Current problems on operative strategy for complicated colon diverticular disease

Perforation of complicated diverticular disease of the colon with generalized peritonitis is common life-threatening emergency requiring surgical intervention. Although the absolute prevalence of perforated diverticulitis complicated by generalized peritonitis is low, its importance lies in the signifcant postoperative mortality, ranging from 4-26%, regardless of selected surgical strategy. The optimal treatment for perforated diverticulitis has been always a matter of debate, changing the ‘‘gold standard`` several times in the last decades. Primary resection has become the standard practice, but fear of anastomotic leakage of ten deterred many surgeons from performing primary anastomosis. Therefore, for many surgeons Hartmann`s procedure has remained the favored option. We share our 10 years de part mental experience in complicated diverticular disease of the colon studying 146 cases with diverticular disease treated in our clinic between 2000-2010. The indications for operation were diverticulitis complications - perforation, obstructiuon and bleeding, demonstrated on clinically by generalized peritonitis - 21, acute obstruction - 4 and rectorrhagia - 2. Operation was performed in 29 patients in urgent setting. Primary resection with anastomosis was done in 12 patients (41.38%). Manual anastomoses were performed in 4 cases, while mechanical anastomoses with staplers were accomplished in 8 cases. In 6/50%/ of the latter we used our standardized technique for linear stapler latero-lateral/functional end-to-end anastomosis, formerly implemented by as for colonic cancer resections and anastomoses. We had have 2 /6.9%/ anastomosis dehiscenses. Hartmann`s procedure was per formed in 17 patients (58.62%).We did not have any complications or death with standardized stapler resections and anastomoses. Hospital operative mortality was 13.79% /4 cases/. We advocate the primary anastomosis as the standard procedure, especially for older patients. Using a standardized technique with linear stapler for primary colon resection and anastomosis in complicated diverticular disease we favor the patient`s outcome with safety, efficiency and effectiveness

Elastic seton procedure for surgical treatment of anorectal fistulas

The anorectal fistula is a disease requiring careful assessment of the local signs and precise localization of the fistula channel. The Seton procedure for treatment of the fistula-in-ano we apply only for the management of trans- or extrasphincteric anorectal fistula. 152 patients with high trans- or extrasphincteric fistula-in-ano were operated. Men were 123/80.92%/, women-29/19.08%/. In 70 /46.05%/ fistula were extrasphincteric, while in 82/53.95%/ they were transsphincteric. Ba sic step is to identify the internal opening of the fistula channel following Goodsal`s rule. The Seton is trespassed through the internal opening and we tight it moderately. Every next tightening is performed at 3 days intervals. Recurrences ware registered in the first 6 months in 8 patients/5.26%/. We conclude that that seton procedure for treatment of trans- and extrasphincteric fistula is an easy to learn and practice radical one stage surgical method with a cure rate of nearly 95%. Elastic Seton ligation technique is a modification of the known from ancient times conventional ligation procedure. The following procedure is an effective method for difficult and high fistula-in-ano

Clinical and diagnostic assessment of Goodsall`s rule in anorectal fistulas

The exact identification of the internal opening in the surgical treatment of anorectal fistulae is of basic importance for their radical treatment. The rule of Goodsall enables identification of the internal opening. 184 patients with anorectal fistulae have been studied (145 male è 39 female). According to the type of the fistulae patients were distributed as follows: 86(46.74%) with transsphincteric, 57(30.98%) with extrasphincteric and 41(22.28%) with intrasphincteric. Most of them 126(68.48%) have had posterior external opening, while 58(31.52%) had anterior external opening. The internal opening has been identified in 169(91.85%) cases. The Goodsall`s rule was observed in 131(77.51%) Exception of this rule was registered in 38 patients - 20 cases with transsphincteric fistulae, 12 with extrasphincteric, 5 with re current fistulae and 1 with intersphincteric. 87.30%(110/126) of the posterior anorectal fistulae fulfilled the rule of Goodsall, while the anterior ones this rule was observed in 33/58(56.90%). From the cases with intersphincteric fistulae in 97.56 % there is match with the rule of Goodsall. The Goodsall`s rule predicts the position of the internal opening, according to the localization of the external opening. Exceptions of this rule were in the anterior fistulae and lying more than 3 cm from the anus /sensitivity of 56.90 %/. The Goodsall`s rule demonstrates highest informativity in posterior fistulae/sensitivity was 87.30 %/

Autologous blood donation in elective surgery of colorectal cancer - is it possible?

