How to deal with an open abdomen?

Appropriate open abdomen treatment is one of the key elements in the management of patients who require decompressive laparotomy or in whom the abdomen is left open prophylactically. Apart from fluid control and protection from external injury, fluid evacuation and facilitation of early closure are now the goals of open abdomen treatment. Abdominal negative pressure therapy has emerged as the most appropriate method to reach these goals. Especially when combined with strategies that allow progressive approximation of the fascial edges, high closure rates can be obtained. Intra-abdominal pressure measurement can be used to guide the surgical strategy and continued attention to intra-abdominal hypertension is necessary. This paper reviews recent advances as well as identifying the remaining challenges in patients requiring open abdomen treatment. The new classification system of the open abdomen is an important tool to use when comparing the efficacy of different strategies, as well as different systems of temporary abdominal closure

Umbilical hernia repair and recurrence: need for a clinical trial?

Abstract Introduction Umbilical hernia repair, despite its perceived simplicity, is associated with recurrence between 2.7 and 27%, in mesh repair and non mesh repair respectively. Many factors are recognized contributors to recurrence however multiple defects in the linea alba, known to occur in up to 30% of patients, appear to have been overlooked by surgeons. Aims This systematic review assessed reporting of second or multiple linea alba defects in patients undergoing umbilical hernia repair to establish if these anatomical variations could contribute to recurrence along with other potential factors. Methods A systematic review of all published English language articles was undertaken using databases PubMed, Embase, Web of Science and Cochrane Library from January 2014 to 2019. The search terms ‘Umbilical hernia’ AND ‘repair’ AND ‘recurrence’ were used across all databases. Analysis was specified in advance to avoid selection bias, was registered with PROSPERO (154173) and adhered to PRISMA statement. Results Six hundred and forty-six initial papers were refined to 10 following article review and grading. The presence of multiple linea alba defects as a contributor to recurrence was not reported in the literature. One paper mentioned the exclusion of six participants from their study due multiple defects. In all 11 factors were significantly associated with umbilical hernia recurrence. These included: large defect, primary closure without mesh, high BMI in 5/10 publications; smoking, diabetes mellitus, surgical site Infection (SSI) and concurrent hernia in 3/10. In addition, the type of mesh, advanced age, liver disease and non-closure of the defect were identified in individual papers. Conclusion This study identified many factors already known to contribute to umbilical hernia recurrence in adults, but the existence of multiple defects in the linea, despite it prevalence, has evaded investigators. Surgeons need to be consider documentation of this potential confounder which may contribute to recurrence

Systematic Review and Meta-Analysis of Wound Bundles in Emergency Midline Laparotomy Identifies That It Is Time for Improvement:Special Issue: Trauma and Emergency: Beyond Damage Control Surgery

Background: Emergency midline laparotomy is the cornerstone of survival in patients with peritonitis. While bundling of care elements has been shown to optimize outcomes, this has focused on elective rather than emergency abdominal surgery. The aim of this study was to undertake a systematic review and meta-analysis of factors affecting the development of surgical site infection (SSI) in patients undergoing midline emergency laparotomy. Methods: An ethically approved, PROSPERO registered (ID: CRD42020193246) meta-analysis and systematic review, searching PubMed, Scopus, Web of Science and Cochrane Library electronic databases from January 2015 to June 2020 and adhering to PRISMA guidelines was undertaken. Search headings included “emergency surgery”, “laparotomy”, “surgical site infection”, “midline incision” and “wound bundle”. Suitable publications were graded using Methodological Index for Non-Randomised Studies (MINORS); papers scoring ≥16/24 were included for data analysis. The primary outcome in this study was SSI rates following the use of wound bundles. Secondary outcomes consisted of the effect of the individual interventions included in the bundles and the SSI rates for superficial and deep infections. Five studies focusing on closure techniques were grouped to assess their effect on SSI. Results: This study identified 1875 articles. A total of 58 were potentially suitable, and 11 were included after applying MINORS score. The final cohort included 2,856 patients from eight countries. Three papers came from the USA, two papers from Japan and the remainder from Denmark, England, Iran, Netherlands, Spain and Turkey. There was a 32% non-significant SSI reduction after the implementation of wound bundles (RR = 0.68; CI, 0.39–1.17; p = 0.16). In bundles used for technical closure the reduction in SSI of 15% was non-significant (RR = 0.85; CI, 0.57–1.26; p = 0.41). Analysis of an effective wound bundle was limited due to insufficient data. Conclusions: This study identified a significant deficit in the world literature relating to emergency laparotomy and wound outcome optimisation. Given the global burden of emergency general surgery urgent action is needed to assess bundle’s ability to potentially improve outcome after emergency laparotomy

Patient-reported outcome measures (PROMs) after laparoscopic cholecystectomy: systematic review

