Acute cholecystitis management in high-risk, critically ill, and unfit-for-surgery patients: the Italian Society of Emergency Surgery and Trauma (SICUT) guidelines

Dealing with acute cholecystitis in high-risk, critically ill, and unfit-for-surgery patients is frequent during daily practice and requires complex management. Several procedures exist to postpone and/or prevent surgical intervention in those patients who temporarily or definitively cannot undergo surgery. After a systematic review of the literature, an expert panel from the Italian Society of Emergency Surgery and Trauma (SICUT) discussed the different issues and statements in subsequent rounds. The final version of the statements was discussed during the annual meeting in Rome (September 2022). The present paper presents the definitive conclusions of the discussion. Fifteen statements based on the literature evidence were provided. The statements gave precise indications regarding the decisional process and the management of patients who cannot temporarily or definitively undergo cholecystectomy for acute cholecystitis. Acute cholecystitis management in high-risk, critically ill, and unfit-for-surgery patients should be multidisciplinary. The different gallbladder drainage methods must be tailored according to each patient and based on the expertise of the hospital. Percutaneous gallbladder drainage is recommended as the first choice as a bridge to surgery or in severely physiologically deranged patients. Endoscopic gallbladder drainage (cholecystoduodenostomy and cholecystogastrostomy) is suggested as a second-line alternative especially as a definitive procedure for those patients not amenable to surgical management. Trans-papillary gallbladder drainage is the last option to be reserved only to those unfit for other techniques. Delayed laparoscopic cholecystectomy in patients with percutaneous gallbladder drainage is suggested in all those patients recovering from the conditions that previously discouraged surgical intervention after at least 6 weeks from the gallbladder drainage.

Adhesive small bowel obstruction: predictive factors of laparoscopic failure

The adoption of laparoscopy for the management of adhesive small bowel obstruction (ASBO) patients is debated. The laparoscopic approach has been associated with a considerable conversion-to-open rate. Nonetheless, reliable predictors of conversion are still unclear. The present study aimed to identify factors associated with conversion to open in ASBO patients who underwent laparoscopic surgery. Patients who underwent laparoscopic surgery for ASBO and were admitted to our unit between December 2014 and October 2022 were retrospectively evaluated. The patients were categorized into two groups: patients who underwent complete laparoscopy approach (Group 1) and patients converted to open technique (Group 2). Demographic, clinical, and radiological features, intraoperative findings, and postoperative outcomes were compared. A total of 168 patients were enrolled: 100 patients (59.5%) were included in Group 1, and 68 patients (40.5%) were included in Group 2. The rate of ischemia (p = 0.023), surgical complications (p = 0.001), operative time (p < 0.0001), days of nasogastric tube maintenance (p < 0.0001), time to canalization (p < 0.0001), and length of hospital stay (p < 0.0001) were significantly higher in Group 2 than Group 1. Following univariate analysis, the presence of feces signs (p = 0.044) and high mean radiodensity of intraperitoneal free fluid (p = 0.031) were significantly associated with Group 2 compared with Group 1. Following multivariate analysis, the feces sign was a significant predictive factor of conversion (OR 1.965 [IC 95%]; p = 0.046). Laparoscopic treatment is a safe and effective approach in patients affected by ASBO. The feces sign may be a predictive factor of conversion and could guide the surgeon in selecting the appropriate management of patients affected by ASBO.

What are the differences between the three most used classifications for acute colonic diverticulitis? A comparative multicenter study

BACKGROUND

Acute left-sided colonic diverticulitis is one of the most common clinical conditions encountered by surgeons in the acute setting. Currently, the most popular classifications, based on radiological findings, are the modified Hinchey, American Association for the Surgery of Trauma (AAST), and World Society of Emergency Surgery (WSES) classifications. We hypothesize that all classifications are equivalent in predicting outcomes.

METHODS

This is a retrospective study of 597 patients from four medical centers between 2014 and 2021. Based on clinical, radiological, and intraoperative findings, patients were graded according to the three classifications. Regression analysis and receiver operating characteristic curve analysis were used to compare six outcomes: need for intervention, complications, major complications (Clavien-Dindo >2), reintervention, hospital length of stay, and mortality.

RESULTS

A total of 597 patients were included. Need for intervention, morbidity, and reintervention rates significantly increased with increasing AAST, modified Hinchey, and WSES grades. The area under the curve (AUC) for the need for intervention was 0.84 for AAST and 0.81 for modified Hinchey ( p = 0.039). The AUC for major complications was 0.75 for modified Hinchey and 0.70 for WSES ( p = 0.009). No differences were found between the three classifications when comparing AUCs for mortality, complications, and reintervention rates.

CONCLUSION

The AAST, WSES, and modified Hinchey classifications are similar in predicting complications, reintervention, and mortality rates. American Association for the Surgery of Trauma and modified Hinchey scores result the most adequate for predicting the need for surgery and the occurrence of major complications.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level III.

Complication analysis in acute appendicitis, results from an international multicenter study

PURPOSE

Acute appendicitis (AA) is frequent, its diagnosis is challenging, and the surgical intervention is not risk free. An accurate diagnosis will reduce unnecessary surgeries and associated risks. This study aimed to analyze the rate of appendectomies' postoperative complications.

METHODS

Multicenter, prospective, observational study conducted at three large hospitals (Pisa University Hospital, Italy; Henri Mondor University Hospital, Paris, France; and Valencia University Hospital, Spain).

RESULTS

A total of 3070 patients with a median age of 28 years (IQR 20-43) were enrolled. 1403 (45.7%) were females. Eight hundred ninety patients (29%) did not undergo preoperative imaging. Ultrasound and CT scans were performed in 1465 (47.7%) and 715 (23.3%) patients. Patients requiring CT scan were older [median 38 (IQR 26-53) vs. no imaging median 24 (IQR 16-35), Ultrasound median 28 (IQR 20-41); p < 0.0001]. Laparoscopic appendectomy was performed in 58.6%. Complications developed in 1279 (41.7%) patients: Clavien-Dindo grades I-II in 1126 (33.9%); Clavien-Dindo grades III-IV in 146 (5.2%). Overall mortality was 0.2%. Following resection of a normal appendix, 15% experienced major complications (Clavien-Dindo grades IIIb and above). Multivariable analysis revealed that age, Charlson comorbidity index, histopathology, and Alvarado score over 7 were associated with a higher risk of Clavien-Dindo complication grades IIIa and higher.

