failure or success of the non-operative treatment (aOR 2.78, 95%CI - 0.66;3.70, P = 0.23)., Conclusions: Non-operative treatment is generally effective for diverticular abscesses. Tobacco smoking's role as an independent risk factor for treatment failure underscores the need for targeted behavioural interventions in diverticular disease management. IIb Hinchey diverticulitis patients, particularly young smokers, require vigilant monitoring due to increased risks of treatment failure and septic progression. Further research into the efficacy of image-guided percutaneous drainage should involve randomized, multicentre studies focussing on homogeneous patient groups., (© 2024. The Author(s).)

Background: The trauma mortality rate is higher in the elderly compared with younger patients. Ageing is associated with physiological changes in multiple systems and correlated with frailty. Frailty is a risk factor for mortality in elderly trauma patients. We aim to provide evidence-based guidelines for the management of geriatric trauma patients to improve it and reduce futile procedures., Methods: Six working groups of expert acute care and trauma surgeons reviewed extensively the literature according to the topic and the PICO question assigned. Statements and recommendations were assessed according to the GRADE methodology and approved by a consensus of experts in the field at the 10th international congress of the WSES in 2023., Results: The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage, including drug history, frailty assessment, nutritional status, and early activation of trauma protocol to improve outcomes. Acute trauma pain in the elderly has to be managed in a multimodal analgesic approach, to avoid side effects of opioid use. Antibiotic prophylaxis is recommended in penetrating (abdominal, thoracic) trauma, in severely burned and in open fractures elderly patients to decrease septic complications. Antibiotics are not recommended in blunt trauma in the absence of signs of sepsis and septic shock. Venous thromboembolism prophylaxis with LMWH or UFH should be administrated as soon as possible in high and moderate-risk elderly trauma patients according to the renal function, weight of the patient and bleeding risk. A palliative care team should be involved as soon as possible to discuss the end of life in a multidisciplinary approach considering the patient's directives, family feelings and representatives' desires, and all decisions should be shared., Conclusions: The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage based on assessing frailty and early activation of trauma protocol to improve outcomes. Geriatric Intensive Care Units are needed to care for elderly and frail trauma patients in a multidisciplinary approach to decrease mortality and improve outcomes., (© 2024. The Author(s).)

Background: Literature suggests colonic resection and primary anastomosis (RPA) instead of Hartmann's procedure (HP) for the treatment of left-sided colonic emergencies. We aim to evaluate the surgical options globally used to treat patients with acute left-sided colonic emergencies and the factors that leading to the choice of treatment, comparing HP and RPA., Methods: This is a prospective, international, multicenter, observational study registered on ClinicalTrials.gov. A total 1215 patients with left-sided colonic emergencies who required surgery were included from 204 centers during the period of March 1, 2020, to May 31, 2020. with a 1-year follow-up., Results: 564 patients (43.1%) were females. The mean age was 65.9 ± 15.6 years. HP was performed in 697 (57.3%) patients and RPA in 384 (31.6%) cases. Complicated acute diverticulitis was the most common cause of left-sided colonic emergencies (40.2%), followed by colorectal malignancy (36.6%). Severe complications (Clavien-Dindo ≥ 3b) were higher in the HP group (P < 0.001). 30-day mortality was higher in HP patients (13.7%), especially in case of bowel perforation and diffused peritonitis. 1-year follow-up showed no differences on ostomy reversal rate between HP and RPA. (P = 0.127). A backward likelihood logistic regression model showed that RPA was preferred in younger patients, having low ASA score (≤ 3), in case of large bowel obstruction, absence of colonic ischemia, longer time from admission to surgery, operating early at the day working hours, by a surgeon who performed more than 50 colorectal resections., Conclusions: After 100 years since the first Hartmann's procedure, HP remains the most common treatment for left-sided colorectal emergencies. Treatment's choice depends on patient characteristics, the time of surgery and the experience of the surgeon. RPA should be considered as the gold standard for surgery, with HP being an exception., (© 2024. The Author(s).)

