Management of intra-abdominal-infections: 2017 World Society of Emergency Surgery guidelines summary focused on remote areas and low-income nations

Development and validation of risk prediction model for bacterial infections in acute liver failure patients

Infections significantly increase mortality in acute liver failure (ALF) patients, and there are no risk prediction models for early diagnosis and treatment of infections in ALF patients. This study aims to develop a risk prediction model for bacterial infections in ALF patients to guide rational antibiotic therapy. The data of ALF patients admitted to the Second Hospital of Hebei Medical University in China from January 2017 to January 2022 were retrospectively analyzed for training and internal validation. Patients were selected according to the updated 2011 American Association for the Study of Liver Diseases position paper on ALF. Serological indicators and model scores were collected within 24 h of admission. New models were developed using the multivariate logistic regression analysis. An optimal model was selected by receiver operating characteristic (ROC) analysis, Hosmer-Lemeshow test, the calibration curve, the Brier score, the bootstrap resampling, and the decision curve analysis. A nomogram was plotted to visualize the results. A total of 125 ALF patients were evaluated and 79 were included in the training set. The neutrophil-to-lymphocyte ratio and sequential organ failure assessment (SOFA) were integrated into the new model as independent predictive factors. The new SOFA-based model outperformed other models with an area under the ROC curve of 0.799 [95% confidence interval (CI): 0.652-0.926], the superior calibration and predictive performance in internal validation. High-risk individuals with a nomogram score ≥26 are recommended for antibiotic therapy. The new SOFA-based model demonstrates high accuracy and clinical utility in guiding antibiotic therapy in ALF patients.

Goodbye Hartmann trial: a prospective, international, multicenter, observational study on the current use of a surgical procedure developed a century ago

BACKGROUND

Literature suggests colonic resection and primary anastomosis (RPA) instead of Hartmann's procedure (HP) for the treatment of left-sided colonic emergencies. We aim to evaluate the surgical options globally used to treat patients with acute left-sided colonic emergencies and the factors that leading to the choice of treatment, comparing HP and RPA.

METHODS

This is a prospective, international, multicenter, observational study registered on ClinicalTrials.gov. A total 1215 patients with left-sided colonic emergencies who required surgery were included from 204 centers during the period of March 1, 2020, to May 31, 2020. with a 1-year follow-up.

RESULTS

564 patients (43.1%) were females. The mean age was 65.9 ± 15.6 years. HP was performed in 697 (57.3%) patients and RPA in 384 (31.6%) cases. Complicated acute diverticulitis was the most common cause of left-sided colonic emergencies (40.2%), followed by colorectal malignancy (36.6%). Severe complications (Clavien-Dindo ≥ 3b) were higher in the HP group (P < 0.001). 30-day mortality was higher in HP patients (13.7%), especially in case of bowel perforation and diffused peritonitis. 1-year follow-up showed no differences on ostomy reversal rate between HP and RPA. (P = 0.127). A backward likelihood logistic regression model showed that RPA was preferred in younger patients, having low ASA score (≤ 3), in case of large bowel obstruction, absence of colonic ischemia, longer time from admission to surgery, operating early at the day working hours, by a surgeon who performed more than 50 colorectal resections.

CONCLUSIONS

After 100 years since the first Hartmann's procedure, HP remains the most common treatment for left-sided colorectal emergencies. Treatment's choice depends on patient characteristics, the time of surgery and the experience of the surgeon. RPA should be considered as the gold standard for surgery, with HP being an exception.

The Challenge of Pneumatosis Intestinalis: A Contemporary Systematic Review

PURPOSE

Pneumatosis intestinalis is a radiological finding with incompletely understood pathogenesis. To date, there are no protocols to guide surgical intervention.

METHODS

A systematic review of literature, according to PRISMA criteria, was performed. Medline and PubMed were consulted to identify articles reporting on the items "emergency surgery, pneumatosis coli, and pneumatosis intestinalis" from January 2010 up to March 2022. This study has not been registered in relevant databases.