CONCLUSION

Appendectomy may be associated with serious postoperative complications. Complications were associated with older age, Charlson comorbidity index, histopathology, and high Alvarado scores. The definition of accurate diagnostic and therapeutic pathways may improve results. The association between clinical scores and radiology is recommended.

Evaluation of a quality improvement intervention to reduce anastomotic leak following right colectomy (EAGLE): pragmatic, batched stepped-wedge, cluster-randomized trial in 64 countries

BACKGROUND

Anastomotic leak affects 8 per cent of patients after right colectomy with a 10-fold increased risk of postoperative death. The EAGLE study aimed to develop and test whether an international, standardized quality improvement intervention could reduce anastomotic leaks.

METHODS

The internationally intended protocol, iteratively co-developed by a multistage Delphi process, comprised an online educational module introducing risk stratification, an intraoperative checklist, and harmonized surgical techniques. Clusters (hospital teams) were randomized to one of three arms with varied sequences of intervention/data collection by a derived stepped-wedge batch design (at least 18 hospital teams per batch). Patients were blinded to the study allocation. Low- and middle-income country enrolment was encouraged. The primary outcome (assessed by intention to treat) was anastomotic leak rate, and subgroup analyses by module completion (at least 80 per cent of surgeons, high engagement; less than 50 per cent, low engagement) were preplanned.

RESULTS

A total 355 hospital teams registered, with 332 from 64 countries (39.2 per cent low and middle income) included in the final analysis. The online modules were completed by half of the surgeons (2143 of 4411). The primary analysis included 3039 of the 3268 patients recruited (206 patients had no anastomosis and 23 were lost to follow-up), with anastomotic leaks arising before and after the intervention in 10.1 and 9.6 per cent respectively (adjusted OR 0.87, 95 per cent c.i. 0.59 to 1.30; P = 0.498). The proportion of surgeons completing the educational modules was an influence: the leak rate decreased from 12.2 per cent (61 of 500) before intervention to 5.1 per cent (24 of 473) after intervention in high-engagement centres (adjusted OR 0.36, 0.20 to 0.64; P < 0.001), but this was not observed in low-engagement hospitals (8.3 per cent (59 of 714) and 13.8 per cent (61 of 443) respectively; adjusted OR 2.09, 1.31 to 3.31).

CONCLUSION

Completion of globally available digital training by engaged teams can alter anastomotic leak rates. Registration number: NCT04270721 (http://www.clinicaltrials.gov).

Antibiotic prophylaxis in trauma: GAIS, SIS-E, WSIS, AAST, WSES guidelines

ABSTRACT

Trauma is a complex disease, and the use of antibiotic prophylaxis (AP) in trauma patients is common practice. However, considering the increasing rates of antibiotic resistance, AP use should be questioned and limited only to specific cases. Antibiotic stewardship is of paramount importance in fighting resistance spread. Definitive rules or precise indications about antibiotic prophylaxis in trauma remain unclear. The present manuscript describes the indications of antibiotic prophylaxis in traumatic lesions to the head, brain, torso, maxillo-facial, extremities, skin, and soft tissues endorsed by the Global Alliance for Infection in Surgery (GAIS), Surgical Infection Society Europe (SIS-E), World Surgical Infection Society (WSIS), American Association for the Surgery of Trauma (AAST), World Society of Emergency Surgery (WSES).

Acute diverticulitis in immunocompromised patients: evidence from an international multicenter observational registry (Web-based International Register of Emergency Surgery and Trauma, Wires-T)

BACKGROUND

Immunocompromised patients with acute diverticulitis are at increased risk of morbidity and mortality. The aim of this study was to compare clinical presentations, types of treatment, and outcomes between immunocompromised and immunocompetent patients with acute diverticulitis.

METHODS

We compared the data of patients with acute diverticulitis extracted from the Web-based International Registry of Emergency Surgery and Trauma (WIRES-T) from January 2018 to December 2021. First, two groups were identified: medical therapy (A) and surgical therapy (B). Each group was divided into three subgroups: nonimmunocompromised (grade 0), mildly to moderately (grade 1), and severely immunocompromised (grade 2).

RESULTS

Data from 482 patients were analyzed-229 patients (47.5%) [M:F = 1:1; median age: 60 (24-95) years] in group A and 253 patients (52.5%) [M:F = 1:1; median age: 71 (26-94) years] in group B. There was a significant difference between the two groups in grade distribution: 69.9% versus 38.3% for grade 0, 26.6% versus 51% for grade 1, and 3.5% versus 10.7% for grade 2 (p < 0.00001). In group A, severe sepsis (p = 0.027) was more common in higher grades of immunodeficiency. Patients with grade 2 needed longer hospitalization (p = 0.005). In group B, a similar condition was found in terms of severe sepsis (p = 0.002), quick Sequential Organ Failure Assessment score > 2 (p = 0.0002), and Mannheim Peritonitis Index (p = 0.010). A Hartmann's procedure is mainly performed in grades 1-2 (p < 0.0001). Major complications increased significantly after a Hartmann's procedure (p = 0.047). Mortality was higher in the immunocompromised patients (p = 0.002).

CONCLUSIONS

Immunocompromised patients with acute diverticulitis present with a more severe clinical picture. When surgery is required, immunocompromised patients mainly undergo a Hartmann's procedure. Postoperative morbidity and mortality are, however, higher in immunocompromised patients, who also require a longer hospital stay.

Colorectal neoplastic emergencies in immunocompromised patients: preliminary result from the Web-based International Register of Emergency Surgery and Trauma (WIRES-T trial)

