WSES/GAIS/WSIS/SIS-E/AAST global clinical pathways for patients with skin and soft tissue infections

Skin and soft-tissue infections (SSTIs) encompass a variety of pathological conditions that involve the skin and underlying subcutaneous tissue, fascia, or muscle, ranging from simple superficial infections to severe necrotizing infections.

Together, the World Society of Emergency Surgery, the Global Alliance for Infections in Surgery, the Surgical Infection Society-Europe, The World Surgical Infection Society, and the American Association for the Surgery of Trauma have jointly completed an international multi-society document to promote global standards of care in SSTIs guiding clinicians by describing reasonable approaches to the management of SSTIs.

An extensive non-systematic review was conducted using the PubMed and MEDLINE databases, limited to the English language. The resulting evidence was shared by an international task force with different clinical backgrounds.

WSES/GAIS/SIS-E/WSIS/AAST global clinical pathways for patients with intra-abdominal infections

Intra-abdominal infections (IAIs) are common surgical emergencies and have been reported as major contributors to non-trauma deaths in hospitals worldwide. The cornerstones of effective treatment of IAIs include early recognition, adequate source control, appropriate antimicrobial therapy, and prompt physiologic stabilization using a critical care environment, combined with an optimal surgical approach. Together, the World Society of Emergency Surgery (WSES), the Global Alliance for Infections in Surgery (GAIS), the Surgical Infection Society-Europe (SIS-E), the World Surgical Infection Society (WSIS), and the American Association for the Surgery of Trauma (AAST) have jointly completed an international multi-society document in order to facilitate clinical management of patients with IAIs worldwide building evidence-based clinical pathways for the most common IAIs. An extensive non-systematic review was conducted using the PubMed and MEDLINE databases, limited to the English language. The resulting information was shared by an international task force from 46 countries with different clinical backgrounds. The aim of the document is to promote global standards of care in IAIs providing guidance to clinicians by describing reasonable approaches to the management of IAIs.

A pandemic recap: lessons we have learned

On January 2020, the WHO Director General declared that the outbreak constitutes a Public Health Emergency of International Concern. The world has faced a worldwide spread crisis and is still dealing with it. The present paper represents a white paper concerning the tough lessons we have learned from the COVID-19 pandemic. Thus, an international and heterogenous multidisciplinary panel of very differentiated people would like to share global experiences and lessons with all interested and especially those responsible for future healthcare decision making. With the present paper, international and heterogenous multidisciplinary panel of very differentiated people would like to share global experiences and lessons with all interested and especially those responsible for future healthcare decision making.

The Operative management in Bariatric Acute abdomen (OBA) Survey: long-term complications of bariatric surgery and the emergency surgeon's point of view

BACKGROUND

The number of bariatric procedures is increasing worldwide. No consensus or guidelines about the emergency management of long-term complications following bariatric surgery are currently available. The aim of this study is to investigate by a web survey how an emergency surgeon approaches this unique group of patients in an emergency medical scenario and to report their personal experience.

METHOD

An international web survey was sent to 197 emergency surgeons with the aim to collect data about emergency surgeons' experience in the management of patients admitted in the emergency department for acute abdominal pain after bariatric surgery. The survey was conceived as a questionnaire composed by 26 (multiple choice and open) questions and approved by a steering committee.

RESULTS

One hundred seventeen international emergency surgeons decided to join the project and answered to the web survey with a response rate of 59.39%.

CONCLUSIONS

The aim of this WSES web survey was to highlight the current management of patients previously submitted to bariatric surgical procedures by ES. Emergency surgeons must be mindful of postoperative bariatric surgery complications. CT scan with oral intestinal opacification may be useful in making a diagnosis if carefully interpreted by the radiologist and the surgeon. In case of inconclusive clinical and radiological findings, when symptoms fail to improve, surgical exploration for bariatric patients presenting acute abdominal pain, by laparoscopy if expertise is available, is mandatory in the first 12-24 h, to have good outcomes and decrease morbidity rate.