Background: Despite advances and improvements in the management of surgical patients, emergency and trauma surgery is associated with high morbidity and mortality. This may be due in part to delays in definitive surgical management in the operating room (OR). There is a lack of studies focused on OR prioritization and resource allocation in emergency surgery. The Operating Room management for emergency Surgical Activity (ORSA) study was conceived to assess the management of operating theatres and resources from a global perspective among expert international acute care surgeons., Method: The ORSA study was conceived as an international web survey. The questionnaire was composed of 23 multiple-choice and open questions. Data were collected over 3 months. Participation in the survey was voluntary and anonymous., Results: One hundred forty-seven emergency and acute care surgeons answered the questionnaire; the response rate was 58.8%. The majority of the participants come from Europe. One hundred nineteen surgeons (81%; 119/147) declared to have at least one emergency OR in their hospital; for the other 20/147 surgeons (13.6%), there is not a dedicated emergency operating room. Forty-six (68/147)% of the surgeons use the elective OR to perform emergency procedures during the day. The planning of an emergency surgical procedure is done by phone by 70% (104/147) of the surgeons., Conclusions: There is no dedicated emergency OR in the majority of hospitals internationally. Elective surgical procedures are usually postponed or even cancelled to perform emergency surgery. It is a priority to validate an effective universal triaging and scheduling system to allocate emergency surgical procedures. The new Timing in Acute Care Surgery (TACS) was recently proposed and validated by a Delphi consensus as a clear and reproducible triage tool to timely perform an emergency surgical procedure according to the clinical severity of the surgical disease. The new TACS needs to be prospectively validated in clinical practice. Logistics have to be assessed using a multi-disciplinary approach to improve patients' safety, optimise the use of resources, and decrease costs., (© 2024. Italian Society of Surgery (SIC).)

Abstract: Trauma is a complex disease, and the use of antibiotic prophylaxis (AP) in trauma patients is common practice. However, considering the increasing rates of antibiotic resistance, AP use should be questioned and limited only to specific cases. Antibiotic stewardship is of paramount importance in fighting resistance spread. Definitive rules or precise indications about AP in trauma remain unclear. The present article describes the indications of AP in traumatic lesions to the head, brain, torso, maxillofacial, extremities, skin, and soft tissues endorsed by the Global Alliance for Infection in Surgery, Surgical Infection Society Europe, World Surgical Infection Society, American Association for the Surgery of Trauma, and World Society of Emergency Surgery., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Association for the Surgery of Trauma.)

Introduction: A textbook outcome patient is one in which the operative course passes uneventful, without complications, readmission or mortality. There is a lack of publications in terms of TO on acute cholecystitis., Objetive: The objective of this study is to analyze the achievement of TO in patients with urgent early cholecystectomy (UEC) for Acute Cholecystitis. and to identify which factors are related to achieving TO., Materials and Methods: This is a post hoc study of the SPRiMACC study. It´s a prospective multicenter observational study run by WSES. The criteria to define TO in urgent early cholecystectomy (TOUEC) were no 30-day mortality, no 30-day postoperative complications, no readmission within 30 days, and hospital stay ≤ 7 days (75th percentile), and full laparoscopic surgery. Patients who met all these conditions were taken as presenting a TOUEC., Outcomes: 1246 urgent early cholecystectomies for ACC were included. In all, 789 patients (63.3%) achieved all TOUEC parameters, while 457 (36.6%) failed to achieve one or more parameters and were considered non-TOUEC. The patients who achieved TOUEC were younger had significantly lower scores on all the risk scales analyzed. In the serological tests, TOUEC patients had lower values for in a lot of variables than non-TOUEC patients. The TOUEC group had lower rates of complicated cholecystitis. Considering operative time, a shorter duration was also associated with a higher probability of reaching TOUEC., Conclusion: Knowledge of the factors that influence the TOUEC can allow us to improve our results in terms of textbook outcome., (© 2024. The Author(s).)

