Search

Abstract Intra-abdominal infections (IAI) are among the most common global healthcare challenges and they are usually precipitated by disruption to the gastrointestinal (GI) tract. Their successful management typically requires intensive resource utilization, and despite the best therapies, morbidity and mortality remain high. One of the main issues required to appropriately treat IAI that differs from the other etiologies of sepsis is the frequent requirement to provide physical source control. Fortunately, dramatic advances have been made in this aspect of treatment. Historically, source control was left to surgeons only. With new technologies non-surgical less invasive interventional procedures have been introduced. Alternatively, in addition to formal surgery open abdomen techniques have long been proposed as aiding source control in severe intra-abdominal sepsis. It is ironic that while a lack or even delay regarding source control clearly associates with death, it is a concept that remains poorly described. For example, no conclusive definition of source control technique or even adequacy has been universally accepted. Practically, source control involves a complex definition encompassing several factors including the causative event, source of infection bacteria, local bacterial flora, patient condition, and his/her eventual comorbidities. With greater understanding of the systemic pathobiology of sepsis and the profound implications of the human microbiome, adequate source control is no longer only a surgical issue but one that requires a multidisciplinary, multimodality approach. Thus, while any breach in the GI tract must be controlled, source control should also attempt to control the generation and propagation of the systemic biomediators and dysbiotic influences on the microbiome that perpetuate multi-system organ failure and death. Given these increased complexities, the present paper represents the current opinions and recommendations for future research of the World Society of Emergency Surgery, of the Global Alliance for Infections in Surgery of Surgical Infection Society Europe and Surgical Infection Society America regarding the concepts and operational adequacy of source control in intra-abdominal infections.

Introduction:. Fragility fractures of the pelvis (FFP) in elderly patients are an underappreciated injury with a significant impact on mobility, independency, and mortality of affected patients and is a growing burden for society/health care. Given the lack of clinical practice guidelines for these injuries, the authors postulate there is heterogeneity in the current use of diagnostic modalities, treatment strategies (both operative and nonoperative), and follow-up of patients with FFP. The goal of this study was to assess international variation in the management of FFP. Methods:. All International Orthopaedic Trauma Association (IOTA) steering committee members were asked to select 15 to 20 experts in the field of pelvic surgery to complete a case-driven international survey. The survey addresses the definition of FFP, use of diagnostic modalities, timing of imaging, mobilization protocols, and indications for surgical management. Results:. In total, 143 experts within 16 IOTA societies responded to the survey. Among the experts, 86% have >10 years of experience and 80% works in a referral center for pelvic fractures. However, only 44% of experts reported having an institutional protocol for the management of FFP. More than 89% of experts feel the need for a (inter)national evidence-based guideline. Of all experts, 73% use both radiographs and computed tomography (CT) to diagnose FFP, of which 63% routinely use CT and 35% used CT imaging selectively. Treatment strategies of anterior ring fractures were compared with combined (anterior and posterior ring) fractures. Thirty-seven percent of patients with anterior ring fractures get admitted to the hospital compared with 75% of patients with combined fractures. Experts allow pain-guided mobilization in 72% after anterior ring fracture but propose restricted weight-bearing in case of a combined fracture in 44% of patients. Surgical indications are primarily based on the inability to mobilize during hospital admission (33%) or persistent pain after 2 weeks (25%). Over 92% plan outpatient follow-up independent of the type of fracture or treatment. Conclusion:. This study shows that there is a great worldwide heterogeneity in the current use of diagnostic modalities and both nonoperative and surgical management of FFP, emphasizing the need for a consensus meeting or guideline.