BACKGROUND: Healthcare requires patient feedback to improve outcomes and experience. This study undertook a systematic review of the depth, variability, and digital suitability of current patient-reported outcome measures (PROMs) in patients undergoing laparoscopic cholecystectomy. METHODS: A PROSPERO-registered (registration number CRD42021261707) systematic review was undertaken for all relevant English language articles using PubMed version of MEDLINE, Scopus, and Web of Science electronic databases in June 2021. The search used Boolean operators and wildcards and included the keywords: laparoscopic cholecystectomy AND patient outcome OR patient-reported outcome OR patient-reported outcome measure OR PRO OR PROM. Medical Subjects Heading terms were used to search PubMed and Scopus. Articles published from 1 January 2011 to 2 June 2021 were included. RESULTS: A total of 4960 individual articles were reviewed in this study, of which 44 were found to evaluate PROMs in patients undergoing laparoscopic cholecystectomy and underwent methodological index for non-randomized studies (MINORS) grading. Twenty-one articles spanning 19 countries and four continents met all inclusion criteria and were included in the qualitative data synthesis. There was significant heterogeneity in PROMs identified with eight different comprehensive PROM tools used in the 21 studies. There was wide variation in the time points at which PROMs were recorded. Fourteen of 21 studies recorded PROMs before and after surgery, and 7 of 21 recorded PROMs only after surgery. Follow-up intervals ranged from 3 days to 2 years after surgery. CONCLUSIONS: This study identified that while post-laparoscopic cholecystectomy PROMs are infrequently measured currently, tools are widely available to achieve this in clinical practice. PROMs may not capture all the outcomes but should be incorporated into future cholecystectomy outcome research. The EQ-5D™ (EuroQoL Group, Rotterdam, the Netherlands) provides a simple platform for the modern digital era

The “Smalls” Nephrops Grounds (FU22) 2022 UWTV Survey Report and catch scenarios for 2023

This report provides the main results and findings of the seventeenth annual underwater television survey on the ‘Smalls grounds’ ICES assessment area; Functional Unit 22. The survey was multi-disciplinary in nature collecting UWTV and other ecosystem data. A total of 42 UWTV stations were surveyed successfully (high quality image data), carried out over an isometric grid at 4.5nmi or 8.3km intervals. The precision, with a CV of 7%, was well below the upper limit of 20% recommended by SGNEPS (ICES, 2012). The 2022 abundance estimate was 36% higher than in 2022 and at 895 million is below the MSY Btrigger reference point (990 million). Using the 2022 estimate of abundance and updated stock data implies catch in 2023 that correspond to the ICES MSY approach of 2548 tonnes, assuming that discard rates and fishery selection patterns do not change from the average of 2019 - 2021. One species of sea pen was recorded as present at the stations surveyed: Virgularia mirabilis. Trawl marks were observed at 29% of the stations surveyed

Establishing position papers by the WSES

A position paper (PP) should establish a unified voice in areas where controversy occurs based upon multiple practices and/or therapeutic choices. Typically, a position paper should elucidate the knowledge gap, followed by an evidence-based review of options, leading to an "endorsed position." A position paper should represent more than the opinion or consensus of the authors but should present current opinions and practices supported by the World Society of Emergency Surgery (WSES). Accordingly, position papers should require the approval of an expert group of WSES and in parallel be presented at an annual meeting prior to submission for publication. It is important that a unified approach for drafting of position papers be established and endorsed by WSES in order to establish credibility and prevent misunderstandings during a smooth transition to publication. The purpose of this article is to suggest a uniform process for the development of WSES guidelines.Peer reviewe

Plasma membrane profiling defines an expanded class of cell surface proteins selectively targeted for degradation by HCMV US2 in cooperation with UL141.

Human cytomegalovirus (HCMV) US2, US3, US6 and US11 act in concert to prevent immune recognition of virally infected cells by CD8+ T-lymphocytes through downregulation of MHC class I molecules (MHC-I). Here we show that US2 function goes far beyond MHC-I degradation. A systematic proteomic study using Plasma Membrane Profiling revealed US2 was unique in downregulating additional cellular targets, including: five distinct integrin α-chains, CD112, the interleukin-12 receptor, PTPRJ and thrombomodulin. US2 recruited the cellular E3 ligase TRC8 to direct the proteasomal degradation of all its targets, reminiscent of its degradation of MHC-I. Whereas integrin α-chains were selectively degraded, their integrin β1 binding partner accumulated in the ER. Consequently integrin signaling, cell adhesion and migration were strongly suppressed. US2 was necessary and sufficient for degradation of the majority of its substrates, but remarkably, the HCMV NK cell evasion function UL141 requisitioned US2 to enhance downregulation of the NK cell ligand CD112. UL141 retained CD112 in the ER from where US2 promoted its TRC8-dependent retrotranslocation and degradation. These findings redefine US2 as a multifunctional degradation hub which, through recruitment of the cellular E3 ligase TRC8, modulates diverse immune pathways involved in antigen presentation, NK cell activation, migration and coagulation; and highlight US2's impact on HCMV pathogenesis.This study was financially supported by grant 101-2917-I-564-035 from the Taiwan National Science Council to JLH; by a Wellcome Trust Fellowship (093966/Z/10/Z) to MPW; an MRC Project Grant and Wellcome Trust Programme Grant (G1000236, WT090323MA) to GWW and PT, European Regional Development Fund and the State Budget of Czech Republic (RECAMO, CZ.1.05/ 2.1.00/03.0101) to ER; a Wellcome Trust Principal Research Fellowship (084957/Z/08/Z) to PJL; and a Medical Research Council (MRC) grant (MC_UU_12014/3) to GSW and AJD. This study was additionally supported by the Cambridge Biomedical Research Centre, UK.This is the final published version. It first appeared at http://journals.plos.org/plospathogens/article?id=10.1371/journal.ppat.1004811