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Background The SARS-CoV-2 pandemic is still ongoing and a major challenge for health care services worldwide. In the first WSES COVID-19 emergency surgery survey, a strong negative impact on emergency surgery (ES) had been described already early in the pandemic situation. However, the knowledge is limited about current effects of the pandemic on patient flow through emergency rooms, daily routine and decision making in ES as well as their changes over time during the last two pandemic years. This second WSES COVID-19 emergency surgery survey investigates the impact of the SARS-CoV-2 pandemic on ES during the course of the pandemic. Methods A web survey had been distributed to medical specialists in ES during a four-week period from January 2022, investigating the impact of the pandemic on patients and septic diseases both requiring ES, structural problems due to the pandemic and time-to-intervention in ES routine. Results 367 collaborators from 59 countries responded to the survey. The majority indicated that the pandemic still significantly impacts on treatment and outcome of surgical emergency patients (83.1% and 78.5%, respectively). As reasons, the collaborators reported decreased case load in ES (44.7%), but patients presenting with more prolonged and severe diseases, especially concerning perforated appendicitis (62.1%) and diverticulitis (57.5%). Otherwise, approximately 50% of the participants still observe a delay in time-to-intervention in ES compared with the situation before the pandemic. Relevant causes leading to enlarged time-to-intervention in ES during the pandemic are persistent problems with in-hospital logistics, lacks in medical staff as well as operating room and intensive care capacities during the pandemic. This leads not only to the need for triage or transferring of ES patients to other hospitals, reported by 64.0% and 48.8% of the collaborators, respectively, but also to paradigm shifts in treatment modalities to non-operative approaches reported by 67.3% of the participants, especially in uncomplicated appendicitis, cholecystitis and multiple-recurrent diverticulitis. Conclusions The SARS-CoV-2 pandemic still significantly impacts on care and outcome of patients in ES. Well-known problems with in-hospital logistics are not sufficiently resolved by now; however, medical staff shortages and reduced capacities have been dramatically aggravated over last two pandemic years.

Colorectal cancer (CRC) is one of the most common cancers worldwide. There are several causes of a mechanical left bowel obstructive but CRC accounts for approximately 50% of cases and in 10–30% of whom it is the presenting syndrome. In most cases, the left colon is involved. At present, the range of therapeutic alternatives in the management of obstructive left CRC in emergency conditions (primary resection vs staged resection with applied self-expanding metallic stents) is broad, whereas internationally validated clinical recommendations in each condition are still lacking. This enormous variability affects the scientific evidence on both the immediate and long-term surgical and oncological outcomes. CROSCO-1 (Colonic Resection, stOma or self-expanding metal Stents for obstruCtive left cOlon cancer) study is a national, multi-center, prospective observational study intending to compare the clinical results of all these therapeutic regimens in a cohort of patients treated for obstructive left-sided CRC. The primary aim of the CROSCO-1 study is the 1-year stoma rate of patients undergoing primary emergency surgical resection (Hartmann procedure or primary resection and anastomosis) compared with patients undergoing staged resection. Secondary outcomes are 30-day and 90-day major morbidity and mortality, 1-year quality of life and the timing of chemotherapy initiation in the two groups. Future CROSCO studies will follow in which, instead, we will evaluate the long-term oncological outcomes of the two treatment strategies ClinicalTrials.Gov ID Number, NCT05801211. Date: April 13, 2023. Protocol Version V2.1.

Introduction According to the literature, there is no clear definition of a High Energy Devices (HEDs), and their proper indications for use are also unclear. Nevertheless, the flourishing market of HEDs could make their choice in daily clinical practice arduous, possibly increasing the risk of improper use for a lack of specific training. At the same time, the diffusion of HEDs impacts the economic asset of the healthcare systems. This study aims to assess the efficacy and safety of HEDs compared to electrocautery devices while performing laparoscopic cholecystectomy (LC). Materials and methods On behalf of the Italian Society of Endoscopic Surgery and New Technologies, experts performed a systematic review and meta-analysis and synthesised the evidence assessing the efficacy and safety of HEDs compared to electrocautery devices while performing laparoscopic cholecystectomy (LC). Only randomised controlled trials (RCTs) and comparative observational studies were included. Outcomes were: operating time, bleeding, intra-operative and post-operative complications, length of hospital stay, costs, and exposition to surgical smoke. The review was registered on PROSPERO (CRD42021250447). Results Twenty-six studies were included: 21 RCTs, one prospective parallel arm comparative non-RCT, and one retrospective cohort study, while three were prospective comparative studies. Most of the studies included laparoscopic cholecystectomy performed in an elective setting. All the studies but three analysed the outcomes deriving from the utilisation of US sources of energy compared to electrocautery. Operative time was significantly shorter in the HED group compared to the electrocautery group (15 studies, 1938 patients; SMD − 1.33; 95% CI − 1.89 to 0.78; I2 = 97%, Random-effect). No other statistically significant differences were found in the other examined variables. Conclusions HEDs seem to have a superiority over Electrocautery while performing LC in terms of operative time, while no difference was observed in terms of length of hospitalisation and blood loss. No concerns about safety were raised.

