Abstract
Background
Immunocompromised patients are at higher risk of surgical site infection and wound complications. However, optimal management in the perioperative period is not well established. ...Present systematic review aims to analyse existing strategies and interventions to prevent and manage surgical site infections and other wound complications in immunocompromised patients.
Methods
A systematic review of the literature was conducted.
Results
Literature review shows that partial skin closure is effective to reduce SSI in this population. There is not sufficient evidence to definitively suggest in favour of prophylactic negative pressure wound therapy. The use of mammalian target of rapamycin (mTOR) and calcineurin inhibitors (CNI) in transplanted patient needing ad emergent or undeferrable abdominal surgical procedure must be carefully and multidisciplinary evaluated. The role of antibiotic prophylaxis in transplanted patients needs to be assessed.
Conclusion
Strict adherence to SSI infection preventing bundles must be implemented worldwide especially in immunocompromised patients. Lastly, it is necessary to elaborate a more widely approved definition of immunocompromised state. Without such shared definition, it will be hard to elaborate the needed methodologically correct studies for this fragile population.
Acute left colonic diverticulitis (ALCD) in the elderly presents with unique epidemiological features when compared with younger patients. The clinical presentation is more nuanced in the elderly ...population, having higher in-hospital and postoperative mortality. Furthermore, geriatric comorbidities are a risk factor for complicated diverticulitis. Finally, elderly patients have a lower risk of recurrent episodes and, in case of recurrence, a lower probability of requiring urgent surgery than younger patients. The aim of the present work is to study age-related factors that may support a unique approach to the diagnosis and treatment of this problem in the elderly when compared with the WSES guidelines for the management of acute left-sided colonic diverticulitis. During the 1° Pisa Workshop of Acute Care & Trauma Surgery held in Pisa (Italy) in September 2019, with the collaboration of the World Society of Emergency Surgery (WSES), the Italian Society of Geriatric Surgery (SICG), the Italian Hospital Surgeons Association (ACOI), the Italian Emergency Surgery and Trauma Association (SICUT), the Academy of Emergency Medicine and Care (AcEMC) and the Italian Society of Surgical Pathophysiology (SIFIPAC), three panel members presented a number of statements developed for each of the four themes regarding the diagnosis and management of ALCD in older patients, formulated according to the GRADE approach, at a Consensus Conference where a panel of experts participated. The statements were subsequently debated, revised, and finally approved by the Consensus Conference attendees. The current paper is a summary report of the definitive guidelines statements on each of the following topics: diagnosis, management, surgical technique and antibiotic therapy.
Abstract
Immunocompromised patients are a heterogeneous and diffuse category frequently presenting to the emergency department with acute surgical diseases. Diagnosis and treatment in ...immunocompromised patients are often complex and must be multidisciplinary. Misdiagnosis of an acute surgical disease may be followed by increased morbidity and mortality. Delayed diagnosis and treatment of surgical disease occur; these patients may seek medical assistance late because their symptoms are often ambiguous. Also, they develop unique surgical problems that do not affect the general population. Management of this population must be multidisciplinary.
This paper presents the World Society of Emergency Surgery (WSES), Surgical Infection Society Europe (SIS-E), World Surgical Infection Society (WSIS), American Association for the Surgery of Trauma (AAST), and Global Alliance for Infection in Surgery (GAIS) joined guidelines about the management of acute abdomen in immunocompromised patients.
Compartment syndrome can occur in many body regions and may range from homeostasis asymptomatic alterations to severe, life-threatening conditions. Surgical intervention to decompress affected organs ...or area of the body is often the only effective treatment, although evidences to assess the best timing of intervention are lacking. Present paper systematically reviewed the literature stratifying timings according to the compartmental syndromes which may beneficiate from immediate, early, delayed, or prophylactic surgical decompression. Timing of decompression have been stratified into four categories: (1) immediate decompression for those compartmental syndromes whose missed therapy would rapidly lead to patient death or extreme disability, (2) early decompression with the time burden of 3-12 h and in any case before clinical signs of irreversible deterioration, (3) delayed decompression identified with decompression performed after 12 h or after signs of clinical deterioration has occurred, and (4) prophylactic decompression in those situations where high incidence of compartment syndrome is expected after a specific causative event.
Background
Existing guidelines for predicting common bile duct stones (CBDS) are not specific for acute calculous cholecystitis (ACC). This paper is a posthoc analysis of the S.P.Ri.M.A.C.C study ...aiming to prospectively validate on a large independent cohort of patients the Israeli Score (IS) in predicting CBDS in patients with ACC.
Methods
The S.P.Ri.M.A.C.C. study is an observational multicenter prospective study endorsed by the World Society of Emergency Surgery (WSES). Between September 1st, 2021, and September 1st, 2022, 1201 participants were included. The Chi-Square test was used to compare categorical data. A Cochran-Armitage test was run to determine whether a linear trend existed between the IS and the presence of CBDS. To assess the accuracy of the prediction model, the receiver operating characteristic (ROC) curve was generated, and the area under the ROC curve (AUC) was calculated. Logistic regression was run to obtain Odds Ratio (OR). A two-tailed
p
< 0.05 was considered statistically significant.
Results
The rate of CBDS was 1.8% in patients with an IS of 0, 4.2% in patients with an IS of 1, 24.5% in patients with 2 and 56.3% in patients with 3 (
p
< 0.001). The Cochran-Armitage test of trend showed a statistically significant linear trend,
p
< 0.001. Patients with an IS of 3 had 64.4 times (95% CI 24.8–166.9) higher odds of having associated CBDS than patients with an IS of 0. The AUC of the ROC curve of IS for the prediction of CBDS was 0.809 (95% CI 0.752–0.865,
p
< 0.001). By applying the highest cut-off point (3), the specificity reached 99%, while using the lowest cut-off value (0), the sensitivity reached 100%.
