Liver trauma: WSES 2020 guidelines

Abstract: Liver injuries represent one of the most frequent life-threatening injuries in trauma patients. In determining the optimal management strategy, the anatomic injury, the hemodynamic status, and the associated injuries should be taken into consideration. Liver trauma approach may require non-operative or operative management with the intent to restore the homeostasis and the normal physiology. The management of liver trauma should be multidisciplinary including trauma surgeons, interventional radiologists, and emergency and ICU physicians. The aim of this paper is to present the World Society of Emergency Surgery (WSES) liver trauma management guidelines

Petersen’s hernia after gastric by-pass procedure: an increasingly frequent condition in emergency surgery

Introduction: Gastric by-pass is the most frequent surgical procedure for morbid obesity worldwide. Internal hernia (IH) may develop in the Petersen’s space as a consequence of an antecolic Roux-en- Y reconstruction. Symptoms may remain not specific for months before the onset of acute abdomen conditions including mechanical bowel obstruction and intestinal ischemia. Pre-operative diagnosis is mostly based on contrast enhanced abdomen CT scan that shows signs of twisting of superior mesenteric vessels. Materials and methods: We retrospectively reviewed 9 patients (8 females) with Petersen’s IH referred to our institution between January 2015 and March 2018 for acute abdomen. Mean age was 40.7 yr. All of them had received a gastric by-pass procedure with antecolic Roux-en-Y reconstruction meanly 914 days before the clinical manifestation of IH. The mean weight loss after bariatric surgery was 56.6 Kg. Results: In all patients the abdominal contrast enhanced CT scan was positive for twisting of superior mesenteric vessels suggesting the diagnosis of Petersen’ IH. The abdominal cavity was explored laparoscopically with identification of the IH. The herniated loop was gently relieved from the Petersen’ space, the blood supply of the bowel loop was assessed, and the defect was closed with a non-adsorbable interrupted suture. Conversion to open surgery was required in one patient. The course of the patients was uneventful. At follow-up no recurrence was observed. Discussion and conclusions: A high degree of suspicion for Petersen’s IH should be maintained in patients after gastric by-pass surgery with antecolic Roux-en-Y reconstruction. In these patients, an unexplained persistent abdominal pain should be investigated by contrast enhanced CT scan. The laparoscopic approach is safe and effective and it allows to relieve the herniated bowel loop and to close the mesenteric defect

Age, BMI and severity of acute diverticulitis: myths or facts?

Introduction: Although it is commonly believed that patients presenting with severe acute diverticulitis are more often obese and elderly, only few evidences are reported in literature about these clinical observations.1,2 In this study, we tried to determine if body mass index (BMI) and old age are associated with a higher incidence of complicated acute diverticulitis. Material and Methods: A retrospective review of patients hospitalized with acute diverticulitis between 2013 and 2015 was conducted. Severity of Acute Diverticulitis was graded in according to modified Hinchey’s classification.3 The mean BMI and mean age for each group of patients were calculated. Statistical analysis was performed by one way anova test with significance set at P<0.05. Results: Charts of 90 patients hospitalized with acute diverticulitis were reviewed. Five groups were identified: 32 patients (36%) were admitted with Hinchey’s stage Ia; 21 (23%) with stage Ib; 20 (22%) with stage II; 12 (13%) with stage III and 5 (6%) with stage IV. Mean BMI and mean age were respectively: 25,45 Kg/m2 (range 40,40-19,10) and 58 years (range 35-87) in group 1; 26,78 Kg/m2 (range 3,33-20,23) and 58 years (range 34-83) in group 2; 26,14 Kg/m2 (range 30,48-22,73) and 63 years (range 49-83) in group 3; 26,68 Kg/m2 (range 34,28-21,25) and 58 years (range 38-87) in group 4; 24,44 Kg/m2 (range 28,3-18,13) and 66 years (range 26-90) in group 5. There was no significant difference among these groups by either age (P=0.762) or BMI (P=0.334). Discussion: Numerous studies have shown a correlation between acute diverticulitis and obesity, particularly in people of advanced age. This retrospective study was undertaken to identify a possible link between BMI, age and complicated acute diverticulitis. No significant differences were recognized, among the groups with different grades of acute diverticulitis, in terms of BMI and age. Despite this result, the aetiological relationship between obesity, old age and diverticular complications still remain unclear

Liver trauma: WSES 2020 guidelines

Liver injuries represent one of the most frequent life-threatening injuries in trauma patients. In determining the optimal management strategy, the anatomic injury, the hemodynamic status, and the associated injuries should be taken into consideration. Liver trauma approach may require non-operative or operative management with the intent to restore the homeostasis and the normal physiology. The management of liver trauma should be multidisciplinary including trauma surgeons, interventional radiologists, and emergency and ICU physicians. The aim of this paper is to present the World Society of Emergency Surgery (WSES) liver trauma management guidelines