RESULTS

A total of 1673 patients were included. The average age was 67.1 ± 17.6 years. The etiology was unknown in 802 (47.9%) patients. Hemodynamic instability (246/1673-14.7% of the patients) was associated with bowel ischemia, necrosis, or perforation (p = 0.019). Conservative management was performed in 824 (49.2%) patients. Surgery was performed 619 (36.9%) times, especially in unstable patients with bowel ischemia signs, lactate levels greater than 2 mmol/L, and PVG (p = 0.0026). In 155 cases, surgery was performed without pathological findings.

CONCLUSIONS

Many variables should be considered in the approach to patients with pneumatosis intestinalis. The challenge facing the surgeons is in truly identifying those who really would benefit and need surgical intervention. The watch and wait policy as a first step seems reasonable, reserving surgery only for patients who are unstable or with high suspicion of bowel ischemia, necrosis, or perforation.

Antimicrobial surveillance: A 20-year history of the SMART approach to addressing global antimicrobial resistance into the future

Antimicrobial resistance (AMR) is a major global public health threat, particularly affecting patients in resource-poor settings. Comprehensive surveillance programmes are essential to reducing the high mortality and morbidity associated with AMR and are integral to informing treatment decisions and guidelines, appraising the effectiveness of intervention strategies, and directing development of new antibacterial agents. Various surveillance programmes exist worldwide, including those administered by government bodies or funded by the pharmaceutical industry. One of the largest and longest running industry-sponsored AMR surveillance programme is the Study for Monitoring Antimicrobial Resistance Trends (SMART), which recently completed its 20th year. The SMART database has grown to almost 500 000 isolates from over 200 sites in more than 60 countries, encompassing all major geographic regions and including many sites in low- and middle-income countries. The SMART surveillance programme has evolved in scope over time, including additional antibacterial agents, pathogens and infection sites, in line with changing epidemiology and medical need. Surveillance data from SMART and similar programmes have been used successfully to detect emerging resistance threats and AMR patterns in specific countries and regions, thus informing national and local clinical treatment guidelines. The SMART database can be accessed readily by physicians and researchers globally, which may be especially valuable to those from countries with limited healthcare resources, where surveillance and resistance data are rarely collected. Continued participation from as many sites as possible worldwide and maintenance of adequate funding are critical factors to fully realising the potential of large-scale AMR surveillance programmes into the future.

Conservative management of complicated colonic diverticulitis: long-term results

BACKGROUND

The management of recurrent diverticulitis after initial non-operative treatment remains controversial. Recurrences after medical treatment have been described up to 36% but only 3 to 5% develop complicated disease.

AIM

To investigate the effectiveness of conservative treatment during a prolonged follow-up after first episode of complicated diverticulitis.

METHODS

This retrospective single-center study describes the conservative management and outcomes of 207 with complicated acute colonic diverticulitis treated at Parma University Hospital from 1 January 2012 until 31 December 2019. The follow-up was performed until December 2020. Diverticulitis severity was staged according to WSES CT driven classification for acute diverticulitis.

RESULTS

We enrolled 207 patients (118 males, 89 females). The mean age was 59 ± 14.5 years. CT scan of the abdomen was always performed. Almost all patients were treated with bowel rest and antibiotics (98.5%). Percutaneous drainage of abscessed diverticulitis was performed 12 times (5.7%). Average follow-up was 48 ± 28.8 months. 79 patients had new episodes of diverticulitis (38.1%) and 23 patients had high severity new episodes (11.1%). 11 patients underwent surgery (7.7%). Lower CT-Stages showed a higher recurrence rate (P = 0.002). Grade III diverticulitis showed a lower recurrence rate (P = 0.007). Patients with chronic NSAID use showed a higher incidence of high severity new episodes (P = 0.039). No recurrence rate differences were noted among patients with or without home therapy (P > 0.05).

CONCLUSIONS

Non-operative treatment is an effective and safe option in selected patients with complicated diverticulitis. The recurrence's severity is generally lower than the previous episodes and this can justify the conservative management.

