Since the COVID-19 pandemic has occurred, nations showed their unpreparedness to deal with a mass casualty incident of this proportion and severity, which resulted in a tremendous number of deaths ...even among healthcare workers. The World Society of Emergency Surgery conceived this position paper with the purpose of providing evidence-based recommendations for the management of emergency surgical patients under COVID-19 pandemic for the safety of the patient and healthcare workers.
A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis Protocols (PRISMA-P) through the MEDLINE (PubMed), Embase and SCOPUS databases. Synthesis of evidence, statements and recommendations were developed in accordance with the GRADE methodology.
Given the limitation of the evidence, the current document represents an effort to join selected high-quality articles and experts' opinion.
The aim of this position paper is to provide an exhaustive guidelines to perform emergency surgery in a safe and protected environment for surgical patients and for healthcare workers under COVID-19 and to offer the best management of COVID-19 patients needing for an emergency surgical treatment. We recommend screening for COVID-19 infection at the emergency department all acute surgical patients who are waiting for hospital admission and urgent surgery. The screening work-up provides a RT-PCR nasopharyngeal swab test and a baseline (non-contrast) chest CT or a chest X-ray or a lungs US, depending on skills and availability. If the COVID-19 screening is not completed we recommend keeping the patient in isolation until RT-PCR swab test result is not available, and to manage him/she such as an overt COVID patient. The management of COVID-19 surgical patients is multidisciplinary. If an immediate surgical procedure is mandatory, whether laparoscopic or via open approach, we recommend doing every effort to protect the operating room staff for the safety of the patient.
Adequately controlling the source of infection and prescribing appropriately antibiotic therapy are the cornerstones of the management of patients with intra-abdominal infections (IAIs). Correctly ...classifying patients with IAIs is crucial to assessing the severity of their clinical condition and deciding the strategy of the treatment, including a correct empiric antibiotic therapy. Best practices in prescribing antibiotics may impact patient outcomes and the cost of treatment, as well as the risk of “opportunistic” infections such as Clostridioides difficile infection and the development and spread of antimicrobial resistance. This review aims to identify a correct classification of IAIs, guiding clinicians in the selection of the best antibiotic therapy in patients with IAIs.
Gallstone disease is very common afflicting 20 million people in the USA. In Europe, the overall incidence of gallstone disease is 18.8% in women and 9.5% in men. The frequency of gallstones related ...disease increases by age. The elderly population is increasing worldwide.
The present guidelines aims to report the results of the World Society of Emergency Surgery (WSES) and Italian Surgical Society for Elderly (SICG) consensus conference on acute calcolous cholecystitis (ACC) focused on elderly population.
The 2016 WSES guidelines on ACC were used as baseline; six questions have been used to investigate the particularities in elderly population; the answers have been developed in terms of differences compared to the general population and to statements of the 2016 WSES Guidelines. The Consensus Conference discusses, voted, and modified the statements. International experts contributed in the elaboration of final statements and evaluation of the level of scientific evidences.
The quality of the studies available decreases when we approach ACC in elderly. Same admission laparoscopic cholecystectomy should be suggested for elderly people with ACC; frailty scores as well as clinical and surgical risk scores could be adopted but no general consensus exist. The role of cholecystostomy is uncertain.
The evaluation of pro and cons for surgery or for alternative treatments in elderly suffering of ACC is more complex than in young people; also, the oldest old age is not a contraindication for surgery; however, a larger use of frailty and surgical risk scores could contribute to reach the best clinical judgment by the surgeon. The present guidelines offer the opportunity to share with the scientific community a baseline for future researches and discussion.
Abstract
Background
Acute pancreatitis is a common inflammatory pancreatic disorder, often caused by gallstone disease and frequently requiring hospitalization.
In 80% of cases, a rapid and ...favourable outcome is described, while a necrosis of pancreatic parenchyma or extra-pancreatic tissues is reported in 10–20% of patients. The onset of pancreatic necrosis determines a significant increase of early organ failure rate and death that has higher incidence if infection of pancreatic necrosis (IPN) or extra-pancreatic collections occur.
IPN always requires an invasive intervention, and, in the last decade, the advent of minimally invasive techniques has gradually replaced the employment of the open traditional approach.
We report a series of three severe cases of IPN managed with primary open necrosectomy (ON) and a systematic review of the literature, in order to understand if emergency surgery still has a role in the current clinical practice.
Methods
From January 2010 to January 2020, 3 cases of IPN were treated in our Academic Department of General and Emergency Surgery. We performed a PubMed MEDLINE search on the ON of IPN, selecting 20 from 654 articles for review.
Results
The 3 cases were male patients with a mean age of 61.3 years. All patients referred to our service complaining an evolving severe clinical condition evocating a sepsis due to IPN. CT scan was the main diagnostic tool. Patients were initially conservatively managed. In consideration of clinical worsening conditions, and at the failure of conservative and minimal invasive treatment, they were, finally, managed with emergency ON. Patients reported no complications nor procedure-related sequelae in the follow-up period.
Conclusion
The ON is confirmed to be the last resort, useful in selected severe cases, with a defined timing and in case of proven non-feasibility and no advantage of other minimally invasive approaches.
Giant hiatal hernia (GHH) is a condition where one-third of the stomach migrates into the thorax. Nowadays, laparoscopic treatment gives excellent postoperative outcomes. Strangulated GHH is rare, ...and its emergent repair is associated with significant morbidity and mortality rates. We report a series of five cases of strangulated GHH treated by a minimally invasive laparoscopic and robot-assisted approach, together with a systematic review of the literature.
