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

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

Extracorporeal membrane oxygenation in coronavirus disease 2019: Experience from a single italian center

Extracorporeal Membrane Oxygenation in coronavirus disease 2019: a single Italian center experience

Pre-hospital plasma in haemorrhagic shock management: current opinion and meta-analysis of randomized trials

Abstract Background Trauma-induced coagulopathy is one of the most difficult issues to manage in severely injured patients. The plasma efficacy in treating haemorrhagic-shocked patients is well known. The debated issue is the timing at which it should be administered. Few evidences exist regarding the effects on mortality consequent to the use of plasma alone given in pre-hospital setting. Recently, two randomized trials reported interesting and discordant results. The present paper aims to analyse data from those two randomized trials in order to obtain more univocal results. Methods A systematic review with meta-analysis of randomized controlled trials (RCTs) of pre-hospital plasma vs. usual care in patients with haemorrhagic shock. Results Two high-quality RCTs have been included with 626 patients (295 in plasma and 331 in usual care arm). Twenty-four-hour mortality seems to be reduced in pre-hospital plasma group (RR = 0.69; 95% CI = 0.48–0.99). Pre-hospital plasma has no significant effect on 1-month mortality (RR = 0.86; 95% CI = 0.68–1.11) as on acute lung injury and on multi-organ failure rates (OR = 1.03; 95% CI = 0.71–1.50, and OR = 1.30; 95% CI = 0.92–1.86, respectively). Conclusions Pre-hospital plasma infusion seems to reduce 24-h mortality in haemorrhagic shock patients. It does not seem to influence 1-month mortality, acute lung injury and multi-organ failure rates. Level of evidence: Level I Study type: Systematic review with Meta-analysi

The weekend effect on the provision of Emergency Surgery before and during the COVID-19 pandemic: case-control analysis of a retrospective multicentre database

Introduction The concept of "weekend effect", that is, substandard healthcare during weekends, has never been fully demonstrated, and the different outcomes of emergency surgical patients admitted during weekends may be due to different conditions at admission and/or different therapeutic approaches. Aim of this international audit was to identify any change of pattern of emergency surgical admissions and treatments during weekends. Furthermore, we aimed at investigating the impact of the COVID-19 pandemic on the alleged "weekend effect". Methods The database of the CovidICE-International Study was interrogated, and 6263 patients were selected for analysis. Non-trauma, 18+ yo patients admitted to 45 emergency surgery units in Europe in the months of March-April 2019 and March-April 2020 were included. Demographic and clinical data were anonymised by the referring centre and centrally collected and analysed with a statistical package. This study was endorsed by the Association of Italian Hospital Surgeons (ACOI) and the World Society of Emergency Surgery (WSES). Results Three-quarters of patients have been admitted during workdays and only 25.7% during weekends. There was no difference in the distribution of gender, age, ASA class and diagnosis during weekends with respect to workdays. The first wave of the COVID pandemic caused a one-third reduction of emergency surgical admission both during workdays and weekends but did not change the relation between workdays and weekends. The treatment was more often surgical for patients admitted during weekends, with no difference between 2019 and 2020, and procedures were more often performed by open surgery. However, patients admitted during weekends had a threefold increased risk of laparoscopy-to-laparotomy conversion (1% vs. 3.4%). Hospital stay was longer in patients admitted during weekends, but those patients had a lower risk of readmission. There was no difference of the rate of rescue surgery between weekends and workdays. Subgroup analysis revealed that interventional procedures for hot gallbladder were less frequently performed on patients admitted during weekends. Conclusions Our analysis revealed that demographic and clinical profiles of patients admitted during weekends do not differ significantly from workdays, but the therapeutic strategy may be different probably due to lack of availability of services and skillsets during weekends. The first wave of the COVID-19 pandemic did not impact on this difference

Impact of early percutaneous dilatative tracheostomy in patients with subarachnoid hemorrhage on main cerebral, hemodynamic, and respiratory variables: A prospective observational study