Association of advanced age, neoplastic disease and immunocompromission (IC) may lead to surgical emergencies. Few data exist about this topic. Present study reports the preliminary data from the WIRES-T trial about patients managed for colorectal neoplastic emergencies in immunocompromised patients. The required data were taken from a prospective observational international register. The study was approved by the Ethical Committee with approval n. 17575; ClinicalTrials.gov Identifier: NCT03643718. 839 patients were collected; 753 (80.7%) with mild-moderate IC and 86 (10.3%) with severe. Median age was 71.9 years and 73 years, respectively, in the two groups. The causes of mild-moderate IC were reported such malignancy (753-100%), diabetes (103-13.7%), malnutrition (26-3.5%) and uremia (1-0.1%), while severe IC causes were steroids treatment (14-16.3%); neutropenia (7-8.1%), malignancy on chemotherapy (71-82.6%). Preoperative risk classification were reported as follow: mild-moderate: ASA 1-14 (1.9%); ASA 2-202 (26.8%); ASA 3-341 (45.3%); ASA 4-84 (11.2%); ASA 5-7 (0.9%); severe group: ASA 1-1 patient (1.2%); ASA 2-16 patients (18.6%); ASA 3-41 patients (47.7%); ASA 4-19 patients (22.1%); ASA 5-3 patients (3.5%); lastly, ASA score was unavailable for 105 cases (13.9%) in mild-moderate group and in 6 cases (6.9%) in severe group. All the patients enrolled underwent urgent/emergency surgery Damage control approach with open abdomen was adopted in 18 patients. Mortality was 5.1% and 12.8%, respectively, in mild-moderate and severe groups. Long-term survival data: in mild-moderate disease-free survival (median, IQR) is 28 (10-91) and in severe IC, it is 21 (10-94). Overall survival (median, IQR) is 44 (18-99) and 26 (20-90) in mild-moderate and severe, respectively; the same is for post-progression survival (median, IQR) 29 (16-81) and 28, respectively. Univariate and multivariate analyses showed as the only factor influencing mortality in mild-moderate and severe IC is the ASA score. Colorectal neoplastic emergencies in immunocompromised patients are more frequent in elderly. Sigmoid and right colon are the most involved. Emergency surgery is at higher risk of complication and mortality; however, management in dedicated emergency surgery units is necessary to reduce disease burden and to optimize results by combining oncological and acute care principles. This approach may improve outcomes to obtain clinical advantages for patients like those observed in elective scenario. Lastly, damage control approach seems feasible and safe in selected patients.

The unrestricted global effort to complete the COOL trial

BACKGROUND

Severe complicated intra-abdominal sepsis (SCIAS) has an increasing incidence with mortality rates over 80% in some settings. Mortality typically results from disruption of the gastrointestinal tract, progressive and self-perpetuating bio-mediator generation, systemic inflammation, and multiple organ failure. A further therapeutic option may be open abdomen (OA) management with negative peritoneal pressure therapy (NPPT) to remove inflammatory ascites and attenuate the systemic damage from SCIAS, although there are definite risks of leaving the abdomen open whenever it might possibly be closed. This potential therapeutic paradigm is the rationale being assessed in the Closed Or Open after Laparotomy (COOL trial) ( https://clinicaltrials.gov/ct2/show/NCT03163095 ). Initially, the COOL trial received Industry sponsorship; however, this funding mandated the use of a specific trademarked and expensive NPPT device in half of the patients allocated to the intervention (open) arm. In August 2022, the 3 M/Acelity Corporation without consultation but within the terms of the contract canceled the financial support of the trial. Although creating financial difficulty, there is now no restriction on specific NPPT devices and removing a cost-prohibitive intervention creates an opportunity to expand the COOL trial to a truly global basis. This document describes the evolution of the COOL trial, with a focus on future opportunities for global growth of the study.

METHODS

The COOL trial is the largest prospective randomized controlled trial examining the random allocation of SCIAS patients intra-operatively to either formal closure of the fascia or the use of the OA with an application of an NPPT dressing. Patients are eligible if they have free uncontained intraperitoneal contamination and physiologic derangements exemplified by septic shock OR severely adverse predicted clinical outcomes. The primary outcome is intended to definitively inform global practice by conclusively evaluating 90-day survival. Initial recruitment has been lower than hoped but satisfactory, and the COOL steering committee and trial investigators intend with increased global support to continue enrollment until recruitment ensures a definitive answer.

DISCUSSION

OA is mandated in many cases of SCIAS such as the risk of abdominal compartment syndrome associated with closure, or a planned second look as for example part of "damage control"; however, improved source control (locally and systemically) is the most uncertain indication for an OA. The COOL trial seeks to expand potential sites and proceed with the evaluation of NPPT agnostic to device, to properly examine the hypothesis that this treatment attenuates systemic damage and improves survival. This approach will not affect internal validity and should improve the external validity of any observed results of the intervention.

TRIAL REGISTRATION

National Institutes of Health ( https://clinicaltrials.gov/ct2/show/NCT03163095 ).

Biological prosthesis, platelet enriched plasma and bone marrow stem cells in complicated incisional hernia reconstruction in emergency surgery: a prospective case control study

Numerous innovations have been aided by abdominal wall surgical repair. Abdominal wall surgery was drastically altered by synthetic materials. Tissue engineering was unquestionably first applied to biomaterials. The purpose of the present study is to compare different repeating approaches with rising tissue engineering complexity in repairing complex incisional hernia in emergency setting. Patients with complicated incisional hernia were prospectively included in the study and divided into 4 groups: DR (Direct Repair) group underwent direct reconstruction of the abdominal wall, BR (Biological mesh Repair) group underwent reconstruction of the abdominal wall with biological mesh (retro-muscular), BPR [Biological mesh and Platelet Enriched Plasma (PEP), gel] group underwent reconstruction of the abdominal wall with Biological mesh (retro-muscular) and PEP, BPSR (biological mesh, PEP gel and Bone Marrow Stem Cells) group underwent reconstruction of the abdominal wall with biological mesh (retromuscular), PEP and Bone Marrow Stem cells (BMSc). Forty patients were enrolled. Patients in the DR group experienced a higher rate of severe complication (p<0.05). Recurrence rates were 60% for DR patients, 20% for BM patients and 10% for the BM+PEP group (p<0.05). Median follow-up period was 64.6, 55.7 and 55.8 months (p<0.05). 7- and 30-days abdominal wall thickness is progressively increased by different techniques: BP, BP+PEP and BP+PEP+BMSc (p<0.05). No mortality was registered. Tissue engineering techniques in abdominal wall reconstruction showed promising results. They seem to reduce the recurrence rate without increasing complication one in complicated incisional abdominal wall hernia. Although many aspects are yet to be determined and standardized, it seems extremely important to continue research and experimentation in this field.

Patients with an Open Abdomen in Asian, American and European Continents: A Comparative Analysis from the International Register of Open Abdomen (IROA)

BACKGROUND

International register of open abdomen (IROA) enrolls patients from several centers in American, European, and Asiatic continent. The aim of our study is to compare the characteristics, management and clinical outcome of adult patients treated with OA in the three continents.

MATERIAL AND METHODS

A prospective analysis of adult patients enrolled in the international register of open abdomen (IROA).

TRIAL REGISTRATION

NCT02382770.

