Noel Naidoo

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.

Diagnosis and treatment of perforated or bleeding peptic ulcers: 2013 WSES position paper

Complicated peptic ulcer is a common disease worldwide, involving several professionals in its multimodal management. Surgery and laparoscopy are currently the main stem of the treatment of PPU. Medical treatment and Endoscopy are the cornerstone for the challenging approach the patients with bleeding peptic ulcers. A thorough review of the current evidence on diagnosis and management of both perforated peptic ulcers and bleeding peptic ulcers is performed. The 2013 suggestions and recommendations from the World Society of Emergency Surgery panel of experts on this field is provided.

Pelvic trauma: WSES classification and guidelines

Complex pelvic injuries are among the most dangerous and deadly trauma related lesions. Different classification systems exist, some are based on the mechanism of injury, some on anatomic patterns and some are focusing on the resulting instability requiring operative fixation. The optimal treatment strategy, however, should keep into consideration the hemodynamic status, the anatomic impairment of pelvic ring function and the associated injuries. The management of pelvic trauma patients aims definitively to restore the homeostasis and the normal physiopathology associated to the mechanical stability of the pelvic ring. Thus the management of pelvic trauma must be multidisciplinary and should be ultimately based on the physiology of the patient and the anatomy of the injury. This paper presents the World Society of Emergency Surgery (WSES) classification of pelvic trauma and the management Guidelines.

Non operative management of liver and spleen traumatic injuries: a giant with clay feet

After years of initial aggressive surgical treatment and a subsequent shift to Damage Control Surgery, NOM has be shown to be safe and effective and in the 90s it became the gold standard for liver injuries in hemodynamically stable patients, regardless of injury grade and degree of hemoperitoneum, allowing better outcomes with fewer complications and lesser transfusions. Nevertheless concerns have been raised regarding continuous monitoring need, safety in higher grades and general applicability of NOM to all hemodynamically stable patients. Similarly, in the same period and following promising results obtained with splenic salvage by using several surgical techniques such as splenorraphy, high intensity ultrasound, hemostatic wraps and staplers, NOM became the treatment of choice for blunt splenic injuries. However it was immediately clear that NOM failure in adults was significantly higher than that observed in children (17% vs 2%). The incidence of immune system sequelae and OPSI, and their real clinical impact in the overall population including children, is perhaps difficult to establish.

WSES classification and guidelines for liver trauma

The severity of liver injuries has been universally classified according to the American Association for the Surgery of Trauma (AAST) grading scale. In determining the optimal treatment strategy, however, the haemodynamic status and associated injuries should be considered. Thus the management of liver trauma is ultimately based on the anatomy of the injury and the physiology of the patient. This paper presents the World Society of Emergency Surgery (WSES) classification of liver trauma and the management Guidelines.

Splenic trauma: WSES classification and guidelines for adult and pediatric patients

Spleen injuries are among the most frequent trauma-related injuries. At present, they are classified according to the anatomy of the injury. The optimal treatment strategy, however, should keep into consideration the hemodynamic status, the anatomic derangement, and the associated injuries. The management of splenic trauma patients aims to restore the homeostasis and the normal physiopathology especially considering the modern tools for bleeding management. Thus, the management of splenic trauma should be ultimately multidisciplinary and based on the physiology of the patient, the anatomy of the injury, and the associated lesions. Lastly, as the management of adults and children must be different, children should always be treated in dedicated pediatric trauma centers. In fact, the vast majority of pediatric patients with blunt splenic trauma can be managed non-operatively. This paper presents the World Society of Emergency Surgery (WSES) classification of splenic trauma and the management guidelines.

