WSES worldwide emergency general surgery formation and evaluation project

Optimal management of emergency surgical patients represents one of the major health challenges worldwide. Emergency general surgery (EGS) was identified as multidisciplinary surgery performed for traumatic and non-traumatic acute conditions during the same admission in the hospital. EGS represents the easiest viable way to provide affordable and high-quality level of care to emergency surgical and trauma patients. It may result from the association of different physicians with other specialties in a cooperative model. The World Society of Emergency Surgery (WSES) has been working on the EGS organization and implementation since its foundation believing in the need of common benchmarks for training and educational programs throughout the world. This is a plea in different languages to all World Prime Ministers and Presidents to support the creation in all nations of an organized hub-spoke system for emergency general surgery to improve standards of care and to save lives.Peer reviewe

Impact of general vs. neuraxial anesthesia on neonatal outcomes in non-elective cesarean sections

Background: Cesarean section is a common surgical procedure, usually performed under neuraxial anesthesia and, more rarely, under general anesthesia. The choice of anesthesia in cesarean sections can significantly influence neonatal outcomes, especially in urgent and emergency cases. Previous studies have shown mixed results, often confounded by the inclusion of both elective and emergency cesarean section cases, varying statistical methods, and a focus solely on resuscitation immediate-term neonatal outcomes. Objective: This study aims to use robust statistical methods to evaluate the impact of anesthesia type on immediate and longer-term neonatal outcomes in urgent and emergency cesarean section cases, where additional detrimental factors might influence this relationship. Methods: We analyzed 395 women who underwent non-elective cesarean sections between 2021 and 2023. Inverse probability of treatment weighting (IPTW) served to focus on the role of anesthesia type eliminating confounding variables effect, in simulated randomized controlled trial conditions. Results: General anesthesia increases odds of neonatal resuscitation (OR 6.1, p < 0.001), NICU admission (OR 1.8, p: 0.04), and a 15% lower Apgar score at 1 min (p: 0.02). General anesthesia also increased NICU admission rate for respiratory insufficiency (OR 7.6, p < 0.001), the need for oxygen (OR 4.8, p: 0.003) and CPAP (OR 3.6, p < 0.001) in NICU. Negative controls and consistent sensitivity analyses further validated the robustness of our findings. Conclusion: General anesthesia in non-elective cesarean sections is associated with worse neonatal outcomes, extending beyond the resuscitation phase to sustained NICU morbidity. Our study provides novel insights into the specific neonatal resuscitation maneuvers required when general anesthesia is used, enhancing clinicians preparedness for managing high-risk deliveries. These findings underscore the critical importance of anesthesia choice, advocate for the preference of neuraxial techniques, and highlight the need for further research into long-term neonatal outcomes

Geriatric Approaches to Rectal Cancer: Moving Towards a Patient-Tailored Treatment Era

Rectal cancer is a significant global health concern, particularly amongst the elderly population, with rectal cancer accounting for approximately one-third of cancer cases in this population. Older adults often present with advanced disease stages and unique clinical manifestations, such as tumors closer to the anal verge and with greater size. Diagnosis typically involves a series of screening and imaging strategies, culminating in accurate staging through pelvic MRI, endoscopic ultrasound, and CT scan. Management of rectal cancer in older adults emphasizes individualized treatment plans that consider both the cancer stage and the patient’s overall health status, including frailty and comorbidities. A multidisciplinary approach, including a mandatory geriatric assessment, is essential for optimizing outcomes, in order to improve survival and quality of life for elderly patients with rectal cancer

Training curriculum in minimally invasive emergency digestive surgery: 2022 WSES position paper