Intra-operative gallbladder scoring predicts conversion of laparoscopic to open cholecystectomy: a WSES prospective collaborative study

Introduction

Laparoscopic cholecystectomy, the gold-standard approach for cholecystectomy, has surprisingly variable outcomes and conversion rates. Only recently has operative grading been reported to define disease severity and few have been validated. This multicentre, multinational study assessed an operative scoring system to assess its ability to predict the need for conversion from laparoscopic to open cholecystectomy.

Methods

A prospective, web-based, ethically approved study was established by WSES with a 10-point gallbladder operative scoring system; enrolling patients undergoing elective or emergency laparoscopic cholecystectomy between January 2016 and December 2017. Gallbladder surgery was considered easy if the G10 score < 2, moderate (2 ≦ 4), difficult (5 ≦ 7) and extreme (8 ≦ 10). Demographics about the patients, surgeons and operative procedures, use of cholangiography and conversion rates were recorded.

Results

Five hundred four patients, mean age 53.5 (range 18-89), were enrolled by 55 surgeons in 16 countries. Surgery was performed by consultants in 70% and was elective in (56%) with a mean operative time of 78.7 min (range 15-400). The mean G10 score was 3.21, with 22% deemed to have difficult or extreme surgical gallbladders, and 71/504 patients were converted. The G10 score was 2.98 in those completed laparoscopically and 4.65 in the 71/504 (14%) converted. (p <  0.0001; AUC 0.772 (CI 0.719-0.825). The optimal cut-off point of 0.067 (score of 3) was identified in G10 vs conversion to open cholecystectomy. Conversion occurred in 33% of patients with G10 scores of ≥ 5. The four variables statistically predictive of conversion were GB appearance-completely buried GB, impacted stone, bile or pus outside GB and fistula.

Conclusion

The G10 operative scores provide simple grading of operative cholecystectomy and are predictive of the need to convert to open cholecystectomy. Broader adaptation and validation may provide a benchmark to understand and improve care and afford more standardisation in global comparisons of care for cholecystectomy.

2019 update of the WSES guidelines for management of Clostridioides (Clostridium) difficile infection in surgical patients

In the last three decades, Clostridium difficile infection (CDI) has increased in incidence and severity in many countries worldwide. The increase in CDI incidence has been particularly apparent among surgical patients. Therefore, prevention of CDI and optimization of management in the surgical patient are paramount. An international multidisciplinary panel of experts from the World Society of Emergency Surgery (WSES) updated its guidelines for management of CDI in surgical patients according to the most recent available literature. The update includes recent changes introduced in the management of this infection.

Physiological parameters for Prognosis in Abdominal Sepsis (PIPAS) Study: a WSES observational study

BACKGROUND

Timing and adequacy of peritoneal source control are the most important pillars in the management of patients with acute peritonitis. Therefore, early prognostic evaluation of acute peritonitis is paramount to assess the severity and establish a prompt and appropriate treatment. The objectives of this study were to identify clinical and laboratory predictors for in-hospital mortality in patients with acute peritonitis and to develop a warning score system, based on easily recognizable and assessable variables, globally accepted.

METHODS

This worldwide multicentre observational study included 153 surgical departments across 56 countries over a 4-month study period between February 1, 2018, and May 31, 2018.

RESULTS

A total of 3137 patients were included, with 1815 (57.9%) men and 1322 (42.1%) women, with a median age of 47 years (interquartile range [IQR] 28-66). The overall in-hospital mortality rate was 8.9%, with a median length of stay of 6 days (IQR 4-10). Using multivariable logistic regression, independent variables associated with in-hospital mortality were identified: age > 80 years, malignancy, severe cardiovascular disease, severe chronic kidney disease, respiratory rate ≥ 22 breaths/min, systolic blood pressure < 100 mmHg, AVPU responsiveness scale (voice and unresponsive), blood oxygen saturation level (SpO₂) < 90% in air, platelet count < 50,000 cells/mm3, and lactate > 4 mmol/l. These variables were used to create the PIPAS Severity Score, a bedside early warning score for patients with acute peritonitis. The overall mortality was 2.9% for patients who had scores of 0-1, 22.7% for those who had scores of 2-3, 46.8% for those who had scores of 4-5, and 86.7% for those who have scores of 7-8.