Minimally invasive surgery (MIS) is a widespread approach in general surgery. Computer guiding software, such as the augmented reality (AR), the virtual reality (VR) and mixed reality (MR), has been proposed to help surgeons during MIS. This study aims to report these technologies' current knowledge and diffusion during surgical training in Italy. A web-based survey was developed under the aegis of the Italian Society of Endoscopic Surgery (SICE). Two hundred and seventeen medical doctors' answers were analyzed. Participants were surgeons (138, 63.6%) and residents in surgery (79, 36.4%). The mean knowledge of the role of the VR, AR and MR in surgery was 4.9 ± 2.4 (range 1-10). Most of the participants (122, 56.2%) did not have experience with any proposed technologies. However, although the lack of experience in this field, the answers about the functioning of the technologies were correct in most cases. Most of the participants answered that VR, AR and MR should be used more frequently for the teaching and training and during the clinical activity (170, 80.3%) and that such technologies would make a significant contribution, especially in training (183, 84.3%) and didactic (156, 71.9%). Finally, the main limitations to the diffusion of these technologies were the insufficient knowledge (182, 83.9%) and costs (175, 80.6%). Based on the present study, in Italy, the knowledge and dissemination of these technologies are still limited. Further studies are required to establish the usefulness of AR, VR and MR in surgical training.

Introduction It has been previously demonstrated that the rise of intra-abdominal pressures and prolonged exposure to such pressures can produce changes in the cardiovascular and pulmonary dynamic which, though potentially well tolerated in the majority of healthy patients with adequate cardiopulmonary reserve, may be less well tolerated when cardiopulmonary reserve is poor. Nevertheless, theoretically lowering intra-abdominal pressure could reduce the impact of pneumoperitoneum on the blood circulation of intra-abdominal organs as well as cardiopulmonary function. However, the evidence remains weak, and as such, the debate remains unresolved. The aim of this systematic review and meta-analysis was to demonstrate the current knowledge around the effect of pneumoperitoneum at different pressures levels during laparoscopic cholecystectomy. Materials and methods This systematic review and meta-analysis were reported according to the recommendations of the 2020 updated Preferred Reporting Items for Systematic reviews and Meta-analyses (PRISMA) guidelines, and the Cochrane handbook for systematic reviews of interventions. Results This systematic review and meta-analysis included 44 randomized controlled trials that compared different pressures of pneumoperitoneum in the setting of elective laparoscopic cholecystectomy. Length of hospital, conversion rate, and complications rate were not significantly different, whereas statistically significant differences were observed in post-operative pain and analgesic consumption. According to the GRADE criteria, overall quality of evidence was high for intra-operative bile spillage (critical outcome), overall complications (critical outcome), shoulder pain (critical outcome), and overall post-operative pain (critical outcome). Overall quality of evidence was moderate for conversion to open surgery (critical outcome), post-operative pain at 1 day (critical outcome), post-operative pain at 3 days (important outcome), and bleeding (critical outcome). Overall quality of evidence was low for operative time (important outcome), length of hospital stay (important outcome), post-operative pain at 12 h (critical outcome), and was very low for post-operative pain at 1 h (critical outcome), post-operative pain at 4 h (critical outcome), post-operative pain at 8 h (critical outcome), and post-operative pain at 2 days (critical outcome). Conclusions This review allowed us to draw conclusive results from the use of low-pressure pneumoperitoneum with an adequate quality of evidence.

Funding Information: The authors are grateful to the Birmingham Surgical Trials Consortium at the University of Birmingham for the use of their servers for secure online data collection. Disclosure: The authors declare no conflict of interest.

Epithelial ovarian cancer (EOC) causes 60% of ovarian cancer cases and is the fourth most common cause of death from cancer in women. The standard of care for EOC includes a combination of surgery followed by intravenous chemotherapy. Intraperitoneal (IP) chemotherapy (CT) has been introduced into the therapeutic algorithm of EOC with positive results. To explore existing results regarding intraperitoneal chemotherapy a systematic review of the literature and an analysis of our own institutional prospective database of patients treated with cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy (HIPEC) for EOC at different stages were conducted. The focused report concerning our personal experience with advanced EOC treated with cytoreductive surgery and HIPEC produced the following results: In 57 patients cisplatin + paclitaxel as HIPEC was the only significant factor improving overall survival (OS) at multivariate analysis (OR 6.54, 95% CI: 1.24-34.47, P=0.027). Patients treated with HIPEC cisplatin + paclitaxel showed a median OS of 46 months (SD 6.4, 95% CI: 33.4-58.6), while patients treated with other HIPEC regimens showed a median OS of 12 months (SD 3.1, 95% CI: 6.0-18.0). The 2y-OS was 72% and 3y-OS was 68% for cisplatin + paclitaxel as HIPEC, while the 2y- and 3y-OS was 0% for other HIPEC regimens. Patients treated with HIPEC cisplatin + paclitaxel showed a median disease-free survival (DFS) of 13 months (SD 1.6, 95% CI: 9.9-16.1), while patients treated with other HIPEC regimens showed a median DFS of 8 months (SD 3.1, 95% CI: 1.9-14.1). In conclusion, HIPEC cisplatin + paclitaxel in ovarian cancer showed positive results that may be considered semi-definitive according to the level of evidence and should be considered a starting point for further investigations. At present HIPEC cisplatin + paclitaxel should be proposed to patients with advanced ovarian cancer as standard treatment at almost all stages of disease. Platinum + taxane-based intraperitoneal regimens demonstrated superior results compared to other regimens.

