Acute lung injury (ALI) is a common cause of morbidity in patients after severe injury due to dysregulated inflammation, which is believed to be driven by gut‐derived inflammatory mediators carried ...via mesenteric lymph (ML). We have previously demonstrated that nano‐sized extracellular vesicles, called exosomes, secreted into ML after trauma/hemorrhagic shock (T/HS) have the potential to activate immune cells in vitro. Here, we assess the function of ML exosomes in the development of T/HS‐induced ALI and the role of TLR4 in the ML exosome‐mediated inflammatory response. ML exosomes isolated from rats subjected to T/HS stimulated NF‐KB activation and caused proinflammatory cytokine production in alveolar macrophages. In vivo experiments revealed that intravenous injection of exosomes harvested after T/HS, but not before shock, caused recruitment of inflammatory cells in the lung, increased vascular permeability, and induced histologic ALI in naive mice. The exosome‐depleted supernatant of ML had no effect on in vitro and in vivo inflammatory responses. We also demonstrated that both pharmacologic inhibition and genetic knockout of TLR4 completely abolished ML exosome‐induced cytokine production in macrophages. Thus, our findings define the critical role of exosomes secreted into ML as a critical mediator of T/HS‐induced ALI through macrophage TLR4 activation.—Kojima, M., Gimenes‐Junior, J. A., Chan, T. W., Eliceiri, B. P., Baird, A., Costantini, T. W., Coimbra, R. Exosomes in postshock mesenteric lymph are key mediators of acute lung injury triggering the macrophage activation via Toll‐like receptor 4. FASEB J. 32,97‐110 (2018). www.fasebj.org
A series of recommendations regarding hospital perioperative preparation for the COVID-19 pandemic were compiled to inform surgeons worldwide on how to provide emergency surgery and trauma care ...during enduring times.The recommendations are divided into eight domains: (1) General recommendation for surgical services; (2) Emergency Surgery for critically ill COVID-19 positive or suspected patients -Preoperative planning and case selection; (3) Operating Room setup; (4) patient transport to the OR; (5) Surgical staff preparation; (6) Anesthesia considerations; (7) Surgical approach; and (8) Case Completion.The European Society of Emergency Surgery board endorsed these recommendations.
Unique book provides comprehensive discussion of MIS versus traditional techniques in modern Acute Care Surgery The combination of a surgeon shortage and poor access to emergency surgical care led to ...establishment of the Acute Care Surgery paradigm and subspecialty in 2003. Concurrently, minimally invasive approaches revolutionized surgical practice in the 21st century. In the U.S., acute care surgeons stand at the front line of patient care for emergency general surgery, trauma, and surgical critical care, and thus are positioned to positively impact healthcare delivery and costs. Surgical Decision Making in Acute Care Surgery by renowned surgeons Kimberly Davis and Raul Coimbra is the first text that comprehensively discusses when to use minimally invasive techniques and advanced technology versus traditional open procedures in acute traumatic and non-traumatic surgical emergencies. The text begins with three opening chapters covering the background of the Acute Care Surgery subspecialty, anatomic and physiological considerations, and the impact of acute surgical illness on pre- and post-operative critical care decisions. Subsequent chapters outline surgical approaches for commonly encountered acute conditions. Trauma chapters cover interventions for cervical, blunt and penetrating abdominal, and thoracic injuries. Emergency general surgery topics run the gamut from appendicitis to emergency management of paraesophageal hernias and esophageal perforations. An impressive group of senior surgeons and younger rising stars in American surgery share their expertise throughout the book. Key Highlights * Disease-specific chapters include epidemiology, pathogenesis, diagnostic tools, treatment strategies, surgical techniques, cost analyses, complications, and national guidelines where available * Subchapters feature expert commentary on preceding chapters, including clinical pearls and controversies (e.g. operative vs. nonoperative management) * In-depth discussion of surgical decision making encompasses the type of surgical approach, as well as indications and contraindications for MIS * The roles of MIS procedures such as laparoscopy, thoracoscopy, radiology-based percutaneous techniques, as well as endovascular surgery are examined The quintessential resource on contemporary Acute Care Surgery practice, this is a must-read for residents, junior faculty, and practicing surgeons in this discipline.
Background
The best surgical approach to treat acute cholecystitis (AC) in cirrhotic patients is controversial. This study aimed to evaluate treatment options in cirrhotic patients with AC. We ...hypothesized that laparoscopic cholecystectomy (LC) would lead to better clinical outcomes when compared to non‐operative management (NOM) and open cholecystectomy (OC), independent of the severity of liver cirrhosis.
Methods
Patients from the National Inpatient Sample diagnosed with AC were stratified into no cirrhosis (NC), compensated cirrhosis (CC), and decompensated cirrhosis (DC) and analyzed according to treatment: NOM, OC, and LC. Primary outcome was in‐hospital mortality. Secondary outcomes included hospital length of stay (HLOS), cost, and surgical complications. Univariate and multivariate analyses using generalized linear models were performed. A P < 0.05 was deemed significant.
Results
Of 1 367 495 AC patients, 49 030 (3.6%) had cirrhosis; 23 260 had CC, and 25 770 had DC. LC (12 080 in CC group and 4840 in DC group) was accompanied by significantly lower mortality, HLOS, complications, and cost when compared to OC and NOM.
