Arianna Birindelli

WSES Jerusalem guidelines for diagnosis and treatment of acute appendicitis

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.

WSES Guidelines for the management of acute left sided colonic diverticulitis in the emergency setting

Acute left sided colonic diverticulitis is one of the most common clinical conditions encountered by surgeons in acute setting. A World Society of Emergency Surgery (WSES) Consensus Conference on acute diverticulitis was held during the 3rd World Congress of the WSES in Jerusalem, Israel, on July 7th, 2015. During this consensus conference the guidelines for the management of acute left sided colonic diverticulitis in the emergency setting were presented and discussed. This document represents the executive summary of the final guidelines approved by the consensus conference.

What is the effectiveness of the negative pressure wound therapy (NPWT) in patients treated with open abdomen technique? A systematic review and meta-analysis

BACKGROUND The open abdomen technique may be used in critically ill patients to manage abdominal injury, reduce the septic complications, and prevent the abdominal compartment syndrome. Many different techniques have been proposed and multiple studies have been conducted, but the best method of temporary abdominal closure has not been determined yet. Recently, new randomized and nonrandomized controlled trials have been published on this topic. We aimed to perform an up-to-date systematic review on the management of open abdomen, including the most recent published randomized and nonrandomized controlled trials, to compare negative pressure wound therapy (NPWT) with no NPWT and define if one technique has better outcomes than the other with regard to primary fascial closure, postoperative 30-day mortality and morbidity, enteroatmospheric fistulae, abdominal abscess, bleeding, and length of stay. METHODS According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and the Cochrane Handbook for Systematic Reviews of Interventions, an online literature research (until July 1, 2015) was performed on MEDLINE, PubMed, Cochrane Central Register of Controlled Trials, and Cochrane Library databases. The MeSH terms and free words used “vacuum assisted closure” “vac;”, “open abdomen”, “damage control surgery”, and “temporary abdominal closure”. No language restriction was made. RESULTS The initial systematic literature search yielded 452 studies. After a careful assessment of the titles and of the full text was obtained, eight articles fulfilled inclusion criteria. We analyzed 1,225 patients, of whom 723 (59%) underwent NPWT and 502 (41%) did not undergo NPWT, and performed four subgroups: VAC versus Bogota bag technique (two studies, 106 participants), VAC versus mesh-foil laparostomy (two studies, 159 participants), VAC versus laparostomy (adhesive impermeable with midline zip) (one study, 106 participants), and NPWT versus no NPWT techniques (three studies, 854 participants) in which it is not possible to perform an analysis of the different types of treatment. Comparing the NPWT group and the group without NPWT, there was no statistically significant difference in fascial closure (63.5% vs 69.5%; odds ratio [OR], 0.74; 95% confidence interval [CI], 0.27–2.06; p = 0.57), postoperative 30-day overall morbidity (p = 0.19), postoperative enteroatmospheric fistulae rate (2.1% vs 5.8%; OR, 0.63; 95% CIs, 0.12–3.15; p = 0.57), in the postoperative bleeding rate (5.7% vs 14.9%; OR, 0.58; 95% CIs, 0.05–6.84; p = 0.87), and postoperative abdominal abscess rate (2.4% vs 5.6%; OR, 0.42; 95% CI, 0.13–1.34; p = 0.14). On the other hand, statistical significance was found between the NPWT group and the group without NPWT in the postoperative mortality rate (28.5% vs 41.4%; OR, 0.46; 95% CI, 0.23–0.91; p = 0.03) and in the length of stay in the intensive care unit (mean difference, −4.53; 95% CI, −5.46 to 3.60; p < 0.00001). CONCLUSION The limitations of the present analysis might be related to the lack of randomized controlled trials, so there is a risk of selection bias favoring NPWT. For several outcomes, there were few studies, confidence intervals were wide, and inconsistency was high, suggesting that although there were no statistically significant differences between the groups, there was insufficient evidence to show that the outcomes were similar. We can conclude from the current available data that NPWT seems to be associated with a trend toward better outcomes compared to the use of no NPWT. It does reflect the evidence presented in the current systematic review; however, the data should be interpreted with substantial caution given a number of weaknesses (in particular, the lack of statistical significance and heterogeneity between studies, i.e., small sample size of the included studies, high variability between studies). We highlight the need for randomized controlled trials having homogeneous inclusion criteria to assess the use of NPWT for the management of open abdomen. LEVEL OF EVIDENCE Systemic review/meta-analysis, level III.

