World journal of emergency surgery [journal]
- WSES Jerusalem guidelines for diagnosis and treatment of acute appendicitis. [Journal Article, Review]
- World J Emerg Surg 2016.:34.
Acute appendicitis (AA) is among the most common cause of acute abdominal pain. Diagnosis of AA is challenging; a variable combination of clinical signs and symptoms has been used together with laboratory findings in several scoring systems proposed for suggesting the probability of AA and the possible subsequent management pathway. The role of imaging in the diagnosis of AA is still debated, with variable use of US, CT and MRI in different settings worldwide. Up to date, comprehensive clinical guidelines for diagnosis and management of AA have never been issued. In July 2015, during the 3rd World Congress of the WSES, held in Jerusalem (Israel), a panel of experts including an Organizational Committee and Scientific Committee and Scientific Secretariat, participated to a Consensus Conference where eight panelists presented a number of statements developed for each of the eight main questions about diagnosis and management of AA. The statements were then voted, eventually modified and finally approved by the participants to The Consensus Conference and lately by the board of co-authors. The current paper is reporting the definitive Guidelines Statements on each of the following topics: 1) Diagnostic efficiency of clinical scoring systems, 2) Role of Imaging, 3) Non-operative treatment for uncomplicated appendicitis, 4) Timing of appendectomy and in-hospital delay, 5) Surgical treatment 6) Scoring systems for intra-operative grading of appendicitis and their clinical usefulness 7) Non-surgical treatment for complicated appendicitis: abscess or phlegmon 8) Pre-operative and post-operative antibiotics.
- Antimicrobials: a global alliance for optimizing their rational use in intra-abdominal infections (AGORA). [Journal Article, Review]
- World J Emerg Surg 2016.:33.
Intra-abdominal infections (IAI) are an important cause of morbidity and are frequently associated with poor prognosis, particularly in high-risk patients. The cornerstones in the management of complicated IAIs are timely effective source control with appropriate antimicrobial therapy. Empiric antimicrobial therapy is important in the management of intra-abdominal infections and must be broad enough to cover all likely organisms because inappropriate initial antimicrobial therapy is associated with poor patient outcomes and the development of bacterial resistance. The overuse of antimicrobials is widely accepted as a major driver of some emerging infections (such as C. difficile), the selection of resistant pathogens in individual patients, and for the continued development of antimicrobial resistance globally. The growing emergence of multi-drug resistant organisms and the limited development of new agents available to counteract them have caused an impending crisis with alarming implications, especially with regards to Gram-negative bacteria. An international task force from 79 different countries has joined this project by sharing a document on the rational use of antimicrobials for patients with IAIs. The project has been termed AGORA (Antimicrobials: A Global Alliance for Optimizing their Rational Use in Intra-Abdominal Infections). The authors hope that AGORA, involving many of the world's leading experts, can actively raise awareness in health workers and can improve prescribing behavior in treating IAIs.
- Safety in selective surgical exploration in penetrating neck trauma. [Journal Article]
- World J Emerg Surg 2016.:32.
Selective management of penetrating neck injuries has been considered the standard of care with minimal risks to patient safety. In a previous non-randomized prospective study conducted at our center, selective management proved to be safe and reduced unnecessary exploratory cervicotomies. In the present study, the role of clinical examination and selective diagnostic tests were assessed by reviewing demographic and clinical data. A comparison of results between two groups (mandatory surgical exploration versus selective surgical exploration) was made to check the safety of selective management in terms of the rates of morbidity and mortality.A retrospective analysis at the Emergency Department of the Hospital das Clínicas of the University of Sao Paulo was performed by a chart review of our trauma registry, identifying 161 penetrating neck trauma victims.Of the 161 patients, 81.6 % were stabbed and 18.4 % had gunshot injuries. Stratifying the wound entry points by neck zones, we observed that zone I was penetrated in 32.8 %, zone II in 44.1 % and zone III in 23.1 % of all the cases. Thirty one patients (19.2 %) had immediate surgical exploration, which had a mean length of stay of 6 days, a complication rate of 12.9 % and a mortality rate of 9.4 %. Of the 130 who underwent selective surgical exploration 34 (26.1 %) required operative procedures after careful physical examination and diagnostic testing based on clinical indications. The mean length of stay for the selective surgical exploration group was 2 days with a complication rate of 17.6 % with no mortality, and virtually all of them were related to associated injuries in distant body segment. No statistical significance was found comparing mortality and complication rates between the two groups. Selective approach avoided 59 % of unnecessary exploratory cervicotomies.Careful evaluation of asymptomatic and stable patients with minor signs of injury can safely avoid unnecessary neck explorations with low rates of morbidity. This should be the standard management of such patients.
- International normalized ratio and serum C-reactive protein are feasible markers to predict complicated appendicitis. [Journal Article]
- World J Emerg Surg 2016.:31.