OC was significantly associated with higher mortality, increased HLOS, total cost, and postoperative complications, independent of the presence or severity of cirrhosis.
Conclusions
LC in cirrhotic patients leads to superior outcomes compared to OC and NOM regardless of the severity of cirrhosis.
Highlight
Finco and colleagues analyzed data from the National Inpatient Sample regarding acute cholecystitis in compensated and decompensated cirrhotic patients. Laparoscopic cholecystectomy was found to lead to superior outcomes compared with open surgery and non‐operative management, with significantly lower mortality, hospital length of stay, complications, and costs, regardless of cirrhosis severity.
Since the mid-1990s the surgical community has seen a surge in the prevalence of open abdomens (OAs) reported in the surgical literature and in clinical practice. The OA has proven to be effective in ...decreasing mortality and immediate postoperative complications; however, it may come at the cost of delayed morbidity and the need for further surgical procedures. Indications for leaving the abdomen open have broadened to include damage control surgery, abdominal compartment syndrome, and abdominal sepsis. The surgical options for management of the OA are now more diverse and sophisticated, but there is a lack of prospective randomized controlled trials demonstrating the superiority of any particular method. Additionally, critical care strategies for optimization of the patient with an OA are still being developed. Review of the literature suggests a bimodal distribution of primary closure rates, with early closure dependent on postoperative intensive care management and delayed closure more affected by the choice of the temporary abdominal closure technique. Invariably, a small fraction of patients requiring OA management fail to have primary fascial closure and require some form of biologic fascial bridge with delayed ventral hernia repair in the future.
Acute calculus cholecystitis (ACC) has a high incidence in the general population. The presence of several areas of uncertainty, along with the availability of new evidence, prompted the current ...update of the 2016 WSES (World Society of Emergency Surgery) Guidelines on ACC.
The WSES president appointed four members as a scientific secretariat, four members as an organization committee and four members as a scientific committee, choosing them from the expert affiliates of WSES. Relevant key questions were constructed, and the task force produced drafts of each section based on the best scientific evidence from PubMed and EMBASE Library; recommendations were developed in order to answer these key questions. The quality of evidence and strength of recommendations were reviewed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria (see https://www.gradeworkinggroup.org/ ). All the statements were presented, discussed and voted upon during the Consensus Conference at the 6th World Congress of the World Society of Emergency Surgery held in Nijmegen (NL) in May 2019. A revised version of the statements was voted upon via an online questionnaire until consensus was reached.
The pivotal role of surgery is confirmed, including in high-risk patients. When compared with the WSES 2016 guidelines, the role of gallbladder drainage is reduced, despite the considerable technical improvements available. Early laparoscopic cholecystectomy (ELC) should be the standard of care whenever possible, even in subgroups of patients who are considered fragile, such as the elderly; those with cardiac disease, renal disease and cirrhosis; or those who are generally at high risk for surgery. Subtotal cholecystectomy is safe and represents a valuable option in cases of difficult gallbladder removal.
ELC has a central role in the management of patients with ACC. The value of surgical treatment for high-risk patients should lead to a distinction between high-risk patients and patients who are not suitable for surgery. Further evidence on the role of clinical judgement and the use of clinical scores as adjunctive tools to guide treatment of high-risk patients and patients who are not suitable for surgery is required. The development of local policies for safe laparoscopic cholecystectomy is recommended.
Abstract
Background
The effectiveness and indications of open-chest cardiopulmonary resuscitation (OCCPR) have been still debatable. Although current guidelines state that the presence of signs of ...life (SOL) is an indication for OCCPR, scientific evidence corroborating this recommendation has been scarce. This study aimed to compare the effectiveness of OCCPR to closed-chest cardiopulmonary resuscitation (CCCPR) in severe trauma patients with SOL upon arrival at the emergency department (ED).
Methods
A retrospective cohort study analyzing data from the Trauma Quality Improvement Program (TQIP) database, a nationwide trauma registry in the USA, between 2010 and 2016 was conducted. Severe trauma patients who had SOL upon arrival at the hospital and received cardiopulmonary resuscitation within the first 6 h of ED admission were identified. Survival to hospital discharge was evaluated using logistic regression analysis, instrumental variable analysis, and propensity score matching analysis adjusting for potential confounders.
Results
A total of 2682 patients (OCCPR 1032; CCCPR 1650) were evaluated; of those 157 patients (15.2%) in the OCCPR group and 193 patients (11.7%) in the CCCPR group survived. OCCPR was significantly associated with higher survival to hospital discharge in both the logistic regression analysis (adjusted odds ratio 95% confidence interval = 1.99 1.42–2.79,
p
< 0.001) and the instrumental variable analysis (adjusted odds ratio 95% confidence interval = 1.16 1.02–1.31,
p
= 0.021). In the propensity score matching analysis, 531 matched pairs were generated, and the OCCPR group still showed significantly higher survival at hospital discharge (89 patients 16.8% in the OCCPR group vs 58 patients 10.9% in the CCCPR group; odds ratio 95% confidence interval = 1.66 1.13–2.42,
p
= 0.009).
Conclusions
Compared to CCCPR, OCCPR was associated with significantly higher survival at hospital discharge in severe trauma patients with SOL upon ED arrival. Further studies to confirm these results and to assess long-term neurologic outcomes are needed.
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