IntroductionPatients with poor-grade subarachnoid hemorrhage (SAH) admitted to the intensive care unit (ICU) often require prolonged invasive mechanical ventilation due to prolonged time to obtain neurological recovery. Impairment of consciousness and airway protective mechanisms usually require tracheostomy during the ICU stay to facilitate weaning from sedation, promote neurological assessment, and reduce mechanical ventilation (MV) duration and associated complications. Percutaneous dilatational tracheostomy (PDT) is the technique of choice for performing a tracheostomy. However, it could be associated with particular risks in neurocritical care patients, potentially increasing the risk of secondary brain damage.MethodsWe conducted a single-center, prospective, observational study aimed to assess PDT-associated variations in main cerebral, hemodynamic, and respiratory variables, the occurrence of tracheostomy-related complications, and their relationship with outcomes in adult patients with SAH admitted to the ICU of a neurosurgery/neurocritical care hub center after aneurysm control through clipping or coiling and undergoing early PDT.ResultsWe observed a temporary increase in ICP during early PDT; this increase was statistically significant in patients presenting with higher therapy intensity level (TIL) at the time of the procedural. The episodes of intracranial hypertension were brief, and appeared mainly due to the activation of cerebral autoregulatory mechanisms in patients with impaired compensatory mechanisms and compliance.DiscussionThe low number of observed complications might be related to our organizational strategy, all based on a dedicated “tracheo-team” implementing both PDT following a strictly defined protocol and accurate follow-up

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

Preserve encephalus in surgery of trauma: online survey. (P.E.S.T.O)

Abstract Background Traumatic brain injury (TBI) is a global health problem. Extracranial hemorrhagic lesions needing emergency surgery adversely affect the outcome of TBI. We conducted an international survey regarding the acute phase management practices in TBI polytrauma patients. Methods A questionnaire was available on the World Society of Emergency Surgery website between December 2017 and February 2018. The main endpoints were the evaluation of (1) intracranial pressure (ICP) monitoring during extracranial emergency surgery (EES), (2) hemodynamic management without ICP monitoring during EES, (3) coagulation management, and (4) utilization of simultaneous multisystem surgery (SMS). Results The respondents were 122 representing 105 trauma centers worldwide. ICP monitoring was utilized in 10–30% of patients at risk of intracranial hypertension (IH) undergoing EES from about a third of the respondents [n = 35 (29%)]. The respondents reported that the safest values of systolic blood pressure during EES in patients at risk of IH were 90–100 mmHg [n = 35 (29%)] and 100–110 mmHg [n = 35 (29%)]. The safest values of mean arterial pressure during EES in patients at risk of IH were > 70 mmHg [n = 44 (36%)] and > 80 mmHg [n = 32 (26%)]. Regarding ICP placement, a large percentage of respondents considered a platelet (PLT) count > 50,000/mm3 [n = 57 (47%)] and a prothrombin time (PT)/activated partial thromboplastin time (aPTT)  100,000/mm3 [n = 67 (55%)] and a PT/aPTT < 1.5 times the normal control [n = 76 (62%)] to be the safest parameters. Almost half of the respondents [n = 53 (43%)], reported that they transfused red blood cells (RBCs)/plasma (P)/PLTs at a ratio of 1/1/1 in TBI polytrauma patients. SMS was performed in 5–19% of patients, requiring both an emergency neurosurgical operation and EES, by almost half of the respondents [n = 49 (40%)]. Conclusions A great variability in practices during the acute phase management of polytrauma patients with severe TBI was identified. These findings may be helpful for future investigations and educational purposes

Surgeons' perspectives on artificial intelligence to support clinical decision-making in trauma and emergency contexts: results from an international survey

Background Artificial intelligence (AI) is gaining traction in medicine and surgery. AI-based applications can offer tools to examine high-volume data to inform predictive analytics that supports complex decision-making processes. Time-sensitive trauma and emergency contexts are often challenging. The study aims to investigate trauma and emergency surgeons’ knowledge and perception of using AI-based tools in clinical decision-making processes. Methods An online survey grounded on literature regarding AI-enabled surgical decision-making aids was created by a multidisciplinary committee and endorsed by the World Society of Emergency Surgery (WSES). The survey was advertised to 917 WSES members through the society’s website and Twitter profile. Results 650 surgeons from 71 countries in five continents participated in the survey. Results depict the presence of technology enthusiasts and skeptics and surgeons' preference toward more classical decision-making aids like clinical guidelines, traditional training, and the support of their multidisciplinary colleagues. A lack of knowledge about several AI-related aspects emerges and is associated with mistrust. Discussion The trauma and emergency surgical community is divided into those who firmly believe in the potential of AI and those who do not understand or trust AI-enabled surgical decision-making aids. Academic societies and surgical training programs should promote a foundational, working knowledge of clinical AI