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.
Esophageal emergencies: WSES guidelines Chirica, Mircea; Kelly, Michael D; Siboni, Stefano ...
World journal of emergency surgery,
05/2019, Letnik:
14, Številka:
1
Journal Article
Recenzirano
Odprti dostop
The esophagus traverses three body compartments (neck, thorax, and abdomen) and is surrounded at each level by vital organs. Injuries to the esophagus may be classified as foreign body ingestion, ...caustic ingestion, esophageal perforation, and esophageal trauma. These lesions can be life-threatening either by digestive contamination of surrounding structures in case of esophageal wall breach or concomitant damage of surrounding organs. Early diagnosis and timely therapeutic intervention are the keys of successful management.
A wide variety of hemostats are available as adjunctive measures to improve hemostasis during surgical procedures if residual bleeding persists despite correct application of conventional methods for ...hemorrhage control. Some are considered active agents, since they contain fibrinogen and thrombin and actively participate at the end of the coagulation cascade to form a fibrin clot, whereas others to be effective require an intact coagulation system. The aim of this study is to provide an evidence-based approach to correctly select the available agents to help physicians to use the most appropriate hemostat according to the clinical setting, surgical problem and patient's coagulation status.
The literature from 2000 to 2016 was systematically screened according to PRISMA Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol. Sixty-six articles were reviewed by a panel of experts to assign grade of recommendation (GoR) and level of evidence (LoE) using the GRADE Grading of Recommendations Assessment, Development and Evaluation system, and a national meeting was held.
Fibrin adhesives, in liquid form (fibrin glues) or with stiff collagen fleece (fibrin patch) are effective in the presence of spontaneous or drug-induced coagulation disorders. Mechanical hemostats should be preferred in patients who have an intact coagulation system. Sealants are effective, irrespective of patient's coagulation status, to improve control of residual oozing. Hemostatic dressings represent a valuable option in case of external hemorrhage at junctional sites or when tourniquets are impractical or ineffective.
Local hemostatic agents are dissimilar products with different indications. A knowledge of the properties of each single agent should be in the armamentarium of acute care surgeons in order to select the appropriate product in different clinical conditions.
Abstract
Background
Multiple studies regarding the use of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in patients with non-compressible torso injuries and uncontrolled ...haemorrhagic shock were recently published. To date, the clinical evidence of the efficacy of REBOA is still debated. We aimed to conduct a systematic review assessing the clinical efficacy and safety of REBOA in patients with major trauma and uncontrolled haemorrhagic shock.
Methods
We systematically searched MEDLINE (PubMed), EMBASE and CENTRAL up to June 2020. All randomized controlled trials and observational studies that investigated the use of REBOA compared to resuscitative thoracotomy (RT) with/without REBOA or no-REBOA were eligible.
We followed the PRISMA and MOOSE guidelines. Two authors independently extracted data and appraised the risk of bias of included studies. Effect sizes were pooled in a meta-analysis using random-effects models. The quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation methodology. Primary outcomes were mortality, volume of infused blood components, health-related quality of life, time to haemorrhage control and any adverse effects. Secondary outcomes were improvement in haemodynamic status and failure/success of REBOA technique.
Results
We included 11 studies (5866 participants) ranging from fair to good quality. REBOA was associated with lower mortality when compared to RT (aOR 0.38; 95% CI 0.20–0.74), whereas no difference was observed when REBOA was compared to no-REBOA (aOR 1.40; 95% CI 0.79–2.46). No significant difference in health-related quality of life between REBOA and RT (
p
= 0.766). The most commonly reported complications were amputation, haematoma and pseudoaneurysm. Sparse data and heterogeneity of reporting for all other outcomes prevented any estimate.
Conclusions
Our findings on overall mortality suggest a positive effect of REBOA among non-compressible torso injuries when compared to RT but no differences compared to no-REBOA. Variability in indications and patient characteristics prevents any conclusion deserving further investigation. REBOA should be promoted in specific training programs in an experimental setting in order to test its effectiveness and a randomized trial should be planned.