CONCLUSIONS

The simple PIPAS Severity Score can be used on a global level and can help clinicians to identify patients at high risk for treatment failure and mortality.

Prospective Observational Study on acute Appendicitis Worldwide (POSAW)

BACKGROUND

Acute appendicitis (AA) is the most common surgical disease, and appendectomy is the treatment of choice in the majority of cases. A correct diagnosis is key for decreasing the negative appendectomy rate. The management can become difficult in case of complicated appendicitis. The aim of this study is to describe the worldwide clinical and diagnostic work-up and management of AA in surgical departments.

METHODS

This prospective multicenter observational study was performed in 116 worldwide surgical departments from 44 countries over a 6-month period (April 1, 2016-September 30, 2016). All consecutive patients admitted to surgical departments with a clinical diagnosis of AA were included in the study.

RESULTS

A total of 4282 patients were enrolled in the POSAW study, 1928 (45%) women and 2354 (55%) men, with a median age of 29 years. Nine hundred and seven (21.2%) patients underwent an abdominal CT scan, 1856 (43.3%) patients an US, and 285 (6.7%) patients both CT scan and US. A total of 4097 (95.7%) patients underwent surgery; 1809 (42.2%) underwent open appendectomy and 2215 (51.7%) had laparoscopic appendectomy. One hundred eighty-five (4.3%) patients were managed conservatively. Major complications occurred in 199 patients (4.6%). The overall mortality rate was 0.28%.

CONCLUSIONS

The results of the present study confirm the clinical value of imaging techniques and prognostic scores. Appendectomy remains the most effective treatment of acute appendicitis. Mortality rate is low.

The Global Alliance for Infections in Surgery: defining a model for antimicrobial stewardship-results from an international cross-sectional survey

BACKGROUND

Antimicrobial Stewardship Programs (ASPs) have been promoted to optimize antimicrobial usage and patient outcomes, and to reduce the emergence of antimicrobial-resistant organisms. However, the best strategies for an ASP are not definitively established and are likely to vary based on local culture, policy, and routine clinical practice, and probably limited resources in middle-income countries. The aim of this study is to evaluate structures and resources of antimicrobial stewardship teams (ASTs) in surgical departments from different regions of the world.

METHODS

A cross-sectional web-based survey was conducted in 2016 on 173 physicians who participated in the AGORA (Antimicrobials: A Global Alliance for Optimizing their Rational Use in Intra-Abdominal Infections) project and on 658 international experts in the fields of ASPs, infection control, and infections in surgery.

RESULTS

The response rate was 19.4%. One hundred fifty-six (98.7%) participants stated their hospital had a multidisciplinary AST. The median number of physicians working inside the team was five [interquartile range 4-6]. An infectious disease specialist, a microbiologist and an infection control specialist were, respectively, present in 80.1, 76.3, and 67.9% of the ASTs. A surgeon was a component in 59.0% of cases and was significantly more likely to be present in university hospitals (89.5%, p < 0.05) compared to community teaching (83.3%) and community hospitals (66.7%). Protocols for pre-operative prophylaxis and for antimicrobial treatment of surgical infections were respectively implemented in 96.2 and 82.3% of the hospitals. The majority of the surgical departments implemented both persuasive and restrictive interventions (72.8%). The most common types of interventions in surgical departments were dissemination of educational materials (62.5%), expert approval (61.0%), audit and feedback (55.1%), educational outreach (53.7%), and compulsory order forms (51.5%).

CONCLUSION

The survey showed a heterogeneous organization of ASPs worldwide, demonstrating the necessity of a multidisciplinary and collaborative approach in the battle against antimicrobial resistance in surgical infections, and the importance of educational efforts towards this goal.