Critically ill patients treated in the intensive care unit (ICU) can present with many abdominal conditions that need a prompt diagnosis and timely treatment because of their general frailty. Clinical evaluation and diagnostic tools like ultrasound or CT scans are not reliable or feasible in these patients. Bedside laparoscopy (BSL) is a minimally invasive procedure that allows surgeons to assess the abdominal cavity directly in the ICU, thus avoiding unnecessary exploratory laparotomy or incidents related to intra-hospital transfer. We conducted a review of the literature to summarize the state-of-the-art of BSL. The Medline, Cochrane Central Register of Controlled Trials (CENTRAL), and Scopus databases were utilized to identify all relevant publications. Indications, contraindications, technical aspects, and outcomes are discussed. The procedure is safe, feasible, and effective. When other diagnostic tools fail to diagnose or exclude an intra-abdominal condition in ICU patients, BSL should be preferred over exploratory laparotomy.

The evidence regarding the role of oral antibiotics alone (oA) or combined with mechanical bowel preparation (MoABP) for elective colorectal surgery remains controversial. A prospective database of 8359 colorectal resections gathered over a 32-month period from 78 Italian surgical units (the iCral 2 and 3 studies), reporting patient-, disease-, and procedure-related variables together with 60-day adverse events, was re-analyzed to identify a subgroup of 1013 cases (12.1%) that received either oA or MoABP. This dataset was analyzed using a 1:1 propensity score-matching model including 20 covariates. Two well-balanced groups of 243 patients each were obtained: group A (oA) and group B (MoABP). The primary endpoints were anastomotic leakage (AL) and surgical site infection (SSI) rates. Group A vs. group B showed a significantly higher AL risk [14 (5.8%) vs. 6 (2.5%) events; OR: 3.77; 95%CI: 1.22-11.67; p = 0.021], while no significant difference was recorded between the two groups regarding SSIs. These results strongly support the use of MoABP for elective colorectal resections.

The European Society of Clinical Microbiology and Infectious Disease (ESCMID) has advised against the use of metronidazole for fulminant Clostridioides difficile ( C. difficile ) infection (CDI) in their latest guidelines. They suggest using oral vancomycin alone instead. This recommendation is based on a few retrospective studies, which have multiple biases. We evaluated the three studies that led ESCMID to advise against intravenous metronidazole for fulminant CDI and performed a meta-analysis. The meta-analysis revealed a mild (2.7%), not statistically significant (p=0.8) difference in mortality between the two groups. The high heterogeneity (I 2 = 89%) should also be noted. The decision to add or remove metronidazole should be discussed in the near future. In the meantime, combination therapy could be a cautious treatment for fulminant CDI., Competing Interests: Conflict of interest: Authors declare no conflict of interest.

Objective: To generate an up-to-date bundle to manage acute biliary pancreatitis using an evidence-based, artificial intelligence (AI)-assisted GRADE method., Background: A care bundle is a set of core elements of care that are distilled from the most solid evidence-based practice guidelines and recommendations., Methods: The research questions were addressed in this bundle following the PICO criteria. The working group summarized the effects of interventions with the strength of recommendation and quality of evidence applying the GRADE methodology. ChatGPT AI system was used to independently assess the quality of evidence of each element in the bundle, together with the strength of the recommendations., Results: The 7 elements of the bundle discourage antibiotic prophylaxis in patients with acute biliary pancreatitis, support the use of a full-solid diet in patients with mild to moderately severe acute biliary pancreatitis, and recommend early enteral nutrition in patients unable to feed by mouth. The bundle states that endoscopic retrograde cholangiopancreatography should be performed within the first 48 to 72 hours of hospital admission in patients with cholangitis. Early laparoscopic cholecystectomy should be performed in patients with mild acute biliary pancreatitis. When operative intervention is needed for necrotizing pancreatitis, this should start with the endoscopic step-up approach., Conclusions: We have developed a new care bundle with 7 key elements for managing patients with acute biliary pancreatitis. This new bundle, whose scientific strength has been increased thanks to the alliance between human knowledge and AI from the new ChatGPT software, should be introduced to emergency departments, wards, and intensive care units., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Colorectal cancer (CRC) is one of the most common cancers worldwide. There are several causes of a mechanical left bowel obstructive but CRC accounts for approximately 50% of cases and in 10-30% of whom it is the presenting syndrome. In most cases, the left colon is involved. At present, the range of therapeutic alternatives in the management of obstructive left CRC in emergency conditions (primary resection vs. staged resection with applied self-expanding metallic stents) is broad, whereas internationally validated clinical recommendations in each condition are still lacking. This enormous variability affects the scientific evidence on both the immediate and long-term surgical and oncological outcomes., Methods: CROSCO-1 (Colonic Resection, Stoma or Self-expanding Metal Stents for Obstructive Left Colon Cancer) study is a national, multi-center, prospective observational study intending to compare the clinical results of all these therapeutic regimens in a cohort of patients treated for obstructive left-sided CRC., Results: The primary aim of the CROSCO-1 study is the 1-year stoma rate of patients undergoing primary emergency surgical resection (Hartmann procedure or primary resection and anastomosis) compared with patients undergoing staged resection. Secondary outcomes are 30-day and 90-day major morbidity and mortality, 1-year quality of life and the timing of chemotherapy initiation in the two groups. Future CROSCO studies will follow in which, instead, we will evaluate the long-term oncological outcomes of the two treatment strategies., Conclusions: The results of a large prospective cohort study which will analyze what really happens in the common clinical practice of managing patients with obstructive left CRC will have the aim of understanding which is the best strategy in terms of surgical and oncological outcomes. Indeed, the CROSCO-1 study will analyze the early surgical outcomes for patients with obstructed left CRC. Future CROSCO studies will follow in which, instead, we will evaluate the long-term oncological outcomes of the two treatment strategies.