This study aims to define possible predictors of the need of invasive and non-invasive ventilatory support, in addition to predictors of mortality in patients with severe thoracic trauma. Data from ...832 patients admitted to our trauma center were collected from 2010 to 2017 and retrospectively analyzed. Demographic data, type of respiratory assistance, chest injuries, trauma scores and outcome were considered. Univariate analysis was performed, and binary logistic regression was applied to significant data. The injury severity score (ISS) and the revised trauma score (RTS) were both found to be predictive factors for invasive ventilation. Multivariate analysis of the anatomical injuries revealed that the association of high-severity thoracic injuries with trauma in other districts is an indicator of the need for orotracheal intubation. From the analysis of physiological parameters, values of systolic blood pressure, lactate, and Glasgow coma scale (GCS) score indicate the need for invasive ventilatory support. Predictive factors for non-invasive ventilation include: RTS, ISS, number of rib fractures and presence of hemothorax. Risk factors for death were: age over 65, the presence of bilateral rib fractures, pulmonary contusion, hemothorax and associated head trauma. In conclusion, the need for invasive ventilatory support in thoracic trauma is associated to the patient’s systemic severity. Non-invasive ventilation is a supportive treatment indicated in physiologically stable patients regardless of the severity of thoracic injury.
This paper reports on the consensus conference on the management of intra-abdominal infections (IAIs) which was held on July 23, 2016, in Dublin, Ireland, as a part of the annual World Society of ...Emergency Surgery (WSES) meeting. This document covers all aspects of the management of IAIs. The Grading of Recommendations Assessment, Development and Evaluation recommendation is used, and this document represents the executive summary of the consensus conference findings.
Motorcyclists are often victims of road traffic incidents. Though elderly patients seem to have worse survival outcomes and sustain more severe injuries than younger patients, concordance in the ...literature for this does not exist. The aim of the study is to evaluate the impact of age and injury severity on the mortality of patients undergoing motorcycle trauma.
Data of 1725 patients consecutively admitted to our Trauma Center were selected from 2002 to 2016 and retrospectively analyzed. The sample was divided into three age groups: ≤ 17 years, 18-54 years, and ≥ 55 years. Mortality rates were analyzed for the overall population and patients with Injury Severity Score (ISS) ≥ 25. Differences in survival among age groups were evaluated with log-rank test, and multivariate logistic regression models were created to identify independent predictors of mortality.
A lower survival rate was detected in patients older than 55 years (83.6% vs 94.7%, p = 0.049) and in those sustaining critical injuries (ISS ≥ 25, 61% vs 83%, p = 0.021). Age (p = 0.027, OR 1.03), ISS (p < 0.001, OR 1.09), and Revised Trauma Score (RTS) (p < 0.001, OR 0.47) resulted as independent predictors of death. Multivariate analysis identified head (p < 0.001, OR 2.04), chest (p < 0.001, OR 1.54), abdominal (p < 0.001, OR 1.37), and pelvic (p = 0.014, OR 1.26) injuries as independent risk factors related to mortality as well. Compared to the theoretical probability of survival, patients of all age groups showed a survival advantage when managed at a level I trauma center.
We detected anatomical injury distributions and mortality rates among three age groups. Patients aging more than 55 years had an increased risk of death, with a prevalence of severe chest injuries, while younger patients sustained more severe head trauma. Age represented an independent predictor of death. Management of these patients at a level I trauma center may lead to improved outcomes.
Robotics represents the most technologically advanced approach in minimally invasive surgery (MIS). Its application in general surgery has increased progressively, with some early experience reported ...in emergency settings. The present position paper, supported by the World Society of Emergency Surgery (WSES), aims to provide a systematic review of the literature to develop consensus statements about the potential use of robotics in emergency general surgery.
This position paper was conducted according to the WSES methodology. A steering committee was constituted to draft the position paper according to the literature review. An international expert panel then critically revised the manuscript. Each statement was voted through a web survey to reach a consensus.
Ten studies (3 case reports, 3 case series, and 4 retrospective comparative cohort studies) have been published regarding the applications of robotics for emergency general surgery procedures. Due to the paucity and overall low quality of evidence, 6 statements are proposed as expert opinions. In general, the experts claim for a strict patient selection while approaching emergent general surgery procedures with robotics, eventually considering it for hemodynamically stable patients only. An emergency setting should not be seen as an absolute contraindication for robotic surgery if an adequate training of the operating surgical team is available. In such conditions, robotic surgery can be considered safe, feasible, and associated with surgical outcomes related to an MIS approach. However, there are some concerns regarding the adoption of robotic surgery for emergency surgeries associated with the following: (i) the availability and accessibility of the robotic platform for emergency units and during night shifts, (ii) expected longer operative times, and (iii) increased costs. Further research is necessary to investigate the role of robotic surgery in emergency settings and to explore the possibility of performing telementoring and telesurgery, which are particularly valuable in emergency situations.