The Effect of Body Mass Index on Outcome of Abdominoplasty Operations

BACKGROUND

Increased body mass index (BMI) increase the incidence of seroma formation and wound infection rates and subsequently increases wound dehiscence and ugly scar formation following abdomenoplasty and body contour surgery and also many other aesthetic and plastic surgery. The aim of this study was to determine the effect of BMI on the outcome of abdominoplasty operation.

METHODS

We carried out a prospective study of all patients who underwent abdominoplasty at our institution. Patient were divided into two groups. Group I were subjects with body mass index <30 kg/m² while group II were patients with body mass index >30 kg/m². Demographics and complications (minor and major) were recorded.

RESULTS

Sixty seven patients were enrolled. Group I were 32 patients with a mean age of 35.71 and group II 35 patients with mean age of 36.26 years. Seroma formation, wound complications, prolonged hospital stay and complications were significantly more in group II.

CONCLUSION

We found that increased BMI significantly increased operative time, hospital stay, drainage duration and drainage amount. Our findings showed that obesity alone could increase the incidence of complications and poor outcome of abdominoplasty.

Antimicrobials: a global alliance for optimizing their rational use in intra-abdominal infections (AGORA)

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.

Non-operative management of blunt liver trauma in a level II trauma hospital in Saudi Arabia

Background:

To evaluate our experience with non-operative management of blunt liver trauma at a level II trauma hospital in the Kingdom of Saudi Arabia.

Materials and Methods:

We prospectively evaluated 56 patients treated for blunt liver trauma at our hospital over a 4-year period (April 2008 to April 2012). Patients who were hemodynamically stable [non-operative group I (NOP)] were treated conservatively in the intensive or intermediate care unit (ICU or IMCU). Patients who were hemodynamically unstable or needed laparotomy for other injuries were treated by urgent laparotomy [operative group II (OP)]. All NOP group patients had computed tomography (CT) of the abdomen with oral and intravenous contrast. Injuries grades were classified according to the American Association for the Surgery of Trauma (AAST). Follow-up CT of the abdomen was performed after 2 weeks in some cases.

Results:

A total of 56 patients were treated over a 4-year period. Twenty patients (35.7%) were treated by immediate surgery. NOP group of 36 patients (64.3%) were managed in the ICU by close monitoring. Surgically treated group had more patients with complex liver injury (90% versus 58.3%), required more units of blood (6.05 versus 1.5), but had a longer hospital stay (16.6 days versus 15.1 days). None of the patients from the non-operated group developed complications nor did they need operation. The only mortality (in two patients) was in the operated group.

Conclusion:

The NOP treatment is a safe and effective method in the management of hemodynamically stable patients with blunt liver trauma. The NOP treatment should be the treatment of choice in such patients whenever CT and ICU facilities are available.

Rhinolith: delayed presentation after head trauma-a case report

Rhinoliths are uncommon clinical entities reported in clinical practice as unusual cause of unilateral nasal obstruction and foul smell nasal discharge. Rhinolith is calcified material found in the nasal cavity incidentally or due to patient complaint. It should be suspected when patient presents with nasal symptoms and found to have stony mass showed radiologically. We reported a 28-year-old Saudi male with left sided (LT) nasal obstruction and foul smell discharge for 5 years suspected as being due to foreign body presence since childhood due to head trauma following car accident in sandy area.

A modified technique for scrotal fixation during orchiopexy

BACKGROUND

Undescended testes are a common problem, affecting up to 3% of newborn males. The goals of orchiopexy in humans are to provide adequate scrotal fixation, to prevent recurrent torsion of the testis and spermatic cord or ascent of the testis, and to achieve these goals with minimal trauma to the testis. The best method of achieving fixation remains controversial.

PURPOSE

The aim of our study is to evaluate our modified extra Dartos pouch technique in retaining testis in the scrotum.