Background The World Society of Emergency Surgery (WSES) spleen trauma classification meets the need of an evolution of the current anatomical spleen injury scale considering both the anatomical lesions and their physiologic effect. The aim of the present study is to evaluate the efficacy and trustfulness of the WSES classification as a tool in the decision-making process during spleen trauma management. Methods Multicenter prospective observational study on adult patients with blunt splenic trauma managed between 2014 and 2016 in two Italian trauma centers (ASST Papa Giovanni XXIII in Bergamo and Sant’Anna University Hospital in Ferrara). Risk factors for operative management at the arrival of the patient and as a definitive treatment were analyzed. Moreover, the association between the different WSES grades of injury and the definitive management was analyzed. Results One hundred twenty-four patients were included. At multivariate analysis, a WSES splenic injury grade IV is a risk factor for the operative management both at the arrival of the patients and as a definitive treatment. WSES splenic injury grade III is a risk factor for angioembolization. Conclusions The WSES classification is a good and reliable tool in the decision-making process in splenic trauma management.

Objective There are very few evidences about safety and usefulness of routine prophylactic ureteral stenting (PUS) before cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). Material and methods An analysis of prospectively collected data about patients who underwent CRS and HIPEC for different sites of primary disease was carried out focusing on ureteral complications. Results A total of 138 patients who underwent CRS and HIPEC between December 2010 and June 2017 were considered. All patients underwent PUS before CRS and HIPEC. Of them, 91 (66.4%) patients received pelvic peritonectomy, 49 (35.8%) pelvic lymphadenectomy, 31 (22.6%) left hemicolectomy, 44 (32.4%) right hemicolectomy, 46 (33.6%) rectal resection, 56 (40.9%) hysteroannessiectomy, and 39 (28.5%) appendectomy. There was one (0.7%) postoperative ureteral fistula. The cumulative risk of ureteral stent-related major complications was 4.3% (two patients (1.4%) had protracted gross hematuria, two patients (1.4%) had urinary sepsis, and three patients (2.9%) developed hydronephrosis after a period from removing ureteral stents and required restenting. Morbidity due to ureteral stenting was associated with a longer length of stay (LOS) (p=0.053). A total of 52 patients (44.1%) developed renal dysfunction according to the RIFLE (Risk, Injury, Failure, Loss of kidney function, End-stage kidney-disease) criteria: 19.5% were in risk class, 10.2% in acute renal injury class, and 14.4% in acute renal failure class. Conclusion PUS could be a useful tool for reducing iatrogenic ureteral injury, but it is associated with a non-negligible morbidity, which implies longer LOS. A more accurate patient selection for PUS is necessary.

Contains fulltext : 215819.pdf (Publisher’s version ) (Open Access) Renal and urogenital injuries occur in approximately 10-20% of abdominal trauma in adults and children. Optimal management should take into consideration the anatomic injury, the hemodynamic status, and the associated injuries. The management of urogenital trauma aims to restore homeostasis and normal physiology especially in pediatric patients where non-operative management is considered the gold standard. As with all traumatic conditions, the management of urogenital trauma should be multidisciplinary including urologists, interventional radiologists, and trauma surgeons, as well as emergency and ICU physicians. The aim of this paper is to present the World Society of Emergency Surgery (WSES) and the American Association for the Surgery of Trauma (AAST) kidney and urogenital trauma management guidelines.

Of the diseases affecting the cecal appendix, mucinous neoplasms, although rare, are the most common epithelial tumor. They are often asymptomatic and diagnosed by anatomopathological exams of sections, collected during appendectomies due to acute appendicitis. These tumors have the potential to become malignant, and their early surgical handling are the most important prognostic factor. So, clinical, image, operatory and histologic spectral aspects should always take into account. The present study reports a case of mucinous neoplasm of the appendix that manifested with intestinal partial obstruction and suggests the need for a comprehensive and uniform classification, which could address the best disease first approach. The information was obtained through a patient records review, photographic documentation of the diagnostic tests and histologic study of operative specimen. In addition, the manuscript opens a discussion about the approach of choice of this complex neoplasia, since great variability persists in clinical and pathological records, due to variations in classifications and definitions. This variability in disease nomenclature may significantly impact the treatment and prognosis.

The treatment of duodenal perforations has scarce options and it is very difficult with an high failure rate. The aim of this work is to describe a new surgical technique that was used to treat ten patients suffering from duodenal perforation. The procedure based on the concept to enforce the duodenal suture with remodeling material allowing to the inflamed and oedematous tissues to heal without to be cut by the repairing stitches themselves, is performed with biological prosthesis patches. 90% of patients treated with this innovative technique experienced a complete healing of the duodenal perforation. This unique surgical technique not only proved to be safe, but it also solved the 90% of duodenal perforations in patients at risk to die.

Surgeons prescribing antibiotics have two potentially conflicting responsibilities. First, they should offer optimal therapy for all patients under their care by offering antibiotics. Second, they should preserve the efficacy of antibiotics and minimize the development of antimicrobial resistance (AMR). The Global Alliance for Infections in Surgery and the World Society of Emergency Surgery have promoted a coalition that should call for increased awareness and action across all surgical departments worldwide in order to combat AMR. The project has been named World Antimicrobial Resistance Nationally Internationally Networking Globally in Surgery (WARNING in Surgery).