Abstract Background In 2017, the World Society of Emergency Surgery published its guidelines for the management of adult and pediatric patients with splenic trauma. Several issues regarding the follow-up of patients with splenic injuries treated with NOM remained unsolved. Methods Using a modified Delphi method, we sought to explore ongoing areas of controversy in the NOM of splenic trauma and reach a consensus among a group of 48 international experts from five continents (Africa, Europe, Asia, Oceania, America) concerning optimal follow-up strategies in patients with splenic injuries treated with NOM. Results Consensus was reached on eleven clinical research questions and 28 recommendations with an agreement rate ≥ 80%. Mobilization after 24 h in low-grade splenic trauma patients (WSES Class I, AAST Grades I–II) was suggested, while in patients with high-grade splenic injuries (WSES Classes II–III, AAST Grades III–V), if no other contraindications to early mobilization exist, safe mobilization of the patient when three successive hemoglobins 8 h apart after the first are within 10% of each other was considered safe according to the panel. The panel suggests adult patients to be admitted to hospital for 1 day (for low-grade splenic injuries—WSES Class I, AAST Grades I–II) to 3 days (for high-grade splenic injuries—WSES Classes II–III, AAST Grades III–V), with those with high-grade injuries requiring admission to a monitored setting. In the absence of specific complications, the panel suggests DVT and VTE prophylaxis with LMWH to be started within 48–72 h from hospital admission. The panel suggests splenic artery embolization (SAE) as the first-line intervention in patients with hemodynamic stability and arterial blush on CT scan, irrespective of injury grade. Regarding patients with WSES Class II blunt splenic injuries (AAST Grade III) without contrast extravasation, a low threshold for SAE has been suggested in the presence of risk factors for NOM failure. The panel also suggested angiography and eventual SAE in all hemodynamically stable adult patients with WSES Class III injuries (AAST Grades IV–V), even in the absence of CT blush, especially when concomitant surgery that requires change of position is needed. Follow-up imaging with contrast-enhanced ultrasound/CT scan in 48–72 h post-admission of trauma in splenic injuries WSES Class II (AAST Grade III) or higher treated with NOM was considered the best strategy for timely detection of vascular complications. Conclusion This consensus document could help guide future prospective studies aiming at validating the suggested strategies through the implementation of prospective trauma databases and the subsequent production of internationally endorsed guidelines on the issue.

Abstract Emergency General Surgery (EGS) was identified as multidisciplinary surgery performed for traumatic and non-traumatic acute conditions during the same admission in the hospital by general emergency surgeons and other specialists. It is the most diffused surgical discipline in the world. To live and grow strong EGS necessitates three fundamental parts: emergency and elective continuous surgical practice, evidence generation through clinical registries and data accrual, and indications and guidelines production: the LIFE TRIAD.

Transport incidents are among the major causes of trauma and injury in Australia and worldwide. While improving infrastructure can decrease the rate of incidents, the required construction imposes challenges regarding simultaneous public use of the relevant road sections. This study focused on construction zones along the New South Wales (NSW) Pacific Highway. We aimed to investigate if the rate of people who had major trauma as a result of a transport incident in a construction zone was higher than the rate of people with similar incidents at other times. This was a retrospective study, conducted by screening the data of patients admitted to the trauma services, or who died due to traffic incidents on the NSW Pacific Highway 2011-2016. We identified 35 causalities who experienced a traffic incident within a construction zone, 19 of these incidents occurred during the construction dates and 16 before or after those dates. The rate of casualty in construction periods was 2.21 per 1000 days, which is significantly higher than the rate in non-construction periods (1.2 per 1000 days, p-value: 0.037). There was no significant difference between the age, injury severity score and mortality rate of casualties who had an incident during the construction dates and those who had an incident in non-construction periods. This study indicated that the rate of incidents increased at NSW Pacific Highway construction zones during construction periods. More investigation is needed to improve the safety of road users during highway road constructions.

Abstract Background We are performing a combined randomised and observational study comparing internal fixation to non-surgical management for common wrist fractures in older patients. This paper describes the statistical analysis plan. Methods/design A Combined Randomised and Observational Study of Surgery for Fractures In the distal Radius in the Elderly (CROSSFIRE) is a randomised controlled trial comparing two types of usual care for treating wrist fractures in older patients, surgical fixation using volar locking plates and non-surgical treatment using closed reduction and plaster immobilisation. The primary aim of this comparative-effectiveness study is to determine whether surgery is superior to non-surgical treatment with respect to patient-reported wrist function at 12 months post treatment. The secondary outcomes include radiographic outcomes, complication rates and patient-reported outcomes including quality of life, pain, treatment success and cosmesis. Primary analysis will use a two-sample t test and an intention-to-treat analysis using the randomised arm of the study. Statistical analyses will be two-tailed and significance will be determined by p