Diagnostic approach for complicated appendicitis is still controversial. We planned this study to analyze preoperative laboratory markers that may predict complications of appendicitis.Patients who underwent appendectomy were retrospectively recruited. They were divided into complicated appendicitis and non-complicated appendicitis groups and their preoperative laboratory results were reviewed.A total of 234 patients were included. Elevated international normalized ratio (INR) and serum C-reactive protein (CRP) were associated with complicated appendicitis (p = 0.001). On ROC curve analysis, area under the curve (AUC) of CRP and INR were 0.796 and 0.723, respectively.INR and CRP increased significantly in patients with complicated appendicitis. Further studies evaluating INR and CRP in patients undergoing conservative management for appendicitis are required.
- Management of traumatic wounds in the Emergency Department: position paper from the Academy of Emergency Medicine and Care (AcEMC) and the World Society of Emergency Surgery (WSES). [Journal Article]
- World J Emerg Surg 2016.:30.
Traumatic wounds are one of the most common problems leading people to the Emergency Department (ED), accounting for approximately 5,4 % of all the visits, and up to 24 % of all the medical lawsuits. In order to provide a standardized method for wound management in the ED, we have organized a workshop, involving several Italian and European experts. Later, all the discussed statements have been submitted for external validation to a multidisciplinary expert team, based on the so called Delphi method. Eight main statements have been established, each of them comprising different issues, covering the fields of wound classification, infectious risk stratification, tetanus and rabies prophylaxis, wound cleansing, pain management, and suture. Here we present the results of this work, shared by the Academy of Emergency Medicine and Care (AcEMC), and the World Society of Emergency Surgery (WSES).
- Correlations of perioperative coagulopathy, fluid infusion and blood transfusions with survival prognosis in endovascular aortic repair for ruptured abdominal aortic aneurysm. [Journal Article]
- World J Emerg Surg 2016.:29.
Factors associated with survival prognosis among patients who undergo endovascular aortic repair (EVAR) for ruptured abdominal aortic aneurysms (rAAA) have not been sufficiently investigated. In the present study, we examined correlations between perioperative coagulopathy and 24-h and 30-day postoperative survival. Relationships between coagulopathy and the content of blood transfusions, volumes of crystalloid infusion and survival.This was a retrospective study of the medical records of all patients who underwent EVAR for rAAA at Chiba-Nishi General Hospital during the period from October 2013 to December 2015. Major coagulopathy was defined using the international normalized ratio or activated partial thromboplastin time (APTT) ratio of at least 1.5, or platelet count less than 50 × 10/l. We quantified the amounts of blood transfusions and crystalloid infusions administered from arrival to the hospital to admission to ICU following operations.Coagulopathy among patients with rAAA was found to progress even after they had presented at the hospital. No statistically significant correlation between preoperative coagulopathy and mortality was found, although a significantly greater degree of postoperative coagulopathy was seen among patients who died both within 24-h and 30 days postoperatively. Among patients with postoperative coagulopathy, lesser quantities of fresh frozen plasma (FFP) compared with red cell concentrate (RCC) were used during the period from hospital arrival to postoperative ICU entry. In both groups of patients who did not survive after 24-h and 30 days, FFP was used less than RCC. Large transfusions of crystalloids administered during the periods from hospital arrival to surgery and from hospital arrival to the end of surgery were associated with postoperative incidence of major coagulopathy, death within 24-h, and death within 30 days.Coagulopathy progressed during care in the emergency outpatient clinic and operations. Postoperative coagulopathy was associated with poorer outcomes. Smaller FFP/RCC ratios and larger volumes of crystalloid infusion were associated with development of coagulopathy and poorer prognosis of survival.This study is retrospectively registered in UMIN Clinical Trials Registry (Registration 19 April 2016, registered number is R000025334 UMIN000021978).
- Anatomical, physiological, and logistical indications for the open abdomen: a proposal for a new classification system. [Journal Article]
- World J Emerg Surg 2016.:28.
A systematic approach to the appropriate use of the open abdomen strategy has not been described. We propose three fundamental reasons for the use of this strategy, anatomical, physiological and logistical. Anatomical reasons pertain to the inability to bring the fascial edges together including soft tissue defects. Physiological reasons relate to features of systemic dysfunction. Logistical reasons involve any anticipated abdominal re-intervention while preserving fascia. These categories occur either as a single reason or in any combination.A single-center prospective observational study of patients with open abdomens in trauma and acute abdomen. Surgeons were asked to select from the three reasons (single or any combination of) their motivation for using the open abdomen upon completion of the initial operation. Patients were compared using the non-parametric Wilcoxon two-sample test or Kruskal-Wallis test. Chi-square or Fisher's exact test was used for categorical variables; Statistical significance set at P-value ≤ 0.05.Forty-five consecutive patients with open abdomens were evaluated (Jan. 1- Dec. 31, 2012). Mean age was 38.8 years, 32 were male, 39 (86.7 %) sustained trauma. The most common single reason for the open abdomen was physiological (24.4 %), 33 patients had multiple reasons, the most common combination being anatomical and physiological (22.2 %). A physiological reason was linked to: lower pH, higher lactate, and lower systolic blood pressure on admission (p < 0.05). A logistical reason was associated with earlier primary fascial closure, intra-operative packing, and bowel left in discontinuity. Logistic regression and adjusted odds ratio of primary fascial closure was: physiological (0.08, 95 % CI, 0.01-0.92, p = 0.043); logistical (6.03, 95 % CI, 1.13-32.29, p = 0.036); and anatomical (0.83, 95 % CI, 0.16-4.18, p = 0.816).We defined three basic indications for the use of the open abdomen, anatomical physiological and logistical. These indications establish a practical and comprehensive terminology that could help to promote appropriate use of the open abdomen.