Left colon perforation usually occurs in complicated diverticulitis or cancer. The most frequent signs are intraperitoneal abscess or peritonitis. In cases of retroperitoneal colonic perforation, diagnosis may be difficult. A 59-year-old woman presented with left thigh pain and with abdominal discomfort associated with mild dyspnea. Computed tomography scan showed air bubbles and purulent collection in the retroperitoneum, with subcutaneous emphysema extending from the left thigh to the neck. Computed tomography scan also revealed portal vein gas and thrombosis with multiple liver abscesses. An emergency laparotomy revealed a perforation of the proximal left colon. No masses were found. A left colectomy was performed. The retroperitoneum was drained and washed extensively. A negative pressure wound therapy was applied. A second-look laparotomy was performed 48 hours later. The retroperitoneum was drained and an end colostomy was performed. Intensive Care Unit postoperative stay was 9 days, and the patient was discharged on the 32nd postoperative day. Pneumoretroperitoneum and pneumomediastinum are rare signs of colonic retroperitoneal perforation. The diagnosis may be delayed, especially in the absence of peritoneal irritation. Clinical, laboratory, and especially radiologic parameters might be useful. Surgical treatment must be prompt to improve prognosis.

Splenectomy represents the first choice for treatment of spontaneous splenic rupture, abscesses, cysts, tumours, and an alternative for control of hereditary, autoimmune, and myeloproliferative disorders. However, its relative indications have been reviewed for better understanding of both the primary affections and of splenectomy per se, particularly with regard to the immune system. The emergence of minimally invasive surgery, the possibility of splenic preservation, and availability of biological therapy has shown that the procedure has often been referred to as salvage therapy upon failure of other therapeutic propositions. On the other hand, patients have their general health status compromised by the underlying disease, by the use corticosteroids or biologic therapy, immunosuppressed, coagulation disorders, which contribute to the incidence of postoperative complications, such as infections, bleeding and venous thrombosis. Therefore, this scenario favours higher morbidity and mortality rates than those of other intra-abdominal surgical procedures. Thus, this review has the primary and comprehensive objective of purpose the best moment for splenectomy, when surgeons can interfere in the natural course of the disease increasing patients’ quality of life and survival. In short, it is desired that the surgeon has complete knowledge of the profound physiological changes imposed on the host. In addition, to distinguish when it is curative and mandatory from when it must be put on hold due to other non-operative treatments with similar outcomes and, lastly, when it is not recommended for not aggregating survival.

Objective Hyperthermic intraperitoneal chemotherapy (HIPEC) has been proposed as a treatment in ovarian cancer. A recently published RCT demonstrated that HIPEC prolongs disease-free survival (DFS) and overall survival (OS) in ovarian cancer. The aim of the study was to investigate oncologic results of cytoreductive surgery+HIPEC compared with cytoreductive surgery alone in advanced primary ovarian cancer with a particular attention to the pattern of recurrence. Methods This is a retrospective case control study with a propensity score (PS) matching of the patients. All the patients treated for primary advanced ovarian cancer who underwent interval surgery with or without HIPEC were collected; a PS was calculated in order to match cases to controls. Results Among 77 eligible patients 56 patients were included in the study. Preoperative patients' characteristics were homogeneous. No difference in morbidity and mortality after surgery were recorded. DFS was not different among the 2 groups (13.2 vs. 13.9 months, p=0.454) but OS was better in patients treated with HIPEC with no median reached vs. 35.5 months (p=0.048). Patients treated with cytoreductive surgery alone were more likely to have a peritoneal recurrence (43% vs. 14%). Conclusion HIPEC seems to affect the relapse pattern with lesser peritoneal recurrence. This difference in relapse pattern seems to affect the OS with better results in patients treated with HIPEC. Further studies are needed to confirm these findings.

Background: An increasing promising evidence and increasing long-term oncologic outcomes support the use of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) as locoregional treatment for peritoneal carcinosis (PC) especially from ovarian and gastrointestinal tumors, but also for others cancers. Methods: A prospective monocentric study was performed in Papa Giovanni XXIII Hospital, Bergamo (Italy). Patients and tumor characteristics were analyzed. Overall survival (OS), disease free survival (DFS) and morbidity were analyzed with Kaplan-Meier curves and log-rank testing. Results: A total of 150 patients undergone CRS + HIPEC were analyzed from January 2011 to June 2017. The principal origins of PC were: gastric cancer (GC) (n=40), colon cancer (n=31), appendiceal cancer (AC) (n=18), ovarian cancer (OC) (n=49), others (n=12). Major morbidity [≥3 Common Terminology Criteria for Adverse Events (CTCAE)] and perioperative mortality rates were 38% and 2.7% respectively. Re-operation rate was 15.3%. Median OS is 9, 35, 47, 51, 82 months (29% 3-year OS; 27% 5-year OS; 48% 5-year OS; 40% 5-year OS; 67% 5-year OS respectively) in GC, colorectal cancer (CRC), OC, others tumors and AC respectively. Median DFS is 4, 14, 17, 19, 82 months (32% 3-year DFS; 22% 5-year DFS; 29% 5-year DFS; 11% 5-year DFS; 67% 5-year DFS respectively) in GC, CRC, others tumors, OC and AC respectively. Conclusions: A therapeutic approach that combined CRS + HIPEC could achieve long-term survival in selected groups of patients with PC from gastrointestinal, gynecological and others tumors with acceptable morbidity and mortality. A good expertise and a high volume of patients are necessary to manage PC and to further improve results.