Background: The importance of environmental sustainability is acknowledged in all sectors, including healthcare. To meet the United Nations Sustainable Development Goals 2030 Agenda, healthcare will need a paradigm shift toward more environmentally sustainable practices that will also impact clinical decision-making. The study investigates trauma and emergency surgeons' perception, acceptance, and employment of environmentally friendly habits., Methods: An online survey based on the most recent literature regarding environmental sustainability in healthcare and surgery was created by a multidisciplinary committee and endorsed by the World Society of Emergency Surgery (WSES). The survey was advertised to the 917 WSES members through the society's website and Twitter/X profile., Results: 450 surgeons from 55 countries participated in the survey. Results underline both a generally positive attitude toward environmental sustainability but also a lack of knowledge about several concepts and practices, especially concerning the potential contribution to patient care., Discussion: The topic of environmental sustainability in healthcare and surgery is still in its infancy. There is a clear lack of salient guidance and knowledge, and there is a critical need for governments, institutions, health agencies, and scientific societies to promote, disseminate, and report environmentally friendly initiatives and their potential impacts while employing an interdisciplinary approach., (© 2024. The Author(s).)

In the multimodal strategy context, to implement healthcare-associated infection prevention, bundles are one of the most commonly used methods to adapt guidelines in the local context and transfer best practices into routine clinical care. One of the most important measures to prevent surgical site infections is surgical antibiotic prophylaxis (SAP). This narrative review aims to present a bundle for the correct SAP administration and evaluate the evidence supporting it. Surgical site infection (SSI) prevention guidelines published by the WHO, CDC, NICE, and SHEA/IDSA/APIC/AHA, and the clinical practice guidelines for SAP by ASHP/IDSA/SIS/SHEA, were reviewed. Subsequently, comprehensive searches were also conducted using the PubMed ® /MEDLINE and Google Scholar databases, in order to identify further supporting evidence-based documentation. The bundle includes five different measures that may affect proper SAP administration. The measures included may be easily implemented in all hospitals worldwide and are based on minimal drug pharmacokinetics and pharmacodynamics knowledge, which all surgeons should know. Antibiotics for SAP should be prescribed for surgical procedures at high risk for SSIs, such as clean-contaminated and contaminated surgical procedures or for clean surgical procedures where SSIs, even if unlikely, may have devastating consequences, such as in procedures with prosthetic implants. SAP should generally be administered within 60 min before the surgical incision for most antibiotics (including cefazolin). SAP redosing is indicated for surgical procedures exceeding two antibiotic half-lives or for procedures significantly associated with blood loss. In principle, SAP should be discontinued after the surgical procedure. Hospital-based antimicrobial stewardship programmes can optimise the treatment of infections and reduce adverse events associated with antibiotics. In the context of a collaborative and interdisciplinary approach, it is essential to encourage an institutional safety culture in which surgeons are persuaded, rather than compelled, to respect antibiotic prescribing practices. In that context, the proposed bundle contains a set of evidence-based interventions for SAP administration. It is easy to apply, promotes collaboration, and includes measures that can be adequately followed and evaluated in all hospitals worldwide.