Reports from recent studies indicate a causal relationship between all transfusion, infectious complications and recurrent disease in surgical patients. The aim of the presented study is to elucidate the possibilities and indications for autologous haemotransfusion in the elective surgery of the colorectal cancer. Retrospective analysis was per formed over 724 electively operated patients with colorectal cancer. The prospective part includes observation of 20 radically operated patients. In these patients autologous haemotransfusion was per - formed. As indications for autologous haemotransfusion we consider age up to 80 years, hemoglobin levels at least 130 g/l, plasma protein > 65 g/l, body weight > 50 kg, good general condition and absence of decompensated cardiovascular or endocrine dis eases. In two patients with hemoglobin level between 90 - 110 g/l we per formed stimulation by means of Erythropoietin. According to retrospective data ad mission hemoglobin levels varies from 54 g/l to 175 g/l (mean 119 g/l ± 22, 6). From all electively operated patients 33, 9% had hemoglobin values over 130 g/l. The frequency of post-operative infectious complications increases from 9.1% in non-transfused patients to 38,7 % in patients with more than 4 units of allogenic blood trans fused. The prospective part of the study is designed to establish feasibility of the autologous haemotransfusion in clinical practice. The fall of hemoglobin values on the next day after donation varies from 11g/l to 19g/l (mean 15.5 g/l ± 2,19). Erythropoietin stimulation was not found to increase hemoglobin values significantly. There were no complications in the post-operative period in autologous haemotransfusion group with exception of one superficial wound infection. Autologous haemotransfusion is feasible in approximately 1/3 of electively operated patients with colorectal cancer with no ad verse effects or post-operative complications. It de creases the necessity of allogenic bioproducts and hence the risks related. Autologous haemotransfusion is easy to perform and propose ben e fits both from medical and logistic nature. Concerning to stimulation with Erythropoetin in our opinion it is without proven short term efficacy in general surgery so far

World society of emergency surgery study group initiative on Timing of Acute Care Surgery classification (TACS).

Timing of surgical intervention is critical for outcomes of patients diagnosed with surgical emergencies. Facing the challenge of multiple patients requiring emergency surgery, or of limited resource availability, the acute care surgeon must triage patients according to their disease process and physiological state. Emergency operations from all surgical disciplines should be scheduled by an agreed time frame that is based on accumulated data of outcomes related to time elapsed from diagnosis to surgery. Although literature exists regarding the optimal timing of various surgical interventions, implementation of protocols for triage of surgical emergencies is lacking. For institutions of a repetitive triage mechanism, further discussion on optimal timing of surgery in diverse surgical emergencies should be encouraged. Standardizing timing of interventions in surgical emergencies will promote clinical investigation as well as a commitment by administrative authorities to proper operating theater provision for acute care surgery

WSES-AAST guidelines: management of inflammatory bowel disease in the emergency setting

Background Despite the current therapeutic options for the treatment of inflammatory bowel disease, surgery is still frequently required in the emergency setting, although the number of cases performed seems to have decreased in recent years. The World Society of Emergency Surgery decided to debate in a consensus conference of experts, the main pertinent issues around the management of inflammatory bowel disease in the emergent situation, with the need to provide focused guidelines for acute care and emergency surgeons. Method A group of experienced surgeons and gastroenterologists were nominated to develop the topics assigned and answer the questions addressed by the Steering Committee of the project. Each expert followed a precise analysis and grading of the studies selected for review. Statements and recommendations were discussed and voted at the Consensus Conference of the 6th World Society of Emergency Surgery held in Nijmegen (The Netherlands) in June 2019. Conclusions Complicated inflammatory bowel disease requires a multidisciplinary approach because of the complexity of this patient group and disease spectrum in the emergency setting, with the aim of obtaining safe surgery with good functional outcomes and a decreasing stoma rate where appropriate.Peer reviewe

2016 WSES guidelines on acute calculous cholecystitis (vol 11, 25, 2016)

Non peer reviewe

Duodeno-pancreatic and extrahepatic biliary tree trauma: WSES-AAST guidelines

Duodeno-pancreatic and extrahepatic biliary tree injuries are rare in both adult and pediatric trauma patients, and due to their anatomical location, associated injuries are very common. Mortality is primarily related to associated injuries, but morbidity remains high even in isolated injuries. Optimal management of duodeno-bilio-pancreatic injuries is dictated primarily by hemodynamic stability, clinical presentation, and grade of injury. Endoscopic and percutaneous interventions have increased the ability to non-operatively manage these injuries. Late diagnosis and treatment are both associated to increased morbidity and mortality. Sequelae of late presentations of pancreatic injury and complications of severe pancreatic trauma are also increasingly addressed endoscopically and with interventional radiology procedures. However, for moderate and severe extrahepatic biliary and severe duodeno-pancreatic injuries, immediate operative intervention is preferred as associated injuries are frequent and commonly present with hemodynamic instability or peritonitis. The aim of this paper is to present the World Society of Emergency Surgery (WSES) and American Association for the Surgery of Trauma (AAST) duodenal, pancreatic, and extrahepatic biliary tree trauma management guidelines

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