Introduction Even in after curative surgery and adequate linfoadenectomy the survival of advanced gastric cancer (AGC) remains poor. At present some data have been published on the effects of NACT and perioperative chemotherapy on AGC and Esophago-gastric cancer (EGC) but not definitive ones. The present meta-analysis aims to evaluate the effects of neoadjuvant chemotherapy (NACT) on the AGC and EGC. Material and methods A systematic review with meta-analysis of randomized controlled trials (RCTs) of NACT + surgery vs. Surgery in patients with AGC and EGC was performed. Results 15 RCTs have been included (2001 patients: 977 into NACT + surgery arm and 1024 into control arm). NACT + Surgery reduces the overall mortality at 1, 3 and 5-year in cumulative analysis (RR = 0.78; 0.81; 0.88 respectively), at 1, 2, 3 and 5-years in EGC (RR = 0.79; 0.83; 0.84; 0.91 respectively) and at 3 and 5-years in AGC (RR = 0.74; 0.82 respectively). Morbidity and perioperative mortality rate are not influenced by NACT. Recurrence rate is reduced by NACT + surgery in EGC (RR = 0.80). Conclusions NACT reduces the mortality in gastric and esophago-gastric cancer. Morbidity and perioperative mortality are not influenced by NACT. The overall recurrence rate is reduced by NACT in esophago-gastric cancer.

In pediatric patients open abdomen (OA) is applied with many and not standardized indications. Several studies have been published regarding the OA management in adults and fewer in pediatrics. Several issues are still unclear and need more high quality data. The World Society of Emergency Surgery (WSES) promoted the International Register of Open Abdomen (IROA) dedicated to adults and pediatric patients. The register is held on a web platform (Clinical Registers®) through a dedicated web site: www.clinicalregisters.org. (ClinicalTrials. gov Identifier: NCT02382770).

Sepsis-3 definition introduces Quick SOFA (qSOFA) as a tool for identifying patients at risk of sepsis with a higher risk of hospital death both inside and outside critical care units. However qSOFA does not define sepsis and the new sepsis definitions recommend using an increase in the SOFA score of 2 points or more to represent organ dysfunction. The SOFA score, is potentially not accessible everywhere, especially for PaO2, which would require an arterial blood gas measurement. In order to validate a new practical sepsis severity score for patients with complicated intra-abdominal infections (cIAIs) including the clinical conditions at the admission (severe sepsis/septic shock), the origin of the cIAIs, the delay in source control, the setting of acquisition and any risk factors such as age and immunosuppression a prospective study was conducted around the world from October 2014 to February 2015. The WISS study (WSES cIAIs Score Study) is a multicenter observational study underwent in 132 medical institutions worldwide during a four-month study period. The data from WISS study showed that mortality was significantly affected by the old sepsis definition. Mortality by sepsis status was: no sepsis 1.2%, sepsis only 4.4%, severe sepsis 27.8% and septic shock 67.8%. Early detection and timely therapeutic intervention improved the prognosis and overall clinical outcome of patients. Severe sepsis represented a reasonable approximation of the tipping point between stable and critical clinical conditions in management of patients with intra-abdominal infections. In patients with complicated intra-abdominal infections, SIRS signs associated with abdominal signs screened patients needing immediate acute care surgery and old sepsis definition better recognized patients at earlier stages when the infective process is most treatable.

Surgery allows the correct evaluation of the peritoneal dissemination of the epithelial ovarian cancer (EOC) and the removal of as much tumor as possible to maximize adjuvant chemotherapy. Neoadjuvant chemotherapy (NACT) and interval debulking surgery have been proposed as a reasonable alternative to primary complete cytoreductive surgery (CRS) in patients not fit for an initial extensive debulking surgery. Intraoperative hyperthermic intraperitoneal chemotherapy (HIPEC) has been offered as a promising therapeutic procedure to increase survival by treating the microscopic component of the neoplastic disease. Matherial and Method. 419 eligible patients with stage III-IV EOC were subjected to CRS, previous NACT in 343 patients, 20 of which with CRS combined with extraperitoneal hysterectomy (EH) + HIPEC. Purposes of our four years retrospective observational study are the revision of the surgical approaches to the EOC, a detailed report of the pelvic peritonectomy in association to hysteroannessiectomy (+/- consensual rectal resection) and the prospective review of the results. Conclusions. This study shows that EH + HIPEC is feasible. The detailed description of the technique here depicted could help to standardize this type of peritonectomy.

Contains fulltext : 175669.pdf (Publisher’s version ) (Open Access) Intra-abdominal infections (IAIs) are common surgical emergencies and have been reported as major contributors to non-trauma deaths in the emergency departments worldwide. The cornerstones of effective treatment of IAIs are early recognition, adequate source control, and appropriate antimicrobial therapy. Prompt resuscitation of patients with ongoing sepsis is of utmost important. In hospitals worldwide, non-acceptance of, or lack of access to, accessible evidence-based practices and guidelines result in overall poorer outcome of patients suffering IAIs. The aim of this paper is to promote global standards of care in IAIs and update the 2013 WSES guidelines for management of intra-abdominal infections.