Emergency surgery; Laparoscopy; Minimally invasive surgeryCirugía de emergencia; Laparoscopia; Cirugía mínimamente invasivaCirurgia d'urgència; Laparoscòpia; Cirurgia mínimament invasivaBackground Minimally invasive surgery (MIS), including laparoscopic and robotic approaches, is widely adopted in elective digestive surgery, but selectively used for surgical emergencies. The present position paper summarizes the available evidence concerning the learning curve to achieve proficiency in emergency MIS and provides five expert opinion statements, which may form the basis for developing standardized curricula and training programs in emergency MIS. Methods This position paper was conducted according to the World Society of Emergency Surgery methodology. A steering committee and an international expert panel were involved in the critical appraisal of the literature and the development of the consensus statements. Results Thirteen studies regarding the learning curve in emergency MIS were selected. All but one study considered laparoscopic appendectomy. Only one study reported on emergency robotic surgery. In most of the studies, proficiency was achieved after an average of 30 procedures (range: 20–107) depending on the initial surgeon’s experience. High heterogeneity was noted in the way the learning curve was assessed. The experts claim that further studies investigating learning curve processes in emergency MIS are needed. The emergency surgeon curriculum should include a progressive and adequate training based on simulation, supervised clinical practice (proctoring), and surgical fellowships. The results should be evaluated by adopting a credentialing system to ensure quality standards. Surgical proficiency should be maintained with a minimum caseload and constantly evaluated. Moreover, the training process should involve the entire surgical team to facilitate the surgeon’s proficiency. Conclusions Limited evidence exists concerning the learning process in laparoscopic and robotic emergency surgery. The proposed statements should be seen as a preliminary guide for the surgical community while stressing the need for further research

Usefulness of Fluorescence imaging with indocyanine green for evaluation of bowel perfusion in the urgency setting: a systematic review and meta-analysis

Introduction:Fluorescence imaging with indocyanine green (ICG) has been extensively utilized to assess bowel perfusion in oncologic surgery. In the emergency setting, there are many situations in which bowel perfusion assessment is required. Large prospective studies or RCTs evaluating feasibility, safety and utility of ICG in the emergency setting are lacking. The primary aim is to assess the usefulness of ICG for evaluation of bowel perfusion in the emergency setting.Materials and methods:The manuscript was drafted following the recommendations of Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement (PRISMA). A systematic literature search was carried out through Pubmed, Scopus, and the ISI Web of Science. Assessment of included study using the methodological index for nonrandomized studies (MINORS) was calculated. The meta-analysis was carried out in line with recommendations from the Cochrane Collaboration and Meta-analysis of Observational Studies in Epidemiology guidelines, and the Mantel-Haenszel random effects model was used to calculate effect sizes.Results:10 093 papers were identified. Eighty-four were reviewed in full-text, and 78 were excluded: 64 were case reports; 10 were reviews without original data; 2 were letters to the editor; and 2 contained unextractable data. Finally, six studies22-27 were available for quality assessment and quantitative synthesis. The probability of reoperation using ICG fluorescence angiography resulted similar to the traditional assessment of bowel perfusion with a RD was -0.04 (95% CI: -0.147 to 0.060). The results were statistically significant P=0.029, although the heterogeneity was not negligible with a 59.9% of the I 2 index. No small study effect or publication bias were found.Conclusions:This first metanalysis on the use of IGC fluorescence for ischemic bowel disease showed that this methodology is a safe and feasible tool in the assessment of bowel perfusion in the emergency setting. This topic should be further investigated in high-quality studies

Primjena programa ubrzanog oporavka nakon barijatrijske kirurgije: analiza kliničkih ishoda i isplativosti