Conclusion
The IS is a reliable tool to predict CBDS associated with ACC. The algorithm derived from the IS could optimize the management of patients with ACC.
Background
Open abdomen (OA) is a surgical option that can be used in patients with severe peritonitis. Few evidences exist to recommend the use of intraperitoneal fluid instillation associated with ...OA in managing septic abdomen.
Materials and methods
A prospective analysis of adult patients enrolled in the International Register of Open Abdomen (trial registration: NCT02382770) was performed.
Results
A total of 387 patients were enrolled in two groups: 84 with peritoneal fluid instillation (FI) and 303 without (NFI). The groups were homogeneous for baseline characteristics. Overall complications were 92.9% in FI and 86.3% in NFI (
p
= 0.106). Complications during OA were 72.6% in FI and 59.9% in NFI (
p
= 0.034). Complications after definitive closure were 70.8% in FI and 61.1% in NFI (
p
= 0.133). Entero-atmospheric fistula was 13.1% in FI and 12% in NFI (
p
= 0.828). Fascial closure was 78.6% in FI and 63.7% in NFI (
p
= 0.02). Analysis of FI in negative pressure wound therapy (NPWT) showed: Overall morbidity in NPWT was 94% and in non-NPWT 91.2% (
p
= 0.622) and morbidity during OA was 68% and 79.4% (
p
= 0.25), respectively. Definitive fascial closure in NPWT was 87.8% and 96.8% in non-NPWT (
p
= 0.173). Overall mortality was 40% in NPWT and 29.4% in non-NPWT (
p
= 0.32) and morality during OA period was 18% and 8.8% (
p
= 0.238), respectively.
Conclusion
We found intraperitoneal fluid instillation during open abdomen in peritonitic patients to increase the complication rate during the open abdomen period, with no impact on mortality, entero-atmospheric fistula rate and opening time. Fascial closure rate is increased by instillation. Fluid instillation is feasible even when associated with nonnegative pressure temporary abdominal closure techniques.
There are very few evidences about safety and usefulness of routine prophylactic ureteral stenting (PUS) before cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC).
An ...analysis of prospectively collected data about patients who underwent CRS and HIPEC for different sites of primary disease was carried out focusing on ureteral complications.
A total of 138 patients who underwent CRS and HIPEC between December 2010 and June 2017 were considered. All patients underwent PUS before CRS and HIPEC. Of them, 91 (66.4%) patients received pelvic peritonectomy, 49 (35.8%) pelvic lymphadenectomy, 31 (22.6%) left hemicolectomy, 44 (32.4%) right hemicolectomy, 46 (33.6%) rectal resection, 56 (40.9%) hysteroannessiectomy, and 39 (28.5%) appendectomy. There was one (0.7%) postoperative ureteral fistula. The cumulative risk of ureteral stent-related major complications was 4.3% (two patients (1.4%) had protracted gross hematuria, two patients (1.4%) had urinary sepsis, and three patients (2.9%) developed hydronephrosis after a period from removing ureteral stents and required restenting. Morbidity due to ureteral stenting was associated with a longer length of stay (LOS) (p=0.053). A total of 52 patients (44.1%) developed renal dysfunction according to the RIFLE (Risk, Injury, Failure, Loss of kidney function, End-stage kidney-disease) criteria: 19.5% were in risk class, 10.2% in acute renal injury class, and 14.4% in acute renal failure class.
PUS could be a useful tool for reducing iatrogenic ureteral injury, but it is associated with a non-negligible morbidity, which implies longer LOS. A more accurate patient selection for PUS is necessary.
Analyzing the data of the International Register of Open Abdomen (IROA), the feasibility of open abdomen treatment has been demonstrated at every age. This new analysis on the IROA database ...investigates the risk factors for mortality in elderly patients treated with open abdomen for intra-abdominal infection.
Data were derived from the IROA, a prospective observational international cohort study that enrolled patients treated with open abdomen worldwide. A univariate analysis of potential risk factors was performed. Inclusion criteria were patients older than 65 years and treated with open abdomen for intra-abdominal infection. End point was overall mortality, calculated within 30 days after open abdomen management, after 1-month and 1-year follow-up.
A total of 116 patients was analyzed with mean age of 76 ± 7 years. Definitive closure was achieved in 93 patients (93/116, 80.2%) for a mean open abdomen duration of 5.0 ± 5.0 days. Complicated patients were 101 (101/116, 87.1%) for a total of 201 complications. Overall, 62 out of 116 patients (53.4%) died: 23 patients (23/62, 37.1%) during open abdomen management, 29 patients (46.8%) within 30 days after abdominal closure, 9 patients (14.5%) after 1-month follow-up, and 1 patient (1.6%) after 1-year follow-up.
Age did not affect mortality (75 ± 6 years in alive patients versus 77 ± 7 years in dead patients, p = 0.773). Definitive abdominal closure was the most important factor to prevent mortality.
This study confirmed that age alone cannot be considered a determinant for death, even in elderly patients managed with open abdomen for severe intra-abdominal infection.
•Open abdomen management is a treatment option to be considered for intra-abdominal infection also in elderly patients.•Definitive abdominal closure is the most important factor to prevent mortality in these cases.•In this setting age alone cannot be considered a determinant for death.
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