Efficacy of antimicrobial therapy in patients with uncomplicated acute colonic diverticulitis: an updated systematic review and meta-analysis

The need for antimicrobial therapy for uncomplicated acute diverticulitis of the colon remains controversial. We conducted a systematic review of the efficacy of antimicrobial agents against this disease, including new randomized controlled trials (RCTs) reported in recent years, and evaluated their efficacy using a meta-analytic approach. RCTs were searched using PubMed, EMBASE, Google Scholar, Cochrane Library, Ichushi-Web, and eight registries. Keywords were 'colonic diverticulitis', 'diverticulitis', 'antimicrobial agents', ''antibiotics, 'complication', 'abscess', 'gastrointestinal perforation', 'gastrointestinal obstruction', 'diverticular hemorrhage', and 'fistula'. Studies with antimicrobial treatment in the intervention group and placebo or no treatment in the control group were selected by multiple reviewers using uniform inclusion criteria, and data were extracted. Prevention of any complication was assessed as the primary outcome, and efficacy was expressed as risk ratio (RR) and risk difference (RD). A meta-analysis was performed using 5 RCTs of the 21 studies that were eligible for scrutiny in the initial search and which qualified for final inclusion. Three of these studies were not included in the previous meta-analysis. Subjects included 1039 in the intervention group and 1040 in the control group. Pooled RR = 0.86 (95% confidence interval, 0.58-1.28) and pooled RD = -0.01 (-0.03 to 0.01) for the effect of antimicrobial agents in reducing any complications. Recurrences, readmissions, and surgical interventions did not significantly show the efficacies of using antimicrobial agents. A meta-analysis of recently reported RCTs did not provide evidence that antimicrobial therapy improves clinical outcomes in uncomplicated acute diverticulitis of the colon.

Percutaneous Endoscopic Necrosectomy-A Review of the Literature

In this article, an attempt was made to clarify the role of percutaneous endoscopic necrosectomy (PEN) in the interventional treatment of pancreatic necrosis. A comprehensive review of the current literature was performed to identify publications on the role of PEN in patients with consequences of acute necrotizng pancreatitis. The aim of the study was to review the literature on minimal invasive necrosectomy, with emphasis on PEN using esophageal self-expanding metal stents (SEMS). The described results come from 15 studies after a review of the current literature. The study group comprised 52 patients (36 men and 16 women; mean age, 50.87 (13-75) years) with walled-off pancreatic necrosis, in whom PEN using a self-expandable esophageal stent had been performed. PEN was successfully completed in all 52 patients (100%). PEN complications were observed in 18/52 (34.62%) patients. Clinical success was achieved in 42/52 (80.77%) patients, with follow-up continuing for an average of 136 (14-557) days. In conclusion, the PEN technique is potentially effective, with an acceptable rate of complications and may be implemented with good clinical results in patients with pancreatic necrosis.

The Role of Antibiotics in Endoscopic Transmural Drainage of Post-Inflammatory Pancreatic and Peripancreatic Fluid Collections

Background

Although endoscopic treatment of symptomatic post-inflammatory pancreatic and peripancreatic fluid collections (PPPFCs) is an established treatment method, some aspects of endotherapy and periprocedural management remain controversial. The role of antibiotics is one of the most controversial issues in interventional endoscopic management of local complications of pancreatitis.

Methods

This study was a randomized, non-inferiority, placebo-controlled, and double-blinded clinical trial to investigate the role of antibiotic prophylaxis in endoscopic transmural drainage in patients with symptomatic non-infected PPPFCs and assess the influence of antibiotic treatment on the results of endotherapy in patients with symptomatic infected PPPFCs.

This trial included 62 patients treated endoscopically for PPPFCs in 2020 at our medical center. Patients were divided into two groups; group 1 comprised patients who had received empirical intravenous antibiotic therapy during endotherapy and group 2 comprised patients who did not receive antibiotic therapy during endoscopic drainage of PPPFCs. The end points were clinical success and long-term success of endoscopic treatment.