RESULTS

1183 patients were enrolled from American, European and Asiatic Continent. Median age was 63 years (IQR 49-74) and was higher in the European continent (65 years, p < 0.001); 57% were male. The main indication for OA was peritonitis (50.6%) followed by trauma (15.4%) and vascular emergency (13.5%) with differences among the continents (p < 0.001). Commercial NPWT was preferred in America and Europe (77.4% and 52.3% of cases) while Barker vacuum pack (48.2%) was the preferred temporary abdominal closure technique in Asia (p < 0.001). Definitive abdominal closure was achieved in 82.3% of cases in America (fascial closure in 90.2% of cases) and in 56.4% of cases in Asia (p < 0.001). Prosthesis were mostly used in Europe (17.3%, p < 0.001). The overall entero-atmospheric fistula rate 2.5%. Median open abdomen duration was 4 days (IQR 2-7). The overall intensive care unit and hospital length-of-stay were, respectively, 8 and 11 days (no differences between continents). The overall morbidity and mortality rates for America, Europe, and Asia were, respectively, 75.8%, 75.3%, 91.8% (p = 0.001) and 31.9%, 51.6%, 56.9% (p < 0.001).

CONCLUSION

There is no uniformity in OA management in the different continents. Heterogeneous adherence to international guidelines application is evident. Different temporary abdominal closure techniques in relation to indications led to different outcomes across the continents. Adherence to guidelines, combined with more consistent data, will ultimately allow to improving knowledge and outcome.

Laparoscopic versus open repair of perforated peptic ulcers: analysis of outcomes and identification of predictive factors of conversion

BACKGROUND

The surgical treatment for perforated peptic ulcers (PPUs) can be safely performed laparoscopically. This study aimed to compare the outcomes of patients who received different surgical approaches for PPU and to identify the predictive factors for conversion to open surgery.

METHODS

This retrospective study analyzed patients treated for PPUs from 2002 to 2020. Three groups were identified: a complete laparoscopic surgery group (LG), a conversion to open group (CG), and a primary open group (OG). After univariate comparisons, a multivariate analysis was conducted to identify the predictive factors for conversion.

RESULTS

Of the 175 patients that underwent surgery for PPU, 104 (59.4%) received a laparoscopic-first approach, and 27 (25.9%) required a conversion to open surgery. Patients treated directly with an open approach were older (p < 0.0001), had more comorbidities (p < 0.0001), and more frequently had a previous laparotomy (p = 0.0001). In the OG group, in-hospital mortality and ICU need were significantly higher, while the postoperative stay was longer. Previous abdominal surgery (OR 0.086, 95% CI 0.012-0.626; p = 0.015), ulcer size (OR 0.045, 95% CI 0.010-0.210; p < 0.0001), and a posterior ulcer location (OR 0.015, 95% CI 0.001-0.400; p = 0.012) were predictive factors for conversion to an open approach.

CONCLUSION

This study confirms the benefits of the laparoscopic approach for the treatment of PPUs. Previous laparotomies, a greater ulcer size, and a posterior location of the ulcer are risk factors for conversion to open surgery during laparoscopic repair.

The LIFE TRIAD of emergency general surgery

Emergency General Surgery (EGS) was identified as multidisciplinary surgery performed for traumatic and non-traumatic acute conditions during the same admission in the hospital by general emergency surgeons and other specialists. It is the most diffused surgical discipline in the world. To live and grow strong EGS necessitates three fundamental parts: emergency and elective continuous surgical practice, evidence generation through clinical registries and data accrual, and indications and guidelines production: the LIFE TRIAD.

Intestinal Ischemia: Unusual but Fearsome Complication of COVID-19 Infection

The pathophysiology of gastrointestinal damage in coronavirus disease (COVID-19) is probably multifactorial. It is not clear whether the etiology of intestinal ischemia may be directly related to viral replication or may result from hyper-coagulability following SARS-CoV-2 infection.To confirm a pathogenic role of COVID-19, we retrospectively investigated the presence of SARS-CoV-2 virus in the ischemic bowel of five COVID-19 patients undergoing emergency surgery for intestinal ischemia in the period of March 2020-May 2021. Immunohistochemical positivity with weak intensity was observed in four out of five cases, but only one case was strongly positive both at immunohistochemistry and at molecular analysis. The histological alterations in the intestinal tissue samples showed similarity with the well-known alterations described in typical targetorgans of the virus (e.g., the lung). This observation suggests a similar mechanism of action of the virus. Further larger studies are, thus, required to confirm this preliminary finding. Clinicians should carefully monitor all COVID-19 patients for the possible presence of a SARS-CoV-2 intestinal infection, a potential cause of ischemia and bowel perforation.

Non-operative management in blunt splenic trauma: A ten-years-experience at a Level 1 Trauma Center

Trauma; Spleen injuries are among the most frequent trauma-related injuries. The approach for diagnosis and management of Blunt Splenic Injury (BSI) has been considerably shifted towards Non- Operative Management (NOM) in the last few decades. NOM of blunt splenic injuries includes Splenic Angio-Embolization (SAE). Aim of this study was to analyze Pisa Level 1 trauma center (Italy) last 10-years-experience in the management of Blunt Splenic Trauma (BST), and more specifically to evaluate NOM rate and failure. Retrospective analysis of all patients admitted with blunt splenic trauma was done. They were divided into two groups according to the treatment: hemodynamically unstable patients treated operatively (OM group) and patients underwent a nonoperative management (NOM group). The CT scan performed in all NOM group patients. Univariate analysis was performed to identify differences between the two groups. Multivariate analysis adjusting for factors with a p value < 0.05 or with clinical relevance was used to identify possible risk factors for NOM failure. 193 consecutive patients with blunt splenic trauma were admitted. Emergency splenectomies were performed in 53 patients (OM group); 140 were managed non-operatively with or without SAE (NOM group). NOM rate in high grade injuries is 57%. Overall NOM failure rate is 9%, and success rate in high grade splenic injuries is 48%; multivariate analysis showed AAST score ≥3 as a risk factor for NOM failure. Non-operative management currently represents the gold standard management for hemodynamically stable patient with blunt splenic trauma even in high grade splenic injuries. AAST ≥3 spleen lesion is a failure risk factor but not a contraindication to for non-operative management.