Introduction: Antifungal resistance (AFR) is a growing global public health concern. Little is currently known about knowledge, attitudes and practices regarding AFR and antifungal stewardship (AFS) in Zambia, and across the globe. To address this evidence gap, we conducted a study through a questionnaire design starting with pharmacy students as they include the next generation of healthcare professionals., Methods: A cross-sectional study among 412 pharmacy students from June 2023 to July 2023 using a structured questionnaire. Multivariable analysis was used to determine key factors of influence., Results: Of the 412 participants, 55.8% were female, with 81.6% aged between 18 and 25 years. Most students had good knowledge (85.9%) and positive attitudes (86.7%) but sub-optimal practices (65.8%) towards AFR and AFS. Overall, 30.2% of students accessed antifungals without a prescription. Male students were less likely to report a good knowledge of AFR (adjusted OR, AOR = 0.55, 95% CI: 0.31-0.98). Similarly, students residing in urban areas were less likely to report a positive attitude (AOR = 0.35, 95% CI: 0.13-0.91). Fourth-year students were also less likely to report good practices compared with second-year students (AOR = 0.48, 95% CI: 0.27-0.85)., Conclusions: Good knowledge and positive attitudes must translate into good practices toward AFR and AFS going forward. Consequently, there is a need to provide educational interventions where students have low scores regarding AFR and AFS. In addition, there is a need to implement strategies to reduce inappropriate dispensing of antifungals, especially without a prescription, to reduce AFR in Zambia., (© The Author(s) 2023. Published by Oxford University Press on behalf of British Society for Antimicrobial Chemotherapy.)

Background: Laparoscopy is widely adopted across nearly all surgical subspecialties in the elective setting. Initially finding indication in minor abdominal emergencies, it has gradually become the standard approach in the majority of elective general surgery procedures. Despite many technological advances and increasing acceptance, the laparoscopic approach remains underutilized in emergency general surgery and in abdominal trauma. Emergency laparotomy continues to carry a high morbidity and mortality. In recent years, there has been a growing interest from emergency and trauma surgeons in adopting minimally invasive surgery approaches in the acute surgical setting. The present position paper, supported by the World Society of Emergency Surgery (WSES), aims to provide a review of the literature to reach a consensus on the indications and benefits of a laparoscopic-first approach in patients requiring emergency abdominal surgery for general surgery emergencies or abdominal trauma., Methods: This position paper was developed according to the WSES methodology. A steering committee performed the literature review and drafted the position paper. An international panel of 54 experts then critically revised the manuscript and discussed it in detail, to develop a consensus on a position statement., Results: A total of 323 studies (systematic review and meta-analysis, randomized clinical trial, retrospective comparative cohort studies, case series) have been selected from an initial pool of 7409 studies. Evidence demonstrates several benefits of the laparoscopic approach in stable patients undergoing emergency abdominal surgery for general surgical emergencies or abdominal trauma. The selection of a stable patient seems to be of paramount importance for a safe adoption of a laparoscopic approach. In hemodynamically stable patients, the laparoscopic approach was found to be safe, feasible and effective as a therapeutic tool or helpful to identify further management steps and needs, resulting in improved outcomes, regardless of conversion. Appropriate patient selection, surgeon experience and rigorous minimally invasive surgical training, remain crucial factors to increase the adoption of laparoscopy in emergency general surgery and abdominal trauma., Conclusions: The WSES expert panel suggests laparoscopy as the first approach for stable patients undergoing emergency abdominal surgery for general surgery emergencies and abdominal trauma., (© 2023. The Author(s).)