Complex pelvic injuries are among the most dangerous and deadly trauma related lesions. Different classification systems exist, some are based on the mechanism of injury, some on anatomic patterns and some are focusing on the resulting instability requiring operative fixation. The optimal treatment strategy, however, should keep into consideration the hemodynamic status, the anatomic impairment of pelvic ring function and the associated injuries. The management of pelvic trauma patients aims definitively to restore the homeostasis and the normal physiopathology associated to the mechanical stability of the pelvic ring. Thus the management of pelvic trauma must be multidisciplinary and should be ultimately based on the physiology of the patient and the anatomy of the injury. This paper presents the World Society of Emergency Surgery (WSES) classification of pelvic trauma and the management Guidelines.

Background: The placement of a metallic stent as a bridge to surgery (SBTS) could represents an option for the treatment of left-sided malignant colonic obstruction in centres with adequate skills. Several meta-analyses demonstrated better short-term outcomes after SBTS when compared with emergency surgery (ES); however, some studies reported a higher local recurrence rate. The aim of the present review is to investigate the long-term outcomes of stent bridge to surgery as compared to ES. Methods: A systematic review was performed to retrieve studies comparing long-term oncologic outcomes of SBTS and ES. Local and overall recurrence rate, overall and disease-free survival were retrieved and results were expressed as risk ratios. Results: Seventeen studies and a total of 1,333 patients were included in the analysis. No significant differences were reported in recurrence rate [risk ratio (RR) =1.11; 95% confidence interval (95% CI): 0.84–1.47, P=0.47], 3-year mortality (RR =0.90; 95% CI: 0.73–1.12, P=0.34) and 5-year mortality (RR =1.00; 95% CI: 0.82–1.22, P=0.99). There were no differences among randomized and observational studies. Conclusions: SBTS has similar long-term oncologic outcomes to ES and in centres with appropriate skill should be considered the best treatment option for left-sided malignant colonic obstructions.

Background: No definitive data about open abdomen (OA) epidemiology and outcomes exist. The World Society of Emergency Surgery (WSES) and the Panamerican Trauma Society (PTS) promoted the International Register of Open Abdomen (IROA). Methods: A prospective observational cohort study including patients with an OA treatment. Data were recorded on a web platform (Clinical Registers (R)) through a dedicated website: www.clinicalregisters.org. Results: Four hundred two patients enrolled. Adult patients: 369 patients; Mean age: 57.39 +/- 18.37; 56% male; Mean BMI: 36 +/- 5.6. OA indication: Peritonitis (48.7%), Trauma (20.5%), Vascular Emergencies/Hemorrhage (9.4%), Ischemia (9.1%), Pancreatitis (4.2%), Post-operative abdominal-compartment-syndrome (3.9%), Others (4.2%). The most adopted Temporary-abdominal-closure systems were the commercial negative pressure ones (44.2%). During OA 38% of patients had complications; among them 10.5% had fistula. Definitive closure: 82.8%; Mortality during treatment: 17.2%. Mean duration of OA: 5.39(+/- 4.83) days; Mean number of dressing changes: 0.88(+/- 0.88). After-closure complications: (49.5%) and Mortality: (9%). No significant associations among TACT, indications, mortality, complications and fistula. A linear correlationexists between days of OA and complications (Pearson linear correlation = 0.326 p

Peritoneal adhesion index (PAI) is a score based on appearance and distribution of peritoneal adhesions. The study aims to assess the validity of PAI in order to standardize the definition of peritoneal adhesions. The study includes an expert survey to assess the feasibility of the score and a prospective observational and multicenter trial to assess its validity. 96% of surgeons of the survey consider PAI a useful tool. From January 2013 to March 2015, 205 patients were enrolled to undergo a surgical intervention for bowel obstruction caused by peritoneal adhesions in 21 centers. PAI was significantly higher in the population with previous surgery (P=0.043) and in patients who underwent two previous surgical interventions, if compared to those with only one previous intervention (P=0.012). Length of surgery was significantly longer in patients with higher PAI (P

Introduction. Emergency resection represents the traditional treatment for left-sided malignant obstruction. However, the placement of self-expanding metallic stents and delayed surgery has been proposed as an alternative approach. The aim of the current meta-analysis was to review the available evidence, with particular interest for the short-term outcomes, including a recent multicentre RCT. Methods. We considered randomized controlled trials comparing stenting as a bridge to surgery and emergency surgery for the management of left-sided malignant large bowel obstruction, performing a systematic review in MEDLINE, PubMed database, and the Cochrane libraries. Results. We initially identified a total of 2543 studies. After the elimination of duplicates and the screening of titles and abstracts, seven studies, for a total of 448 patients, were considered. The current meta-analysis revealed no difference in the mortality rate between the stent group and the emergency surgery group; the postoperative complication rate (37.84% versus 54.87%, P=0.02), the stoma rate (28.8% versus 46.02%, P<0.0001), and the incidence of wound infection (8.11% versus 15.49%, P=0.01) were reduced after stent as a bridge to surgery. Conclusion. Colonic stenting as a bridge to surgery appears to be a safe approach to malignant large bowel obstruction. Possible advantages of this treatment can be identified in a reduced incidence of postoperative complications and a lower stoma rate. Further RCTs considering long-term outcomes and cost-effectiveness analysis are needed.

