Miklosh Bala

The role of the open abdomen procedure in managing severe abdominal sepsis: WSES position paper

The open abdomen (OA) procedure is a significant surgical advance, as part of damage control techniques in severe abdominal trauma. Its application can be adapted to the advantage of patients with severe abdominal sepsis, however its precise role in these patients is still not clear.In severe abdominal sepsis the OA may allow early identification and draining of any residual infection, control any persistent source of infection, and remove more effectively infected or cytokine-loaded peritoneal fluid, preventing abdominal compartment syndrome and deferring definitive intervention and anastomosis until the patient is appropriately resuscitated and hemodynamically stable and thus better able to heal.However, the OA may require multiple returns to the operating room and may be associated with significant complications, including enteroatmospheric fistulas, loss of abdominal wall domain and large hernias.Surgeons should be aware of the pathophysiology of severe intra-abdominal sepsis and always keep in mind the option of using open abdomen to be able to use it in the right patient at the right time.

World Society of Emergency Surgery (WSES) guidelines for management of skin and soft tissue infections

Skin and soft tissue infections (SSTIs) encompass a variety of pathological conditions ranging from simple superficial infections to severe necrotizing soft tissue infections. Necrotizing soft tissue infections (NSTIs) are potentially life-threatening infections of any layer of the soft tissue compartment associated with widespread necrosis and systemic toxicity. Successful management of NSTIs involves prompt recognition, timely surgical debridement or drainage, resuscitation and appropriate antibiotic therapy. A worldwide international panel of experts developed evidence-based guidelines for management of soft tissue infections. The multifaceted nature of these infections has led to a collaboration among surgeons, intensive care and infectious diseases specialists, who have shared these guidelines, implementing clinical practice recommendations.

Abdominal trauma after terrorist bombing attacks exhibits a unique pattern of injury

Background:The recent growth in the volume of civilian blast trauma caused by terrorist bombings warrants special attention to the specific pattern of injury associated with such attacks. Objective:To characterize the abdominal injuries inflicted by terrorist-related explosions and to compare the pattern of injury with civilian, penetrating and blunt, abdominal trauma. Methods:Retrospective analysis of prospectively collected data from 181 patients with abdominal trauma requiring laparotomy, who were admitted to the Hadassah Hospital, Jerusalem, Israel, from October 2000 to December 2005. Patients were divided into 3 groups according to mechanism of injury: terror-related blast injury (n = 21), gunshot wounds (GSW) (n = 73) and blunt trauma (n = 87). Results:Median injury severity score in the blast group was significantly higher compared with GSW and blunt groups (34, 18, and 29, respectively, P < 0.0001). Injury to multiple body regions (≥3) occurred in 85.7% of blast group, 28.8% of GSW group, and 59.7% of blunt group (P < 0.001). The pattern of intra-abdominal injury was different between the groups. Bowel injury was found in 71.4% of blast victims, 64.4% of GSW, and 25.3% of blunt group (P < 0.001). Parenchymal injury was found in one third of patients in blast and GSW groups versus 60.9% of patients in blunt group (P = 0.001). Penetrating shrapnel was the cause of bowel injury in all but 1 patient in the blast group (94.4%). Conclusions:Terrorist attacks generate more severe injuries to more body regions than other types of trauma. Abdominal injury inflicted by terrorist bombings causes a unique pattern of wounds, mainly injury to hollow organs. Shrapnel is the leading cause of abdominal injury following terrorist bombings.

Complications of high grade liver injuries: management and outcomewith focus on bile leaks.

BackgroundAlthough liver injury scale does not predict need for surgical intervention, a high-grade complex liver injury should alert the physician to expect an increased risk of hepatic complications following trauma. The aim of the current study was to define hepatic related morbidity in patients sustaining high-grade hepatic injuries that could be safely managed non-operatively.Patients and methodsThis is a retrospective study of patients with liver injury admitted to Hadassah-Hebrew University Medical Centre over a 10-year period. Grade 3-5 injuries were considered to be high grade. Collected data included the number and types of liver-related complications. Interventions which were required for these complications in patients who survived longer than 24 hours were analysed.ResultsOf 398 patients with liver trauma, 64 (16%) were found to have high-grade liver injuries. Mechanism of injury was blunt trauma in 43 cases, and penetrating in 21. Forty patients (62%) required operative treatment. Among survivors 22 patients (47.8%) developed liver-related complications which required additional interventional treatment. Bilomas and bile leaks were diagnosed in 16 cases post-injury. The diagnosis of bile leaks was suspected with abdominal CT scan, which revealed intraabdominal collections (n = 6), and ascites (n = 2). Three patients had continuous biliary leak from intraabdominal drains left after laparotomy. Nine patients required ERCP with biliary stent placement, and 2 required percutaneous transhepatic biliary drainage. ERCP failed in one case. Four angioembolizations (AE) were performed in 3 patients for rebleeding. Surgical treatment was found to be associated with higher complication rate. AE at admission was associated with a significantly higher rate of biliary complications. There were 24 deaths (37%), the majority from uncontrolled haemorrhage (18 patients). There were only 2 hepatic-related mortalities due to liver failure.ConclusionsA high complication rate following high-grade liver injuries should be anticipated. In patients with clinical evidence of biliary complications, CT scan is a useful diagnostic and therapeutic tool. AE, ERCP and temporary internal stenting, together with percutaneous drainage of intra-abdominal or intrahepatic bile collections, represents a safe and effective strategy for the management of complications following both blunt and penetrating hepatic trauma.