Many hospitals are currently equipped with a robotic surgical platform which needs to be implemented efficiently. The role of robotic surgery for emergency procedures remains under investigation. However, its use is expanding with a careful assessment of costs and timeliness of operations. The proposed statements should be seen as a preliminary guide for the surgical community stressing the need for reevaluation and update processes as evidence expands in the relevant literature.
A part of damage-control laparotomy is to leave the fascial edges and the skin open to avoid abdominal compartment syndrome and allow further explorations. This condition, known as open abdomen (OA), ...although effective, is associated with severe complications. Our aim was to develop evidence-based recommendations to define indications for OA, techniques for temporary abdominal closure, management of enteric fistulas, and methods of definitive wall closure.
The literature from 1990 to 2014 was systematically screened according to PRISMA Preferred Reporting Items for Systematic Reviews and Meta-analyses protocol. Seventy-six articles were reviewed by a panel of experts to assign grade of recommendations (GoR) and level of evidence (LoE) using the GRADE Grading of Recommendations Assessment, Development, and Evaluation system, and an international consensus conference was held.
OA in trauma is indicated at the end of damage-control laparotomy, in the presence of visceral swelling, for a second look in vascular injuries or gross contamination, in the case of abdominal wall loss, and if medical treatment of abdominal compartment syndrome has failed (GoR B, LoE II). Negative-pressure wound therapy is the recommended temporary abdominal closure technique to drain peritoneal fluid, improve nursing, and prevent fascial retraction (GoR B, LoE I). Lack of OA closure within 8 days (GoR C, LoE II), bowel injuries, high-volume replacement, and use of polypropylene mesh over the bowel (GoR C, LoE I) are risk factors for frozen abdomen and fistula formation. Negative-pressure wound therapy allows to isolate the fistula and protect the surrounding tissues from spillage until granulation (GoR C, LoE II). Correction of fistula is performed after 6 months to 12 months. Definitive closure of OA has to be obtained early (GoR C, LoE I) with direct suture, traction devices, component separation with or without mesh. Biologic meshes are an option for wall reinforcement if bacterial contamination is present (GoR C, LoE II).
OA and negative-pressure techniques improve the care of trauma patients, but closure must be achieved early to avoid complications.
Abstract
Backgrounds
The COVID-19 pandemic drastically strained the health systems worldwide, obligating the reassessment of how healthcare is delivered. In Lombardia, Italy, a Regional Emergency ...Committee (REC) was established and the regional health system reorganized, with only three hospitals designated as hubs for trauma care. The aim of this study was to evaluate the effects of this reorganization of regional care, comparing the distribution of patients before and during the COVID-19 outbreak and to describe changes in the epidemiology of severe trauma among the two periods.
Methods
A cohort study was conducted using retrospectively collected data from the Regional Trauma Registry of Lombardia (LTR). We compared the data of trauma patients admitted to three hub hospitals before the COVID-19 outbreak (September 1 to November 19, 2019) with those recorded during the pandemic (February 21 to May 10, 2020) in the same hospitals. Demographic data, level of pre-hospital care (Advanced Life Support-ALS, Basic Life Support-BLS), type of transportation, mechanism of injury (MOI), abbreviated injury score (AIS, 1998 version), injury severity score (ISS), revised trauma score (RTS), and ICU admission and survival outcome of all the patients admitted to the three trauma centers designed as hubs, were reviewed. Screening for COVID-19 was performed with nasopharyngeal swabs, chest ultrasound, and/or computed tomography.
Results
During the COVID-19 pandemic, trauma patients admitted to the hubs increased (46.4% vs 28.3%,
p
< 0.001) with an increase in pre-hospital time (71.8 vs 61.3 min,
p
< 0.01), while observed in hospital mortality was unaffected. TRISS, ISS, AIS, and ICU admission were similar in both periods. During the COVID-19 outbreak, we observed substantial changes in MOI of severe trauma patients admitted to three hubs, with increases of unintentional (31.9% vs 18.5%,
p
< 0.05) and intentional falls (8.4% vs 1.2%,
p
< 0.05), whereas the pandemic restrictions reduced road- related injuries (35.6% vs 60%,
p
< 0.05). Deaths on scene were significantly increased (17.7% vs 6.8%,
p
< 0.001).
Conclusions
The COVID-19 outbreak affected the epidemiology of severe trauma patients. An increase in trauma patient admissions to a few designated facilities with high level of care obtained satisfactory results, while COVID-19 patients overwhelmed resources of most other hospitals.
PDF