none 68 si Spleen injuries are among the most frequent trauma-related injuries. At present, they are classified according to the anatomy of the injury. The optimal treatment strategy, however, should keep into consideration the hemodynamic status, the anatomic derangement, and the associated injuries. The management of splenic trauma patients aims to restore the homeostasis and the normal physiopathology especially considering the modern tools for bleeding management. Thus, the management of splenic trauma should be ultimately multidisciplinary and based on the physiology of the patient, the anatomy of the injury, and the associated lesions. Lastly, as the management of adults and children must be different, children should always be treated in dedicated pediatric trauma centers. In fact, the vast majority of pediatric patients with blunt splenic trauma can be managed non-operatively. This paper presents the World Society of Emergency Surgery (WSES) classification of splenic trauma and the management guidelines. open Coccolini, Federico; Montori, G; Catena, F; Kluger, Y; Biffl, W; Moore, Ee; Reva, V; Bing, C; Bala, M; Fugazzola, P; Bahouth, H; Marzi, I; Velmahos, G; Ivatury, R; Soreide, K; Horer, T; Nullr, nullTen Broek; Pereira, Bm; Fraga, Gp; Inaba, K; Kashuk, J; Parry, N; Masiakos, Pt; Mylonas, Ks; Kirkpatrick, A; Abu zidan, F; Gomes, Ca; Benatti, Sv; Naidoo, N; Salvetti, F; Maccatrozzo, S; Agnoletti, V; Gamberini, E; Solaini, Leonardo; Costanzo, A; Celotti, A; Tomasoni, M; Khokha, V; Arvieux, C; Napolitano, L; Handolin, L; Pisano, M; Magnone, S; Spain, Da; Nullm, nullDe Moya; Davis, Ka; Nulln, nullDe Angelis; Leppaniemi, A; Ferrada, P; Latifi, R; Navarro, Dc; Otomo, Y; Coimbra, R; Maier, Rv; Moore, F; Rizoli, S; Sakakushev, B; Galante, Jm; Chiara, O; Cimbanassi, S; Mefire, Ac; Weber, D; Ceresoli, M; Peitzman, Ab; Wehlie, L; Sartelli, M; Nulls, nullDi Saverio; Ansaloni, L. Coccolini, Federico; Montori, G; Catena, F; Kluger, Y; Biffl, W; Moore, Ee; Reva, V; Bing, C; Bala, M; Fugazzola, P; Bahouth, H; Marzi, I; Velmahos, G; Ivatury, R; Soreide, K; Horer, T; Nullr, nullTen Broek; Pereira, Bm; Fraga, Gp; Inaba, K; Kashuk, J; Parry, N; Masiakos, Pt; Mylonas, Ks; Kirkpatrick, A; Abu zidan, F; Gomes, Ca; Benatti, Sv; Naidoo, N; Salvetti, F; Maccatrozzo, S; Agnoletti, V; Gamberini, E; Solaini, Leonardo; Costanzo, A; Celotti, A; Tomasoni, M; Khokha, V; Arvieux, C; Napolitano, L; Handolin, L; Pisano, M; Magnone, S; Spain, Da; Nullm, nullDe Moya; Davis, Ka; Nulln, nullDe Angelis; Leppaniemi, A; Ferrada, P; Latifi, R; Navarro, Dc; Otomo, Y; Coimbra, R; Maier, Rv; Moore, F; Rizoli, S; Sakakushev, B; Galante, Jm; Chiara, O; Cimbanassi, S; Mefire, Ac; Weber, D; Ceresoli, M; Peitzman, Ab; Wehlie, L; Sartelli, M; Nulls, nullDi Saverio; Ansaloni, L.

The prognosis in patients with advanced gastric cancer with carcinosis remains poor with a median survival of less than one year. High rates of peritoneal recurrence of patients undergoing resection with potentially curative intent are strictly related with lymphatic spread and penetration of the serosa. To increase survival rates, during the last thirty years different strategies about screening and treatment have been tested and proposed. Early detection of occult peritoneal micrometastasis is a base step to reduce local and serosa recurrences and to offer a tailored surgical and neoadjuvant therapeutic treatment. The complete cytoreductive surgery, however, remains the cornerstone of treatment. It could be associated with different combinations of chemotherapy regimens. Adjuvant, neoadjuvant and intraperitoneal chemotherapy have been demonstrated effective in improving the survival. In the last years, a few new molecules have been introduced which enhance the effect of chemotherapy by biologically targeting its objective. Lastly the prevention of macroscopic peritoneal carcinosis in all those patients at high risk due to serosal infiltration by treating them with intraperitoneal chemotherapy has been demonstrated to be one of the future winning approaches. In patients with peritoneal carcionosis, multimodal comprehensive treatment should be mandatory, with a pivotal role of intraperitoneal chemotherapy associate to CC0 cytoreduction. Neoadjuvant chemotherapy followed by cytoreductive surgery and intraperitoneal chemotherapy gave promising results. The new molecules as monoclonal antibodies seem to improve outcomes.