During 10 years (December 2009-December 2019), 31 patients affected by GHH were treated by robot-assisted or conventional laparoscopic surgical approach. Among them, five cases were treated in an emergency setting. We performed a PubMed MEDLINE search about the minimally invasive emergent treatment of GHH, selecting 18 articles for review.
The five cases were male patients with a mean age of 70 ± 18 years. All patients referred to the emergency service complaining of severe abdominal and thoracic pain, nausea and vomiting. CT scan and endoscopy were the main diagnostic tools. All patients showed stable hemodynamic conditions so that they could undergo a minimally invasive attempt. The surgical approach was robotic-assisted in three patients (60%) and laparoscopic in two (40%). Patients reported no complications or recurrences.
Reviewing current literature, no general recommendations are available about the emergent treatment of strangulated hiatal hernia. Acute mechanical outlet obstruction, ischemia of gastric wall or perforation and severe bleeding are the reasons for an emergent surgical indication. In stable conditions, a minimally invasive approach is often feasible. Moreover, the robot-assisted approach, allowing a stable 3D view and using articulated instruments, represents a reasonable option in challenging situations.
Background
Adhesions are a major cause of long-term postsurgical complications in abdominal and pelvic surgery. Existing adhesion scores primarily measure morphological characteristics of adhesions ...that do not necessarily correlate with morbidity. The aim of this study was to develop a clinical adhesion score (CLAS) measuring overall clinical morbidity of adhesion-related complications in abdominal and pelvic surgery.
Methods
An international Delphi study was performed to identify relevant score items for adhesion-related complications, including small bowel obstruction, female infertility, chronic abdominal or pelvic pain, and difficulties at reoperation. The CLAS includes clinical outcomes, related to morbidity of adhesions, and weight factors, to correct the outcome scores for the likelihood that symptoms are truly caused by adhesions. In a pilot study, two independent researchers retrospectively scored the CLAS in 51 patients to evaluate inter-observer reliability, by calculating the Intraclass correlation coefficient. During a feasibility assessment, we evaluated whether the CLAS completely covered different clinical scenarios of adhesion-related morbidity.
Results
Three Delphi rounds were performed. 43 experts agreed to participate, 38(88%) completed the first round, and 32 (74%) the third round. Consensus was reached on 83.4% of items. Inter-observer reliability for the CLAS was 0.95 (95% CI 0.91–0.97). During feasibility assessment, six items were included. As a result, the CLAS includes 22 outcomes and 23 weight factors.
Conclusion
The CLAS represents a promising scoring system to measure and monitor the clinical morbidity of adhesion-related complications. Further studies are needed to confirm its utility in clinical practice.
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 placement of a metallic stent as a bridge to surgery (SBTS) could represents an option for the treatment of left-sided malignant colonic obstruction in centres with adequate skills. Several ...meta-analyses demonstrated better short-term outcomes after SBTS when compared with emergency surgery (ES); however, some studies reported a higher local recurrence rate. The aim of the present review is to investigate the long-term outcomes of stent bridge to surgery as compared to ES.
A systematic review was performed to retrieve studies comparing long-term oncologic outcomes of SBTS and ES. Local and overall recurrence rate, overall and disease-free survival were retrieved and results were expressed as risk ratios.
Seventeen studies and a total of 1,333 patients were included in the analysis. No significant differences were reported in recurrence rate risk ratio (RR) =1.11; 95% confidence interval (95% CI): 0.84-1.47, P=0.47, 3-year mortality (RR =0.90; 95% CI: 0.73-1.12, P=0.34) and 5-year mortality (RR =1.00; 95% CI: 0.82-1.22, P=0.99). There were no differences among randomized and observational studies.
SBTS has similar long-term oncologic outcomes to ES and in centres with appropriate skill should be considered the best treatment option for left-sided malignant colonic obstructions.
: The management of complicated diverticulitis in the elderly can be a challenge and initial non-operative treatment remains controversial. In this study, we investigate the effectiveness of ...conservative treatment in elderly people after the first episode of complicated diverticulitis.
: This retrospective single-centre study describes 71 cases of elderly patients with complicated acute colonic diverticulitis treated with conservative management at Parma University Hospital from 1 January 2012 to 31 December 2019. Diverticulitis severity was staged according to WSES CT driven classification for acute diverticulitis. Patients was divided into two groups: early (65-74 yo) and late elderly (>75 yo).
: We enrolled 71 elderly patients conservatively treated for complicated acute colonic diverticulitis, 25 males and 46 females. The mean age was 74.78 ± 6.8 years (range 65-92). Localized abdominal pain and fever were the most common symptoms reported in 34 cases (47.88%). Average white cells count was 10.04 ± 5.05 × 109/L in the early elderly group and 11.24 ± 7.89 in the late elderly group. CRP was elevated in 29 (78.3%) cases in early elderly and in 23 late elderly patients (67.6%). A CT scan of the abdomen was performed in every case (100%). Almost all patients were treated with bowel rest and antibiotics (95.7%). Average length of stay was 7.74 ± 7.1 days (range 1-48). Thirty-day hospital readmission and mortality were not reported. Average follow-up was 52.32 ± 31.8 months. During follow-up, home therapy was prescribed in 48 cases (67.6%). New episodes of acute diverticulitis were reported in 20 patients (28.1%), elevated WBC and chronic NSAID therapy were related to a higher risk of recurrence in early elderly patients (
< 0.05). Stage IIb-III with elevated WBC during first episode, had a higher recurrence rate compared to the other CT-stage (
= 0.006).
: The management of ACD in the elderly can be a challenge. Conservative treatment is safe and effective in older patients, avoiding unnecessary surgery that can lead to unexpected complications due to co-morbidities.
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