Antibiotic Prophylaxis in Torso, Maxillofacial, and Skin Traumatic Lesions: A Systematic Review of Recent Evidence

Use of antibiotic prophylaxis (AP) in trauma patients is a common practice. However, considering the increasing rates of antibiotic resistance, AP use should be questioned and limited only to specific cases. We performed a systematic review of recent literature (from year 2000), aiming to summarize the state of the art on efficacy and appropriateness of AP in patients with traumatic injuries of torso, maxillofacial complex and skin (including burns). Twenty-six articles were selected. In thoracic trauma, AP could be useful in reducing infective complications in tube thoracostomy for penetrating trauma. In maxillo-facial trauma, AP could find a role in the peri-operative trauma setting in the case of a graft or prosthetic implant. In abdominal trauma, there is a lack of consensus on the definition of contamination, infection, antibiotic therapy, and prophylaxis. In burned patients, routine AP is not suggested. In the case of human bites to the extremities, AP could find an indication. Future studies should focus on the subcategories of patients at higher risk of infection, identifying those who would benefit from AP. Attention to antimicrobial stewardship and guidelines focused on AP in trauma are required, to reduce antibiotic abuse, and increase quality research.

Laparoscopic cholecystectomy for acute calculous cholecystitis in elderly. More complex but equally safe and effective

AIM

Acute calculous cholecystitis (ACC) is one of the most common pathologies in the elderly. Laparoscopy is the gold standard for ACC treatment, regardless of age. This study aimed to compare different classes of elderly patients affected by ACC and assess whether laparoscopy has the same safety and effectiveness as younger patients.

MATERIALS AND METHODS

Patients aging ≠ 70 y-o presenting with ACC treated with laparoscopic cholecystectomy were prospectively enrolled from 2010 to 2020. Three groups were identified: age 70-75 (Group 1); age 76-80 (Group 2); Age > 80 (Group 3). Major postoperative complications were considered as more than grade II according to the Clavien and Dindo classification. Demographic, intra-, and postoperative outcomes were compared. A multivariate analysis was also performed to identify predictive factors of morbidity.

RESULTS

We reviewed 832 patients: 302 (36.3%) were ≠ 70 y-o. Group 1 accounted for 124 patients (41.1%), group 2 for 74 (24.5%) and group 3 for 104 (34.3%). Male gender was significantly less represented with increasing ages (p<0.001). ASA score >2 (p=0.010), CACI score (p<0.001), and ERD score (p<0.001) were more frequent in group 3. No significant differences were found about AAST distribution and comorbidities. Conversion to open rate was significantly higher in group 1 (6.5%) and group 3 (8.7%) (p=0.019). Common bile duct stones rate was higher in group 3 (14.5% vs 13.5% vs 31.7%; p<0.001). Median postoperative hospital length of stay was increasingly longer (p<0.001). AAST grade ≠ 3 (OR 3.187; 95% CI 1.356-7.489; p=0.008), age ≠ 70 y-o (OR 3.358; p<0.001), and CBD stones (OR 2.912; 95% CI 1.456-5.824; p=0.003) were identified as predictive factors of morbidity between < and ≠ 70 ys. Among the three groups of elderly, age > 80 ys was associated with an increase of OR of postoperative complication by 2.94 (95% CI 1.099-7.912; p = 0.032).

CONCLUSIONS

Laparoscopy can be safely offered in elderly patients, although longer postoperative hospital stay. The presence of associated CBD stones may increase the risk of morbidity.

KEY WORDS

Acute calculous cholecystitis, Cholecystectomy, Common bile duct lithiasis, Elderly, Frailty, Laparoscopy.

Diagnosing penetrating diaphragmatic injuries: CT scan is valuable but not reliable

BACKGROUND

The diagnosis of penetrating isolated diaphragmatic injuries can be challenging because they are usually asymptomatic. Diagnosis by chest X-ray (CXR) is unreliable, while CT scan is reported to be more valuable. This study evaluated the diagnostic ability of CXR and CT in patients with proven DI.

METHODS

Single center retrospective study (2009-2019), including all patients with penetrating diaphragmatic injuries (pDI) documented at laparotomy or laparoscopy with preoperative CXR and/or CT evaluation. Imaging findings included hemo/pneumothorax, hemoperitoneum, pneumoperitoneum, elevated diaphragm, definitive DI, diaphragmatic hernia, and associated abdominal injuries.

RESULTS

230 patients were included, 62 (27%) of which had isolated pDI, while 168 (73%) had associated abdominal or chest trauma. Of the 221 patients with proven DI and preoperative CXR, the CXR showed hemo/pneumothorax in 99 (45%), elevated diaphragm in 51 (23%), and diaphragmatic hernia in 4 (1.8%). In 86 (39%) patients, the CXR was normal. In 126 patients with pDI and preoperative CT, imaging showed hemo/pneumothorax in 95 (75%), hemoperitoneum in 66 (52%), pneumoperitoneum in 35 (28%), definitive DI in 56 (44%), suspected DI in 26 (21%), and no abnormality in 3 (2%). Of the 57 patients with isolated pDI the CXR showed a hemo/pneumothorax in 24 (42%), elevated diaphragm in 14 (25%) and was normal in 24 (42%).

CONCLUSIONS

Radiologic diagnosis of DI is unreliable. CT scan is much more sensitive than CXR. Laparoscopic evaluation should be considered liberally, irrespective of radiological findings.

Sarcina Ventriculi infection: a rare but fearsome event. A Systematic Review of the Literature

OBJECTIVES

This study is aimed to report a case of SV-related gastritis and the results of a systematic literature review of SV infections.

METHODS

Following a case presentation, we systematically searched different databases (MEDLINE, PubMed, Scopus, Web of Science, EMBASE, google scholar) for the items "sarcina," "ventriculi," "clostridium" with AND/OR.

RESULTS

A total of 55 articles reporting 65 cases of Sarcina Ventriculi were found. Thus, 66 patients, including our case, were reviewed. The median age was 51 years (IQR: 0-87 years). Females accounted for 51% of cases. 68% of patients had one or more comorbidities. SV was isolated in the gastrointestinal tract (88%), respiratory (5%), urine (4%), and bloodstream (3%) systems. Upper endoscopy was performed in 52 patients (79%). Biopsies were obtained in all 52 cases and were normal in 23%. Surgery was warranted in 15 patients (23%), and specific antimicrobial therapy was delivered in 34 (52%) patients. Mortality was 14%. At follow-up, 88% of patients showed complete eradication of the SV infection.

CONCLUSIONS

Upper gastrointestinal biopsy positive for SV should prompt an evaluation of the clinical conditions, considering the risk of gastric perforation is not negligible. Antibiotic therapy may eradicate the infection and prevent complications. Emergency surgery is required in case of source control.