The open abdomen in trauma and non-trauma patients: WSES guidelines

Damage control resuscitation may lead to postoperative intra-abdominal hypertension or abdominal compartment syndrome. These conditions may result in a vicious, self-perpetuating cycle leading to severe physiologic derangements and multiorgan failure unless interrupted by abdominal (surgical or other) decompression. Further, in some clinical situations, the abdomen cannot be closed due to the visceral edema, the inability to control the compelling source of infection or the necessity to re-explore (as a “planned second-look” laparotomy) or complete previously initiated damage control procedures or in cases of abdominal wall disruption. The open abdomen in trauma and non-trauma patients has been proposed to be effective in preventing or treating deranged physiology in patients with severe injuries or critical illness when no other perceived options exist. Its use, however, remains controversial as it is resource consuming and represents a non-anatomic situation with the potential for severe adverse effects. Its use, therefore, should only be considered in patients who would most benefit from it. Abdominal fascia-to-fascia closure should be done as soon as the patient can physiologically tolerate it. All precautions to minimize complications should be implemented.

Raising concerns about the Sepsis-3 definitions

The Global Alliance for Infections in Surgery appreciates the great effort of the task force who derived and validated the Sepsis-3 definitions and considers the new definitions an important step forward in the evolution of our understanding of sepsis. Nevertheless, more than a year after their publication, we have a few concerns regarding the use of the Sepsis-3 definitions.

Surgical Treatment of Spleen Trauma

In the era of nonoperative management and angioembolization surgical treatment of splenic injuries is seldomly necessary. However, NOM and angioembolization have a significant early and delayed incidence of failure and complications, especially when used for high-grade splenic injuries. Surgery remains the standard of care in hemodynamically unstable patients, when a rapid splenectomy for a rapid bleeding control is strongly advocated. Surgery is also advised for continuing blood loss from an injured spleen with need of multiple and repeated blood transfusions, as well as during a trauma laparotomy for associated intra-abdominal injuries. Splenectomy is currently the treatment of choice. It is advisable not to attempt life-threatening conservative management of severely injured spleen and/or in unstable patients and damage control situations and/or in presence of severe associated intra-abdominal injuries and/or in neurologically impaired patients. Midline is the access of choice for trauma laparotomy and splenectomy. Nowadays, operative splenic salvage techniques are almost abandoned and replaced by NOM and embolization. In the case of minor splenic injury finding during a trauma laparotomy for associated injuries, given hemodynamic stability of the patient, splenic salvage can be easily and quickly attempted with compression and use of topical hemostatic agents. If the hemostasis is not reliable and/or the patient is not stable enough, time should not be wasted in long and complex salvage procedures, and a rapid total splenectomy is rather advised. Splenectomy is preferably performed via a posterior approach in trauma setting, with a wise use of a blunt dissection and careful separate ligation of hilar vessels and short gastric vessels. In the most demanding cases, such as massive hemoperitoneum with hemodynamic instability with multiple severe associated intra-abdominal injuries, when the grade of splenic is high (IV–V) or the parenchyma is completely shattered and/or the hilar vessels difficult to recognize and ligate or the spleen is anatomically difficult to reach and hard to fully divide from its attachments and mobilize, performing a stapled splenectomy with a long stem Endo-GIA can be a safe and effective technique for a fast bleeding control. To date, minimally invasive procedures (multiport laparoscopy) play a very limited role in trauma setting.

Establishing a Trauma Service

Trauma accounts for more years of life lost than any other disease process and the establishment of a dedicated trauma system reduces morbidity and mortality. The system must incorporate the prehospital services, a central Level I tertiary facility which serves as the lead hospital for a regional service, a dedicated trauma intensive care unit, and a rehabilitation facility. Staffing must include a lead surgeon with extensive experience in trauma and critical care and a 24-h presence of trainees in general surgery, orthopedic surgery, and anesthesiology. The unit must possess dedicated trauma theaters and point of care laboratory and have immediate access to imaging facilities. Closed intensive care units have better outcomes and all management decisions should be made by the trauma team. Protocols and criteria must be established for admission, resuscitation, damage control, and all aspects of intensive care management.