Erratum to: The management of intra-abdominal infections from a global perspective: 2017 WSES guidelines for management of intra-abdominal infections

Intra-abdominal infections (IAIs) are common surgical emergencies and have been reported as major contributors to non-trauma deaths in the emergency departments worldwide.The cornerstones of effective treatment of IAIs are early recognition, adequate source control, and appropriate antimicrobial therapy. Prompt resuscitation of patients with ongoing sepsis is of utmost important.In hospitals worldwide, non-acceptance of, or lack of access to, accessible evidence-based practices and guidelines result in overall poorer outcome of patients suffering IAIs.The aim of this paper is to promote global standards of care in IAIs and update the 2013 WSES guidelines for management of intra-abdominal infections.

Classification, prevention and management of entero-atmospheric fistula: a state-of-the-art review

BackgroundEntero-atmospheric fistula (EAF) is an enteric fistula occurring in the setting of an open abdomen, thus creating a communication between the GI tract and the external atmosphere. Management and nursing of patients suffering EAF carries several challenges, and prevention of EAF should be the first and best treatment option.PurposeHere, we present a novel modified classification of EAF and review the current state of the art in its prevention and management including nutritional issues and feeding strategies. We also provide an overview on surgical management principles, highlighting several surgical techniques for dealing with EAF that have been reported in the literature throughout the years.ConclusionsThe treatment strategy for EAF should be multidisciplinary and multifaceted. Surgical treatment is most often multistep and should be tailored to the single patient, based on the type and characteristics of the EAF, following its correct identification and classification. The specific experience of surgeons and nursing staff in the management of EAF could be enhanced, applying distinct simulation-based ex vivo training models.

“See one, do one, teach one”: Education and training in surgery and the correlation between surgical exposure with patients outcomes

We are a group of relatively young surgeons, who recently founded a Society having a dedicated and specific commitment in Surgical Research and Education, and we have read with interest the article entitled “Surgical Skill and Complication Rates after Bariatric Surgery” from Birkmeyer et al. [1]. Starting from this reading, wewould like to express several considerations and thoughts on the topic of Surgical Research and Education, which is a critical issue in modern surgical systems. A considerable body of research suggests that some surgeons have better results than others. The findings from Birkmeyer et al. are intriguing but provoking and represent an interesting matter of debate on several issues such as education and training in surgery and the correlation between operative ability and peri-operative management with the patients outcomes. Our first concern raises about the selection and rating criteria used for assessing the surgical skills or the operating surgeons. Only one video was used for this purpose, selected as themost “representative” one and submitted by the operating surgeon upon his personal preference, edited in a way that, although comprising the critical steps of the procedure, it may still suffer the subjective bias of including only the “well done” scenes, choosing those cases having a perfect and clear anatomy and/or “cutting” during video editing any procedural mistakes or uncertainties. We are wondering if just one single video, self-selected and self-edited, showing a single procedure, can be a reliable and representative piece of a surgeons experience and therefore able to predict the outcomes. May different anatomy or variable patients body characteristics affect the judgement of the surgeons skills and/or predict the outcome of an anastomosis or the overall surgical outcomes? Perhaps, as noted by Jacobs [2] in a commentary to the study

Surgeon accountability for patient safety in the Acute Care Surgery paradigm: a critical appraisal and need of having a focused knowledge of the patient and a specific subspecialty experience.

There is an increasing evidence in the literature showing that Acute Care surgical patients, likewise patients from every other surgical subspeciality, should be best first approached and managed only by attending surgeons with approriate expertise in the field of Emergency and Trauma Surgery, as well as the occurrence of postoperative complications can be prevented or safely and appropriately treated when arising, only by those attending surgeons having a focused knowledge of the patient and specific subspeciality experience. The advantages of a consultant-led, patient-centered surgical management come along with the opportunity of maintaining the principles of continuity of care and specificity of expertise in managing surgical patients and their complications and readmissions. These principles should be particularly valid in the well-recognized subspeciality of Acute Care and Trauma Surgery; managing the challenging emergency surgical patients either in the preoperative and postoperative periods with the aim to improve the outcomes of Emergency Surgery, should only be by surgeons trained and experienced in both Acute Care Surgery and Trauma.

Laparoscopy for Trauma and the Changes in its Use From 1990 to 2016: A Current Systematic Review and Meta-Analysis.

