Rate of stoma formation following damage-control surgery for severe intra-abdominal sepsis: a single-centre consecutive case series

Cesena guidelines: WSES consensus statement on laparoscopic-first approach to general surgery emergencies and abdominal trauma

BACKGROUND

Laparoscopy is widely adopted across nearly all surgical subspecialties in the elective setting. Initially finding indication in minor abdominal emergencies, it has gradually become the standard approach in the majority of elective general surgery procedures. Despite many technological advances and increasing acceptance, the laparoscopic approach remains underutilized in emergency general surgery and in abdominal trauma. Emergency laparotomy continues to carry a high morbidity and mortality. In recent years, there has been a growing interest from emergency and trauma surgeons in adopting minimally invasive surgery approaches in the acute surgical setting. The present position paper, supported by the World Society of Emergency Surgery (WSES), aims to provide a review of the literature to reach a consensus on the indications and benefits of a laparoscopic-first approach in patients requiring emergency abdominal surgery for general surgery emergencies or abdominal trauma.

METHODS

This position paper was developed according to the WSES methodology. A steering committee performed the literature review and drafted the position paper. An international panel of 54 experts then critically revised the manuscript and discussed it in detail, to develop a consensus on a position statement.

RESULTS

A total of 323 studies (systematic review and meta-analysis, randomized clinical trial, retrospective comparative cohort studies, case series) have been selected from an initial pool of 7409 studies. Evidence demonstrates several benefits of the laparoscopic approach in stable patients undergoing emergency abdominal surgery for general surgical emergencies or abdominal trauma. The selection of a stable patient seems to be of paramount importance for a safe adoption of a laparoscopic approach. In hemodynamically stable patients, the laparoscopic approach was found to be safe, feasible and effective as a therapeutic tool or helpful to identify further management steps and needs, resulting in improved outcomes, regardless of conversion. Appropriate patient selection, surgeon experience and rigorous minimally invasive surgical training, remain crucial factors to increase the adoption of laparoscopy in emergency general surgery and abdominal trauma.

CONCLUSIONS

The WSES expert panel suggests laparoscopy as the first approach for stable patients undergoing emergency abdominal surgery for general surgery emergencies and abdominal trauma.

Damage Control Surgery and Transfer in Emergency General Surgery

Selective non traumatic emergency surgery patients are targets for damage control surgery (DCS) to prevent or treat abdominal compartment syndrome and the lethal triad. However, DCS is still a subject of controversy. As a concept, DCS describes a series of abbreviated surgical procedures to allow rapid source control of hemorrhage and contamination in patients with circulatory shock to allow resuscitation and stabilization in the intensive care unit followed by delayed return to the operating room for definitive surgical management once the patient becomes physiologic stable. If appropriately applied, the DCS morbidity and mortality can be significantly reduced.

Implementing a surgical site infection prevention bundle for emergency appendectomy: Worth the effort or waste of time?

BACKGROUND

The aim of this study was to evaluate feasibility and impact of an intraoperative surgical site infection prevention bundle for emergency appendectomy.

METHODS

Consecutive adult patients undergoing emergency appendectomy were prospectively included during a 10-year study period (2011-2020). The care bundle was implemented as of November 1, 2018, and focused on 4 intraoperative items (disinfection, antibiotic prophylaxis, induction temperature control >36.5°C, and intracavity lavage). The primary outcome was the compliance to bundle items. Thirty-day surgical site infections were assessed by the independent Swiss National SSI Surveillance Program (2011 to October 2018) and by an institutional audit (November 2018-2020). Independent risk factors for surgical site infection were identified through multinominal logistic regression analysis.

RESULTS

Of 1,901 patients, 449 (23.6%) were included after bundle implementation. Overall surgical site infection rate was 111 (5.8%). In 42 patients with surgical site infection (37.8%), antibiotic treatment alone was done, and additional surgical management was necessary in 31 patients (27.9%), computed tomography-guided drainage in 30 patients (27%), and bedside wound opening in 9 cases (8.1%). Overall compliance to the bundle was 79.9%. Overall surgical site infection rates were decreased after bundle implementation (17/449 [3.8%] vs 94/1,452 [6.5%], P = .038), mainly due to a decrease in superficial incisional infections (P = .014). Independent risk factors for surgical site infection were surgical duration ≥60 minutes (odds ratio: 1.66, P = .018), contamination class IV (odds ratio: 2.64, P < .001), and open or converted approach (odds ratio: 4.0, P < .001), and the bundle was an independent protective factor (odds ratio: 0.58, P = .048).

CONCLUSION

Implementation of an intraoperative surgical site infection prevention bundle was feasible and might have a beneficial impact on surgical site infection rates after emergency appendectomy.