Enhanced recovery after surgery (ERAS) programs are perioperative evidencebased interventions that have the purpose of making the perioperative pathway more efficient in safeguarding patient safety and quality of care. Recently, several ERAS components have been introduced in the setting of bariatric surgery (Enhanced Recovery After Bariatric Surgery, ERABS). The aim of the present study was to evaluate clinical efficiency and cost-effectiveness of the implementation of an ERABS program. It was a retrospective case-control study comparing a group of adult obese (body mass index >40) patients treated according to the ERABS protocol (2014-2015) with a historical control group that received standard care (2013-2014) in the General and Emergency Surgery Department, Arcispedale S. Maria Nuova Hospital, Reggio Emilia, Italy. Data on the occurrence of complications, mortality, re-admissions and re-operations were extracted retrospectively from medical case notes and emergency patient admission lists. Length of hospital stay was significantly different between the two cohort patients. In the control group, the mean length of stay was 12.6±10.9 days, whereas in the ERABS cohort it was 7.1±2.9 days (p=0.02). During hospital stay, seven patients in the control group developed surgical complications, including one patient with major complications, whereas in the ERABS group three patients developed minor complications. Economic analysis revealed a different cost distribution between the two groups. On the whole, there were significant savings for almost all the variables taken into consideration, mainly driven by exclusion of using intensive are unit, which is by far more expensive than the average cost of post-anesthesia care unit. Our study confirmed the implementation of an ERABS protocol to have shortened hospital stay and was cost-saving while safeguarding patient safety.Programi ubrzanog oporavka nakon operacije (Enhanced Recovery After Surgery, ERAS) su perioperacijske intervencije zasnovane na dokazima kojima je svrha učiniti perioperacijski tijek učinkovitijim osiguravajući bolesnikovu sigurnost i kvalitetu skrbi. Odnedavno je nekoliko sastavnica programa ERAS uvedeno u okruženje barijatrijske kirurgije (Enhanced Recovery After Bariatric Surgery, ERABS). Cilj ovoga istraživanja bio je procijeniti kliničku učinkovitost i isplativost provođenja programa ERABS. U ovoj retrospektivnoj studiji slučaja i kontrola uspoređena je skupina odraslih pretilih bolesnika (indeks tjelesne mase >40) liječenih prema protokolu ERABS (2014.-2015.) s povijesnom kontrolnom skupinom koja je primala standardnu skrb (2013.-2014.) u Klinici za opću i hitnu kirurgiju, Bolnica Arcispedale S. Maria Nuova, Reggio Emilia, Italija. Podaci o pojavnosti komplikacija, smrtnosti, ponovnom prijmu i ponovljenim operacijama retrospektivno su izvedeni iz bolesničkih kartona i prijamnih lista. Duljina boravka u bolnici značajno se razlikovala među dvjema skupinama bolesnika. U kontrolnoj skupini srednja duljina boravka u bolnici bila je 12,6±10,9 dana, dok je skupini ERABS iznosila 7,1±2,9 dana (p=0,02). Kod prijma se kirurška komplikacija razvila u 7 osoba iz kontrolne skupine; od toga je jedan bolesnik imao teže komplikacije, dok su u skupini ERABS manje komplikacije zabilježene kod 3 bolesnika. Ekonomska analiza pokazala je drukčiju raspoređenost troškova u dvjema skupinama. Sve u svemu, značajne uštede u gotovo svim ispitivanim varijablama uglavnom su nastale zbog isključenja uporabe jedinice intenzivnog liječenja, što je daleko skuplje od prosječnih troškova u jedinici skrbi poslije anestezije. Naše je istraživanje potvrdilo da primjena protokola ERABS skraćuje boravak u bolnici i snižava troškove pritom osiguravajući sigurnost bolesnika

Plasma concentration of presepsin and its relationship to the diagnosis of infections in multiple trauma patients admitted to intensive care

Background and aims: Septic complications represent the pre- dominant cause of late death in poly-trauma patients. The necessi- ty to differentiate septic from non septic patients is more relevant at the early stage of the illness in order to improve the clinical out- come and to reduce the mortality. The identification of a sensitive and specific, clinically reliable, biomarker capable to early recog- nize incoming septic complications in trauma patients whose expression is not influenced by concomitant traumatic injuries, is still a challenge for the researchers in the field. patients (9 females and 39 males, mean age 47.6\ub119 years) with mul- tiple trauma was performed. The inclusion criterion was to suffer from acute trauma since no more than 24 hours and the exclusion cri- teria were the following: antibiotic treatment on admission and main- tained for more than 48 hours; on-going infection on admission not associated with trauma; treatment with immunosuppressors/ immunomodulants; age <18 years old. Presepsin was measured using an automated chemiluminescence analyser at 1, 3, 5 and 8 days post of hospitalization. The diagnosis of systemic inflammatory response syndrome (SIRS)/infection was established according to the criteria of the Surviving Sepsis Campaign. Materials and methods: A retrospective analysis on 48 adult Results and conclusions: In patients with SIRS, the mean pre- sepsin concentration was 917,08 (\ub169.042) ng/L vs 980,258 (\ub11951.32) ng/L in patients without SIRS (P=0.769). In the infected patients, the mean presepsin concentration was 1513.25 (\ub12296.54) ng/L vs 654.21 (\ub1511,068) ng/L (P<0.05) calculated among the non infected upon admission. The plasma presepsin concentration increased progressively during the first 8 days of hospitalization. Presepsin concentration in the infected patients was significantly higher than in non-infected patients. On the other hands no signifi- cant differences were found in the plasma level of presepsin among patients with and without SIRS. Any other clinical condition related to the trauma did not affect presepsin. Our data clearly suggest that presepsin may be considered an helpful diagnostic tool to early diagnose sepsis in trauma patients