Indocyanine Green (ICG) for the assessment of splenic perfusion during laparoscopic splenic artery aneurysmectomy. A case report

CASE REPORT

We describe the case of a 54-year-old man with a 20mm splenic aneurysm, who underwent laparoscopic aneurysmectomy, without splenic removal. The residual splenic blood supply was assessed by using indocyanine green i.v. administration.

CLINICAL FINDINGS

The patient presented at ED with abdominal pain, syncopal episode, and tachycardia. A CT scan with contrast showed hemoperitoneum with a 20mm splenic aneurysm, which was located at the bifurcation of the splenic and left gastroepiploic artery. Treatment and Outcome Laparoscopic surgery was then warranted. Abdominal exploration revealed a serohemorrhagic collection without active source of bleeding. After opening the gastro-colic ligament and obtaining vascular control of the splenic artery, the aneurysm was clipped and resected. No macroscopic modifications occurred to the spleen. This finding was confirmed by intravenous administration of indocyanine green. The operating time was 265 minutes. During the postoperative course, a grade A pancreatic fistula occurred. The patient was discharged on postoperative day seventh.

CLINICAL RELEVANCE

The management of true splenic artery aneurysms should be patient-tailored, considering the location of the aneurysm, operative risks and the patient's age, life expectancy and clinical status. The use of ICG in splenic surgery helps delineate the splenic parenchyma and evaluate residual splenic vascularization.

KEY WORDS

Indocyanine Green, Laparoscopy, Mini-invasive Surgery, Splenic Artery Aneurysm.

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.

Acute abdomen in the immunocompromised patient: WSES, SIS-E, WSIS, AAST, and GAIS guidelines

Immunocompromised patients are a heterogeneous and diffuse category frequently presenting to the emergency department with acute surgical diseases. Diagnosis and treatment in immunocompromised patients are often complex and must be multidisciplinary. Misdiagnosis of an acute surgical disease may be followed by increased morbidity and mortality. Delayed diagnosis and treatment of surgical disease occur; these patients may seek medical assistance late because their symptoms are often ambiguous. Also, they develop unique surgical problems that do not affect the general population. Management of this population must be multidisciplinary.This paper presents the World Society of Emergency Surgery (WSES), Surgical Infection Society Europe (SIS-E), World Surgical Infection Society (WSIS), American Association for the Surgery of Trauma (AAST), and Global Alliance for Infection in Surgery (GAIS) joined guidelines about the management of acute abdomen in immunocompromised patients.

Venous thromboembolic pharmacological prophylaxis in severe traumatic acute subdural hematomas: Early prophylaxis is effective and safe

BACKGROUND

The purpose of this study was to evaluate the optimal timing and type of pharmacological venous thromboembolism prophylaxis (VTEp) in patients with severe blunt head trauma with acute subdural hematomas (ASDH).

METHODS

Matched cohort study using ACS-TQIP database (2013-2016) including patients with isolated ASDH. Outcomes of matched patients receiving early prophylaxis (EP, ≤48 h) and late prophylaxis (LP, >48 h) were compared with univariable and multivariable regression analysis.

RESULTS

In 1,660 matched cases VTE complications (3.1% vs 0.5%, p < 0.001) were more common in the LP compared to the EP group. Multivariable regression analysis identified EP as an independent protective factor for VTE complications (OR 0.169, p < 0.001) but not mortality (p = 0.260). The adjusted risk for delayed craniectomy was not associated with EP compared to LP (p = 0.095). LMWH was independently associated with a lower mortality (OR 0.480, p = 0.008) compared to UH.

CONCLUSIONS

Early VTEp (≤48 h) does not increase the risk for craniectomies and is independently associated with fewer VTE complications in patients with isolated ASDH. LMWH was independently associated with a lower mortality compared to UH.

Predictive factors of mortality in open abdomen for abdominal sepsis: a retrospective cohort study on 113 patients

Over the past few years, the open abdomen (OA) as a part of Damage Control Surgery (DCS) has been introduced as a surgical strategy with the intent to reduce the mortality of patients with severe abdominal sepsis. Aims of our study were to analyze the OA effects on patients with abdominal sepsis and identify predictive factors of mortality. Patients admitted to our institution with abdominal sepsis requiring OA from 2010 to 2019 were retrospectively analyzed. Primary outcomes were mortality, morbidity and definitive fascial closure (DFC). Comparison between groups was made via univariate and multivariate analyses. On 1474 patients operated for abdominal sepsis, 113 (7.6%) underwent OA. Male gender accounted for 52.2% of cases. Mean age was 68.1 ± 14.3 years. ASA score was > 2 in 87.9%. Mean BMI, APACHE II score and Mannheim Peritonitis Index were 26.4 ± 4.9, 15.3 ± 6.3, and 22.6 ± 7.3, respectively. A negative pressure wound system technique was used in 47% of the cases. Overall, mortality was 43.4%, morbidity 76.6%, and DFC rate was 97.8%. Entero-atmospheric fistula rate was 2.2%. At multivariate analysis, APACHE II score (OR 1.18; 95% CI 1.05–1.32; p = 0.005), Frailty Clinical Scale (OR 4.66; 95% CI 3.19–6.12; p < 0.0001) and ASA grade IV (OR 7.86; 95% CI 2.18–28.27; p = 0.002) were significantly associated with mortality. OA seems to be a safe and reliable treatment for critically ill patients with severe abdominal sepsis. Nonetheless, in these patients, co-morbidity and organ failure remain the major obstacles to a better prognosis.

Evaluation of the efficacy of commercial and noncommercial tourniquets for extremity hemorrhage control in a perfused cadaver model

BACKGROUND

Tourniquets are a critical tool in the immediate response to life-threatening extremity hemorrhage; however, the optimal tourniquet type and effectiveness of noncommercial devices remain unclear. Our aim was to evaluate the efficacy of five tourniquets in a perfused-cadaver model.

METHODS

This prospective study used a perfused-cadaver model with standardized superficial femoral artery injury bleeding at 700 mL/min. Five tourniquets were tested: combat application tourniquet; rapid application tourniquet system; Stretch, Wrap, And Tuck Tourniquet; an improvised triangle bandage windlass; and a leather belt. Forty-eight medical students underwent a practical hands-on demonstration of each tourniquet. Using a random number generator, they placed the tourniquets on the bleeding cadaver in random order. Time to hemostasis, time to secure devices, estimated blood loss, and difficulty rating were assessed. A one-way repeated measures analysis of variance was used to compare efficacy between the tourniquets in achieving the outcomes.