WSES guidelines for management of Clostridium difficile infection in surgical patients

In the last two decades there have been dramatic changes in the epidemiology of Clostridium difficile infection (CDI), with increases in incidence and severity of disease in many countries worldwide. The incidence of CDI has also increased in surgical patients. Optimization of management of C difficile, has therefore become increasingly urgent. An international multidisciplinary panel of experts prepared evidenced-based World Society of Emergency Surgery (WSES) guidelines for management of CDI in surgical patients.

Complicated Intra-Abdominal Infections in a Worldwide Context: An Observational Prospective Study (CIAOW Study)

Despite advances in diagnosis, surgery, and antimicrobial therapy, mortality rates associated with complicated intra-abdominal infections remain exceedingly high. The World Society of Emergency Surgery (WSES) has designed the CIAOW study in order to describe the clinical, microbiological, and management-related profiles of both community- and healthcare-acquired complicated intra-abdominal infections in a worldwide context. The CIAOW study (Complicated Intra-Abdominal infection Observational Worldwide Study) is a multicenter observational study currently underway in 57 medical institutions worldwide. The study includes patients undergoing surgery or interventional drainage to address complicated intra-abdominal infections. This preliminary report includes all data from almost the first two months of the six-month study period. Patients who met inclusion criteria with either community-acquired or healthcare-associated complicated intra-abdominal infections (IAIs) were included in the study. 702 patients with a mean age of 49.2 years (range 18–98) were enrolled in the study. 272 patients (38.7%) were women and 430 (62.3%) were men. Among these patients, 615 (87.6%) were affected by community-acquired IAIs while the remaining 87 (12.4%) suffered from healthcare-associated infections. Generalized peritonitis was observed in 304 patients (43.3%), whereas localized peritonitis or abscesses was registered in 398 (57.7%) patients.The overall mortality rate was 10.1% (71/702). The final results of the CIAOW Study will be published following the conclusion of the study period in March 2013.

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.

A proposal for a CT driven classification of left colon acute diverticulitis

Computed tomography (CT) imaging is the most appropriate diagnostic tool to confirm suspected left colonic diverticulitis. However, the utility of CT imaging goes beyond accurate diagnosis of diverticulitis; the grade of severity on CT imaging may drive treatment planning of patients presenting with acute diverticulitis.The appropriate management of left colon acute diverticulitis remains still debated because of the vast spectrum of clinical presentations and different approaches to treatment proposed. The authors present a new simple classification system based on both CT scan results driving decisions making management of acute diverticulitis that may be universally accepted for day to day practice.

Acute mesenteric ischemia: guidelines of the World Society of Emergency Surgery

Acute mesenteric ischemia (AMI) is typically defined as a group of diseases characterized by an interruption of the blood supply to varying portions of the small intestine, leading to ischemia and secondary inflammatory changes. If untreated, this process will eventuate in life threatening intestinal necrosis. The incidence is low, estimated at 0.09–0.2% of all acute surgical admissions. Therefore, although the entity is an uncommon cause of abdominal pain, diligence is always required because if untreated, mortality has consistently been reported in the range of 50%. Early diagnosis and timely surgical intervention are the cornerstones of modern treatment and are essential to reduce the high mortality associated with this entity. The advent of endovascular approaches in parallel with modern imaging techniques may provide new options. Thus, we believe that a current position paper from World Society of Emergency Surgery (WSES) is warranted, in order to put forth the most recent and practical recommendations for diagnosis and treatment of AMI. This review will address the concepts of AMI with the aim of focusing on specific areas where early diagnosis and management hold the strongest potential for improving outcomes in this disease process.Some of the key points include the prompt use of CT angiography to establish the diagnosis, evaluation of the potential for revascularization to re-establish blood flow to ischemic bowel, resection of necrotic intestine, and use of damage control techniques when appropriate to allow for re-assessment of bowel viability prior to definitive anastomosis and abdominal closure.

The pattern of thoracic trauma after suicide terrorist bombing attacks

BACKGROUND The worldwide escalation in the volume of suicide terrorist bombing attacks warrants special attention to the specific pattern of injury associated with such attacks. The goal of this study was to characterize thoracic injuries inflicted by terrorist-related explosions and compare pattern of injury to penetrating and blunt thoracic trauma. METHODS Prospectively collected database of patients with chest injury who were admitted to Hadassah Hospital Level I trauma centre, in Jerusalem, Israel, from October 2000 to December 2005. Patients were divided into three groups according to the mechanism of injury: terrorist explosions (n = 55), gunshot wounds (GSW; n = 78), and blunt trauma (n = 747). RESULTS There were many female victims after suicide bombing attacks (49.1%) compared with GSW (21.8%) and blunt trauma (24.6%; p = 0.009). The number of body regions injured was significantly higher in the terror group compared with the GSW and blunt groups (median, 4, 2, and 3, respectively, p < 0.0001). The pattern of chest injury after suicide bombing attacks was caused by a unique combination of the effects of the blast wave and penetrating shrapnel. More than half (52.7%) of the terror victims suffered from lung contusion and 25 (45.5%) required tube thoracostomy. Five patients (9.1%) underwent thoracotomy for lung lacerations (n = 3), injury to great vessels (n = 2), cardiac lacerations (n = 1), and esophageal injury (n = 1). Penetrating shrapnel was the mechanism of injury in all these cases. CONCLUSIONS Injury inflicted by terrorist bombings causes a unique pattern of thoracic wounds. Victims are exposed to a combination of lung injury caused by the blast wave and penetrating injury caused by metallic objects.