- Surgical treatment of multiple rib fractures and flail chest in trauma: a one-year follow-up study. [Journal Article]
- World J Emerg Surg 2016.:27.
Multiple rib fractures and unstable thoracic cage injuries are common in blunt trauma. Surgical management of rib fractures has received increasing attention in recent years and the aim of this 1-year, prospective study was to assess the long-term effects of surgery.Fifty-four trauma patients with median Injury Severity Score 20 (9-66) and median New Injury Severity Score 34 (16-66) who presented with multiple rib fractures and flail chest, and underwent surgical stabilization with plate fixation were recruited. Patients responded to a standardized questionnaire concerning pain, local discomfort, breathlessness and use of analgesics and health-related quality of life (EQ-5D-3 L) questionnaire at 6 weeks, 3 months, 6 months and 1 year. Lung function, breathing movements, range of motion and physical function were measured at 3 months, 6 months and 1 year.Symptoms associated with pain, breathlessness and use of analgesics significantly decreased from 6 weeks to 1 year following surgery. After 1 year, 13 % of patients complained of pain at rest, 47 % had local discomfort and 9 % used analgesics. The EQ-5D-3 L index increased from 0.78 to 0.93 and perceived overall health state increased from 60 to 90 % (p < 0.0001) after 6 weeks to 1 year. Lung function improved significantly with predicted Forced vital capacity and Peak expiratory flow increasing from 86 to 106 % (p = 0.0002) and 81 to 110 % (p < 0.0001), respectively, from 3 months to 1 year after surgery. Breathing movements and range of motion tended to improve over time. Physical function improved significantly over time and the median Disability rating index was 0 after 1 year.Patients with multiple rib fractures and flail chest show a gradual improvement in symptoms associated with pain, quality of life, mobility, disability and lung function over 1 year post surgery. Therefore, the final outcome of surgery cannot be assessed before 1 year post-operatively.
- Focus on the prophylaxis, epidemiology and therapy of methicillin-resistant Staphylococcus aureus surgical site infections and a position paper on associated risk factors: the perspective of an Italian group of surgeons. [Journal Article, Review]
- World J Emerg Surg 2016.:26.
The aim of this research was to study the epidemiology, microbiology, prophylaxis, and antibiotic therapy of surgical site infections (SSIs), especially those caused by methicillin-resistant Staphylococcus aureus (MRSA), and identify the risk factors for these infections. In Italy SSIs occur in about 5 % of all surgical procedures. They are predominantly caused by staphylococci, and 30 % of them are diagnosed after discharge. In every surgical specialty there are specific procedures more associated with SSIs.The authors conducted a systematic review of the literature on SSIs, especially MRSA infections, and used the Delphi method to identify risk factors for these resistant infections.Risk factors associated with MRSA SSIs identified by the Delphi method were: patients from long-term care facilities, recent hospitalization (within the preceding 30 days), Charlson score > 5 points, chronic obstructive pulmonary disease and thoracic surgery, antibiotic therapy with beta-lactams (especially cephalosporins and carbapenem) and/or quinolones in the preceding 30 days, age 75 years or older, current duration of hospitalization >16 days, and surgery with prothesis implantation. Protective factors were adequate antibiotic prophylaxis, laparoscopic surgery and the presence of an active, in-hospital surveillance program for the control of infections. MRSA therapy, especially with agents that enable the patient's rapid discharge from hospital is described.The prevention, identification and treatment of SSIs, especially those caused by MRSA, should be implemented in surgical units in order to improve clinical and economic outcomes.
- 2016 WSES guidelines on acute calculous cholecystitis. [Journal Article, Review]
- World J Emerg Surg 2016.:25.
Acute calculus cholecystitis is a very common disease with several area of uncertainty. The World Society of Emergency Surgery developed extensive guidelines in order to cover grey areas. The diagnostic criteria, the antimicrobial therapy, the evaluation of associated common bile duct stones, the identification of "high risk" patients, the surgical timing, the type of surgery, and the alternatives to surgery are discussed. Moreover the algorithm is proposed: as soon as diagnosis is made and after the evaluation of choledocholitiasis risk, laparoscopic cholecystectomy should be offered to all patients exception of those with high risk of morbidity or mortality. These Guidelines must be considered as an adjunctive tool for decision but they are not substitute of the clinical judgement for the individual patient.