RESULTS

The mean ± SD participant age was 25 ± 2.6 years, and 29 (60%) were male. All but one tourniquet was able to stop bleeding, but the rapid application tourniquet system had a 4% failure rate. Time to hemostasis and estimated blood loss did not differ significantly (p > 0.05). Stretch, Wrap, And Tuck Tourniquet required the longest time to be secured (47.8 ± 17.0 seconds), whereas the belt was the fastest (15.2 ± 6.5 seconds; p < 0.001). The improvised windlass was rated easiest to learn and apply, with 22 participants (46%) assigning a score of 1.

CONCLUSION

Four of five tourniquets evaluated, including both noncommercial devices, effectively achieved hemostasis. A standard leather belt was the fastest to place and was able to stop the bleeding. However, it required continuous pressure to maintain hemostasis. The improvised windlass was as effective as the commercial devices and was the easiest to apply. In an emergency setting where commercial devices are not available, improvised tourniquets may be an effective bridge to definitive care.

Management and outcomes of severe pelvic fractures in level I and II ACS verified trauma centers

BACKGROUND

The aim of this study was to evaluate the management strategies and outcomes of isolated severe pelvic fractures in level I and II ACS verified trauma centers.

METHODS

ACS-TQIP database study, including patients with blunt, isolated severe pelvic facture (AIS 3-5).

RESULTS

2629 level I and 1277 level II patients were included. Early blood product transfusion was significantly higher, pharmacological VTE prophylaxis significantly lower and ICU length of stay significantly longer in level II centers (p < 0.001). On multivariate analysis, treatment at level II centers was independently associated with increased overall complications, specifically ARDS, but not mortality.

CONCLUSIONS

In isolated severe pelvic fractures there was a significantly higher use of early blood products, less VTE pharmacological prophylaxis, longer ICU length of stay and higher overall complications and ARDS in level II centers. Blood product utilization and pharmacological VTE prophylaxis are potential areas of quality improvement in level II centers.

Traumatic epidural hematomas in the pediatric population: clinical characteristics and diagnostic pitfalls

BACKGROUND/PURPOSE

The purpose of this study was to review the initial clinical presentation of EDH, identify potential clinical markers and highlight diagnostic pitfalls.

METHODS

Retrospective review of all pediatric patients admitted to a Level I Trauma Center diagnosed with blunt traumatic EDH from 2008 to 2018.

RESULTS

A total of 699 pediatric patients were identified with blunt traumatic brain injury (TBI); 106 with EDH made up the study population. A skull fracture was present in 84%. Overall, the most common clinical finding was a scalp hematoma (86%), followed by loss of consciousness (66%), emesis (34%), headache (27%), amnesia (18%), and seizures (12%). Importantly, 40% of patients with EDH presented with GCS 15. Four children (4%) had GCS 15 and were completely asymptomatic on admission. In three children (3%) the only symptom was a scalp hematoma. 50% of all EDH required craniotomy, and this was not significantly different if GCS was 15 on presentation (45%, p = 0.192). Mortality was 2%. Fourteen patients (13%) were discharged with cognitive/motor deficits.

CONCLUSIONS

Pediatric EDH frequently present with subtle clinical signs, including a normal GCS half the time. Irrespective of asymptomatic presentation, threshold for CT scan or an observation period should be low after head injuries in children.

TYPE OF STUDY

Prognosis study.

LEVEL OF EVIDENCE

Level II/III.

Incidentally discovered Meckel's diverticulum: should I stay or should I go?

BACKGROUND

The aim of this study was to assess the indication for surgical treatment of incidentally discovered Meckel's diverticulum (MD) on the basis of clinical and histological features.

METHODS

The charts of patients undergoing surgery for MD were analysed. Two groups were identified: (1) patients who had incidentally discovered MD resected (incidental MD, IMD) and (2) patients who received first-line surgery for a complicated MD (CMD). Demographics and intraoperative and post-operative outcomes were compared. Histological findings were also analysed and compared.

RESULTS

Sixty-five patients were included in the study. IMD was observed in 39 patients (60%), while CMD was observed in 26 (40%). Male gender was significantly more frequent in CMD (P = 0.020), and mean age was significantly higher in IMD (P = 0.025). Body mass index and the American Society of Anesthesiologists score >2 were similar in both groups. Laparoscopy was carried out in 36% of IMD and in 50% of CMD patients (P = 0.309). A tangential resection was performed in 92% of IMD and 73% of CMD patients (P = 0.07). No complications related to diverticular resection were found in IMD, while they occurred in 8% of CMD patients (P = 0.931). Meanly, diverticula were longer when complicated (P = 0.001). CMD showed significant histological differences and more frequent gastric ectopic mucosa (P = 0.039). A malignant tumour was incidentally found in IMD.

CONCLUSION

As surgery is mandatory in CMD, the optimal management of IMD remains uncertain. Mucosal abnormalities may favour complications, but these cannot be identified before excision. Stapled diverticulectomy is safe and effective. A surgical approach to IMD may prevent complications at a very low cost.

Aortic balloon occlusion (REBOA) in pelvic ring injuries: preliminary results of the ABO Trauma Registry

EndoVascular and Hybrid Trauma Management (EVTM) has been recently introduced in the treatment of severe pelvic ring injuries. This multimodal method of hemorrhage management counts on several strategies such as the REBOA (resuscitative endovascular balloon occlusion of the aorta). Few data exist on the use of REBOA in patients with a severely injured pelvic ring. The ABO (aortic balloon occlusion) Trauma Registry is designed to capture data for all trauma patients in hemorrhagic shock where management includes REBOA placement. Among all patients included in the ABO registry, 72 patients presented with severe pelvic injuries and were the population under exam. 66.7% were male. Mean and median ISS were respectively 43 and 41 (SD ± 13). Isolated pelvic injuries were observed in 12 patients (16.7%). Blunt trauma occurred in 68 patients (94.4%), penetrating in 2 (2.8%) and combined in 2 (2.8%). Type of injury: fall from height in 15 patients (23.1%), traffic accident in 49 patients (75.4%), and unspecified impact in 1 patient (1.5%). Femoral access was gained pre-hospital in 1 patient, in emergency room in 43, in operating room in 12 and in angio-suite in 16. REBOA was positioned in zone 1 in 59 patients (81,9%), in zone 2 in 1 (1,4%) and in zone 3 in 12 (16,7%). Aortic occlusion was partial/periodical in 35 patients (48,6%) and total occlusion in 37 patients (51,4%). REBOA associated morbidity rate: 11.1%. Overall mortality rate was 54.2% and early mortality rate (≤ 24 h) was 44.4%. In the univariate analysis, factors related to early mortality (≤ 24 h) are lower pH values (p = 0.03), higher base deficit (p = 0.021), longer INR (p = 0.012), minor increase in systolic blood pressure after the REBOA inflation (p = 0.03) and total aortic occlusion (p = 0.008). None of these values resulted significant in the multivariate analysis. In severe hemodynamically unstable pelvic trauma management, REBOA is a viable option when utilized in experienced centers as a bridge to other treatments; its use might be, however, accompanied with severe-to-lethal complications.