Results

Thirty-one patients were included in group 1 (walled-off pancreatic necrosis [WOPN, 51.6%; pseudocyst, 48.4%) and 31 patients in group 2 (WOPN, 58.1%; pseudocyst, 41.9%) (p=0.6098/nonsignificant statistical [NS]). Infection with PPPFCs was observed in 15/31 (48.39%) patients in group 1 and in 15/31 (48.39%) patients in group 2 (p=1.0/NS). The average time of active (with flushing through nasocystic drainage) drainage in group 1 was 13.0 (6 – 21) days and was 14.0 (7 – 25) days in group 2 (p=0.405/NS). The average total number endoscopic procedures on one patient was 3.3 (2 – 5) in group 1 and 3.4 (2 – 7) in group 2 (p=0.899/NS). Clinical success of PPPFCs was observed in 29/31 (93.5%) patients from group 1 and in 30/31 (96.8%) patients from group 2 (p=0.5540/NS). Complications of endotherapy were noted in 8/31 (25.8%) patients in group 1 and in 10/31 (32.3%) patients in group 2 (p=0.576/NS). Long-term success in group 1 and 2 was reported in 26/31 (83.9%) and 24/31 (77.4%) patients, respectively (p=0.520/NS).

Conclusions

The effective endoscopic drainage of sterile PPPFCs requires no preventive or prophylactic use of antibiotics. In infected PPPFCs, antibiotic therapy is not required for effective endoscopic transmural drainage.

Conservative Management of Complicated Colonic Diverticulitis in Early and Late Elderly

Background and Objectives: The management of complicated diverticulitis in the elderly can be a challenge and initial non-operative treatment remains controversial. In this study, we investigate the effectiveness of conservative treatment in elderly people after the first episode of complicated diverticulitis. Materials and Methods: This retrospective single-centre study describes 71 cases of elderly patients with complicated acute colonic diverticulitis treated with conservative management at Parma University Hospital from 1 January 2012 to 31 December 2019. Diverticulitis severity was staged according to WSES CT driven classification for acute diverticulitis. Patients was divided into two groups: early (65-74 yo) and late elderly (>75 yo). Results: We enrolled 71 elderly patients conservatively treated for complicated acute colonic diverticulitis, 25 males and 46 females. The mean age was 74.78 ± 6.8 years (range 65-92). Localized abdominal pain and fever were the most common symptoms reported in 34 cases (47.88%). Average white cells count was 10.04 ± 5.05 × 109/L in the early elderly group and 11.24 ± 7.89 in the late elderly group. CRP was elevated in 29 (78.3%) cases in early elderly and in 23 late elderly patients (67.6%). A CT scan of the abdomen was performed in every case (100%). Almost all patients were treated with bowel rest and antibiotics (95.7%). Average length of stay was 7.74 ± 7.1 days (range 1-48). Thirty-day hospital readmission and mortality were not reported. Average follow-up was 52.32 ± 31.8 months. During follow-up, home therapy was prescribed in 48 cases (67.6%). New episodes of acute diverticulitis were reported in 20 patients (28.1%), elevated WBC and chronic NSAID therapy were related to a higher risk of recurrence in early elderly patients (p < 0.05). Stage IIb-III with elevated WBC during first episode, had a higher recurrence rate compared to the other CT-stage (p = 0.006). Conclusions: The management of ACD in the elderly can be a challenge. Conservative treatment is safe and effective in older patients, avoiding unnecessary surgery that can lead to unexpected complications due to co-morbidities.

Open abdomen in the management of complicated diaphragmatic hernia: a case report

Diaphragmatic hernia (DH) can be congenital or acquired. DH is a potentially life-threatening condition and the management in emergency setting remain unclear. Nonspecific symptoms can delay the diagnosis. We report a case of a 63-year-old man admitted for abdominal pain and nausea. He was successfully treated with damage control surgery.