Background: The role of laparoscopy in the diagnosis and treatment of stable abdominal trauma patients is still a matter of serious debate and only incomplete data are available. Materials and Methods: We performed a systematic review and meta-analysis of the literature between January 1990 and August 2016. Results: Overall, 9817 laparoscopies were performed for abdominal trauma; only 26.2% of the cases were converted to a laparotomy. The incidence of therapeutic laparotomies showed a reduction from 69% to 47.5%, whereas the incidence of therapeutic laparoscopies increased from 7.2% to 22.7%. The overall perioperative mortality rate was significantly lower in the laparoscopy group [odds ratio (M-H, random); 95% confidence interval, 0.35 (0.26-0.48)]. The same group showed shorter length of hospital stay [odds ratio (M-H, random); 95% confidence interval, −3.48 (−8.91 to 1.96)]. Conclusions: This systematic review shows a significant decrease in the use of laparoscopy in trauma patients. Most likely the widespread use of imaging techniques allows a more accurate selection of patients for diagnostic laparoscopy. Infact, a reduction in incidence of nontherapeutic laparotomies is evident in these selected patients undergoing diagnostic laparoscopy. Moreover, the literature reported an increasing trend of therapeutic laparoscopy, demonstrating that it is safe and effective. The small number and poor quality of the studies identified, the retrospective observational nature of the studies (low level of evidence), the high risk of bias, and the high heterogeneity of some outcomes make the applicability of the results of this meta-analysis unclear.

Retroperitoneal colonic perforation from a foreign body: “cannibalization” effect of a toothpick: video vignette

for the stoma in the left lower quadrant. A wound protector-retractor (Alexis S by Applied Medical, Santa Margarita, CA, USA) was placed into this incision and twisted to narrow the open aperture. Under direct laparoscopic control, a laparoscopic Babcock forceps was inserted via this site and used to bring the mobile apex of the sigmoid loop up to the abdomen surface to allow a loop colostomy to be performed. As the AirSeal system has been designed to sustain a continuous pneumoperitoneum despite an open circuit, it maintained a stable pneumatic working space in the absence of a tight seal around the working instrument (at least up to a total open aperture of approximately 1 cm). The operation was performed without complication, illustrating fully the technology’s capacity and indicating this operative technique as a potential alternative to single port [2] and trephine-alone [3] stoma formation.

Application of the AAST EGS Grade for Adhesive Small Bowel Obstruction to a Multi-national Patient Population

BackgroundThe American Association for the Surgery of Trauma (AAST) anatomic severity grading system for adhesive small bowel obstruction (ASBO) has demonstrated to be a valid tool in North American patient populations. Using a multi-national patient cohort, we retrospectively assessed the validity the AAST ASBO grading system and estimated disease severity in a global population in order to correlate with several key clinical outcomes.MethodsMulticenter retrospective review during 2012–2016 from four centers, Minnesota USA, Bologna Italy, Pietermaritzburg South Africa, and Bucharest Romania, was performed. Adult patients (age ≥ 18) with ASBO were identified. Baseline demographics, physiologic parameters, laboratory results, operative and imaging details, outcomes were collected. AAST ASBO grades were assigned by independent reviewers. Univariate and multivariable analyses with odds ratio (OR) and 95% confidence intervals (CIs) were performed.ResultsThere were 789 patients with a median [IQR] age of 58 [40–75] years; 47% were female. The AAST ASBO grades were I (n = 180, 23%), II (n = 443, 56%), III (n = 87, 11%), and IV (n = 79, 10%). Successful non-operative management was 58%. Conversion rate from laparoscopy to laparotomy was 33%. Overall mortality and complication and temporary abdominal closure rates were 2, 46, and 4.7%, respectively. On regression, independent predictors for mortality included grade III (OR 4.4 95%CI 1.1–7.3), grade IV (OR 7.4 95%CI 1.7–9.4), pneumonia (OR 5.6 95%CI 1.4–11.3), and failing non-operative management (OR 2.4 95%CI 1.3–6.7).ConclusionThe AAST EGS grade can be assigned with ease at any surgical facility using operative or imaging findings. The AAST ASBO severity grading system has predictive validity for important clinical outcomes and allows for standardization across institutions, providers, and future research. Disease severity and outcomes varied between countries.Level of evidence IIIStudy type Retrospective multi-institutional cohort study.