Acute abdomen caused by greater omentum torsion: A case report and review of the literature

Torsion of the greater omentum is a rare cause of acute abdomen. Based on etiopathogenesis, it can be classified as primary or secondary. However, regardless of the cause, segmentary or diffuse omental necrosis will follow. Preoperative diagnosis is not easy, though abdominal ultrasound and computed tomography (CT) scans may show peculiar features suggestive of omental torsion. Laparoscopic resection of the affected omentum is the treatment of choice. Presently reported was a case of primary omental torsion, in addition to a comprehensive literature review.

Molecular genetic features and risk assessment in a series of 30 patients who underwent an operation for gastrointestinal stormal tumours

BACKGROUND

The objective of the study was to investigate the relationship between molecular genetic features and the standard criteria of risk assessment in patients affected by gastrointestinal stromal tumours (GISTs).

METHOD

A review was conducted of a series of 30 patients, with a mean age of 67 years, who underwent surgery for primary GISTs. R0 resection was accomplished in 27 patients. CD117, CD34 desmin, vimentin, S-100 and smooth muscle actin were immunohistochemically tested to achieve a diagnosis of GIST. The loss of wild-type KIT or platelet-derived growth factor receptor alpha (PDGFRα) genes was investigated by sequencing the tumour DNA.

RESULTS

Tumour genes mutations were reported in 23 patients (77%), and wild-type in seven. Mutations on the KIT gene occurred in 18 patients, and mutations on the PDGFRα gene in five. The average sizes of the GIST were 8.7 cm, 5.4 cm and 5.9 cm for KIT gene-mutated, PDGFRα gene-mutated and wild-type tumours, respectively. KIT gene mutations were detected in 50% of gastric and in 70% of extragastric GISTs. Moreover, 70% of tumours with a mitotic rate ≥ 5 x 50 highpower fi elds (HPFs) underwent KIT gene mutations. Conversely, PDGFRα mutations were observed only in gastric GISTs with a mitotic rate ≤ 5 x 50 HPFs. By stratifying GISTs according to classes of risk, KIT mutation was shown in most of the high-risk tumours. PDGFRα mutations occurred exclusively in lower classes of risk.

CONCLUSION

Molecular analysis data might have a role as a prognostic variable in models of risk assessment for patients with GISTs.

High doses of alpha-interferon are required in chronic hepatitis due to coinfection with hepatitis B virus and hepatitis C virus: long term results of a prospective randomized trial

OBJECTIVE

Coinfection with hepatitis B (HBV) and hepatitis C (HCV) viruses is associated with a more severe liver disease, increased frequency in the development of hepatocellular carcinoma, and resistance to interferon (IFN) therapy when performed with the standard dosages used in single infections. In the attempt to verify whether the outcome of IFN therapy in patients with hepatitis B and hepatitis C coinfection can be improved, we have planned a prospective, randomized trial with medium to high dosages of interferon three times a week for 6 months.

METHODS

Thirty patients with HBV-HCV coinfection, and chronic hepatitis were randomized to receive either 6 or 9 MU alpha-interferon three times a week for 6 months. Patients were HBsAg positive, anti-HBe positive, HBV DNA negative by dot blot (6/30 positive by polymerase chain reaction), and anti-HCV-positive, HCV RNA positive. Pretreatment and posttreatment liver biopsies were performed.

RESULTS

Five patients treated with 9 MU IFN consistently cleared HCV RNA and HBV DNA, whereas none of those treated with 6 MU reacted in a similar fashion (p = 0.045). Responders showed significant improvement of histological activity index in comparison with nonresponders (mean Ishak score pretreatment versus posttreatment p = 0.002). Long term follow-up showed that none of the patients treated with high doses developed cirrhosis whereas 4/14 treated with low doses did develop cirrhosis.

CONCLUSION

Even though the percentage was not very high, the sustained response, the striking histological improvement, and the lack of development of cirrhosis achieved in these patients, indicate that with HBV-HCV coinfection, a trial with high doses of interferon is strongly recommended.

Sources of bile pigment overproduction in Gilbert's syndrome: studies with non-radioactive bilirubin kinetics and with delta-[3,5-3H]aminolaevulinic acid and [2-14C]glycine

1. The kinetics of non-radioactive bilirubin were investigated in 100 patients with chronic non-haemolytic unconjugated hyperbilirubinaemia and in nine normal volunteers. 2. The patients with Gilbert's syndrome were divided on the basis of a two-compartment model into two distinct groups: group 1 (74 patients) with decreased hepatic uptake and conjugation of bilirubin and a bilirubin turnover rate within the normal range, and group 2 (26 patients) having normal uptake, impaired conjugation and increased bilirubin turnover rate. 3. On the basis of these findings, studies were made of early pigment production in four patients of group 1, in six patients of group 2 and in four of the normal volunteers, with [14C]glycine and delta-[3H]aminolaevulinic acid. 4. After receiving injections of labelled haem precursors, the four patients in group 1 had a normal rate of incorporation of both tracers, whereas abnormalities in incorporation were found in group 2. Four patients showed an increase of the first component of the early peak of [14C]bilirubin as well as of the early peak of [3H]bilirubin, suggesting an increased turnover of hepatic haem. Two patients showed an increased incorporation of [14C]glycine characterized by the fusion of the two early peaks, whereas the incorporation of the delta-[3H]aminolaevulinic acid was normal, indicating the presence of a primary shunt hyperbilirubinaemia. 5. The results confirm that Gilbert's syndrome is a heterogeneous condition with respect to bilirubin turnover rate. The population of Gilbert's syndrome with increased bilirubin turnover rate comprises not only patients with an increased haem erythroid turnover, but also patients with increased metabolism of non-erythroid haem protein in the liver.