PATIENTS AND METHODS

A prospective randomized study included 159 patients with 185 orchiopexies age ranging from 5 months to 14 years with the mean age of 49.5 ± 33.3 months (4.08 years). They were divided into two groups: Group I for whom the extra Dartos pouch technique was applied were compared to Group II for whom classic sub-Dartos pouch technique was done.

RESULTS

Testis was located in the superficial inguinal pouch in 102 cases (64.1%) and intra-canalicular in 57 cases (35.6%). Hernial sac was found in 153 cases (96.2%), postoperative wound infection occurred in 3 cases (1.9%) and hematoma formation in three cases (1.9%); one case reported ascent of the testis and another one had testicular atrophy in the follow-up period which extends now up to 3 years and we are still in follow-up with those cases.

CONCLUSION

Our modified technique for extra Dartos pouch fixation seems to be a fast reliable method for orchiopexy; however, comparative studies and long-term assessment is still needed to establish this method.

Rate of conversion and complications of laparoscopic cholecystectomy in a tertiary care center in Saudi Arabia

BACKGROUND AND OBJECTIVES

Problems during laparoscopic cholecystectomy include bile duct injury, conversion to open operation, and other postoperative complications. We retrospectively evaluated the causes for conversion and the rate of conversion from laparoscopic to open cholecystectomy and assessed the postoperative complications.

METHODS

Of 340 patients who presented with symptomatic gall bladder disease over a 2-year period, 290 (85%) patients were evaluated on an elective basis and scheduled for surgery, while the remaining 50 (14.7%) patients were admitted emergently with a diagnosis of acute cholecystitis.

RESULTS

The mean age of the patients was 41.9 (12.6) years. Conversion to laparotomy occurred in 17 patients (5%). The incidence of complications was 3.2%. The most common complication was postoperative transient pyrexia, which was seen in four patients (1.2%) followed by postoperative wound infection in three patients (0.9%), postoperative fluid collection and bile duct injury in two patients each (0.6%).

CONCLUSION

Laparoscopic cholecystectomy remains the 'gold standard' by which all other treatment modalities are judged. Conversion from laparoscopic to open cholecystectomy should be based on the sound clinical judgment of the surgeon and not be due to a lack of individual expertise.

Fournier's gangrene in Mansoura Egypt: a review of 74 cases

BACKGROUND

Fournier's gangrene (FG), caused by synergistic aerobic and anaerobic organisms, is a life-threatening disorder in which infection of the perineum and scrotum (can affect penis alone) spreads along fascial planes, leading to soft-tissue necrosis. Despite antibiotics and aggressive debridement, the mortality rate of FG remains high.

MATERIALS AND METHODS

We analyzed 74 patients admitted to our institution's emergency surgical unit presenting with FG between January 2002 and January 2007, considering the anatomical site of infective gangrene, predisposing factors, etiological agents, and outcomes.

RESULTS

All the 74 patients included in this study were males; their mean age was 51+/-10.8 years (21-72 years). The mean duration from the onset of symptoms to admission to the hospital was 3.74+/-2.09 days (1-8 days). The mean hospitalization time was 9.2+/- 6.6 days (1-31). Forty patients (54.05%) had FG secondary to anorectal conditions. No etiologic factors for FG were found in 27 patients (36.5%). Diabetes mellitus as a predisposing factor was found in 38 patients (51.35%). There was no definite predisposing factor in 24 patients (32.43%). The microbiological finding was polymicrobial in 48 patients (64.8%) and monomicrobial in 26 patients (35.1%). The most frequent bacterial organisms were Escherichia coli (75.6%). Simple sigmoid loop colostomy was done in one patient (1.4%). Unilateral orchidectomy was done in one case (1.4%). The overall mortality rate was 16 patients (21.6%).

CONCLUSION

FG is a rapidly progressive, fulminant infection. Even with aggressive surgical and medical treatment, mortality of the disease is high. In the present cases, such a high ratio of 21.6% means that this disease is still serious and fatal in Egypt.