Background We reviewed our experience with patients presenting with trauma and peritonitis who underwent an open abdomen (OA) procedure, and compared outcomes between Negative Pressure Wound Therapy (NPWT) and a modified Barker Vacuum Pack (mBVP) technique. Methods In this descriptive study, we retrospectively analyzed data regarding all patients who underwent OA for intra-abdominal sepsis or abdominal trauma at our Centre from January 2012 to December 2015. Demographic data, co-morbidities, indications to surgery, intra-operative details and Björck classification grade were considered. Outcomes included were: time to closure in days, fascial closure rates, ICU and hospital stay, in-hospital and overall mortality, and entero-atmospheric fistula rate. Results A total of 83 cases were considered. Mean closure time was 6 days versus 6.5 days (p = 0.71) in NPWT and mBVP groups, respectively; the fascial closure rate was 75.4% versus 93.8% (p = 0.10). At multivariate analysis, in-hospital and overall mortality were significantly higher within the mBVP, as compared to NPWT (OR 3.8, 95% CI 1.1 to 13.1, p = 0.02 – OR 4.2, 95% CI 1.2 to 14.1, p = 0.01). Entero-atmospheric fistula rate was 2.6% in the two groups. Conclusions NPWT as a temporary abdominal closure technique, as compared to mBVP, appears to be associated with better outcomes in terms of mortality. Electronic supplementary material The online version of this article (doi:10.1186/s12893-017-0281-3) contains supplementary material, which is available to authorized users.

Objective: Purulent peritonitis from acute left colon diverticulitis is a relatively common presentation of diverticular disease; historically the treatment was the Hartmann procedure. Laparoscopic peritoneal lavage has been proposed as a lesser invasive treatment option with great interest and debate among surgeons and with contrasting results. The aim of this meta-analysis was to compare the results of sigmoid resection with laparoscopic lavage. Methods: A systematic review was performed to select randomized controlled trials comparing laparoscopic lavage versus resection in Hinchey III diverticulitis. Studies' selection, data extraction and risk of bias assessment were done by two independent authors; results were shown as OR with 95 % C.I. Results: Three RCT were selected for the meta-analysis including 315 patents. Laparoscopic lavage was associated with significantly more reoperations (OR 3.75, p = 0.006) and more intra-abdominal abscesses (OR 3.50, p = 0.0003) with no differences in mortality (OR 0.93, p = 0.92). At 12 months follow up laparoscopic lavage was associated with lesser reoperations (OR 0.32, p = 0.0004); there were no differences in term of stoma presence (OR 0.44 p = 0.27) and mortality (OR 0.74 p = 0.51). Conclusions: The present meta-analysis shows that in acute perforated diverticulitis with purulent peritonitis laparoscopic lavage is comparable to sigmoid resection in term of mortality but it is associated with a significantly higher rate of reoperations and a higher rate of intra-abdominal abscess. No differences in term of mortality were demonstrated at follow-up. Further studies are needed to better define the safety and appropriateness of this treatment.

Intra-abdominal infections (IAIs) are common surgical emergencies and have been reported as major contributors to non-trauma deaths in the emergency departments worldwide. The cornerstones of effective treatment of IAIs are early recognition, adequate source control, and appropriate antimicrobial therapy. Prompt resuscitation of patients with ongoing sepsis is of utmost important. In hospitals worldwide, non-acceptance of, or lack of access to, accessible evidence-based practices and guidelines result in overall poorer outcome of patients suffering IAIs. The aim of this paper is to promote global standards of care in IAIs and update the 2013 WSES guidelines for management of intra-abdominal infections.

The severity of liver injuries has been universally classified according to the American Association for the Surgery of Trauma (AAST) grading scale. In determining the optimal treatment strategy, however, the haemodynamic status and associated injuries should be considered. Thus the management of liver trauma is ultimately based on the anatomy of the injury and the physiology of the patient. This paper presents the World Society of Emergency Surgery (WSES) classification of liver trauma and the management Guidelines.

Background: The possibility to enlarge criteria for intra-peritoneal chemotherapy (IPC) to all patients at high-risk to develop peritoneal carcinosis (i.e., with serosal invasion) is still discussed. Methods: Retrospective case-control study. Three-groups: advanced-gastric-cancer (AGC) (pT4) without proven carcinosis: prophylactic group (PG), those with PC: treatment group (TG), AGC (pT3–pT4) operated without hyperthermic intraperitoneal chemotherapy (HIPEC), surgery alone group (SG T3, SG T4). Results: Forty four patients. 26 (59.1%) were male. Sixteen (36%) patients underwent 16 HIPEC: 6 (38%) had AGC (pT4) without PC (PG), 10 (62%) had carcinosis (TG), 28 were operated without HIPEC (SG T3, SG T4). The mean disease free survival (DFS): TG: 7.7 months, SG T4: 21.6 months, SG T3: 27.7 months, PG: 34.5 months. DFS was significantly different for TG (P=0.03, P=0.021, P=0.013 respectively). The mean OS TG: 10 months, SG T4: 27.1 months, SG T3: 28.2 months, PG: 34.6 months. OS was significantly different for TG (P=0.04, P=0.04, P=0.045 respectively). Severe complication rate: TG: 60%, PG: 16.7%, SG T3: 7.7% and SG T4: 25% (P=0.035). Length-of-stay differs significantly (P=0.003); overall length-of-stay: 19.41 days [standard deviation (SD) ±15.03]; TG: 33.01 (SD ±23.08), PG: 20.17 (SD ±6.21), SG T3: 11.33 (SD ±3.22), SG T4: 15.36 (SD ±5.48). Conclusions: Prophylactic intraperitoneal chemotherapy associated to neoadjuvant chemotherapy increases the DFS and OS in patients with AGC without carcinosis. More data are needed in order to confirm these results.

Background: Acute appendicitis (AA) is one of the most common diseases affecting especially young but also older people. A systematic evaluation of bacteriology of AA has been frequently conducted in children but is not well known and discussed in adult population. Study design: The study has been obtained from two multicenter prospective observational studies (CIAO and CIAOW studies). The aim of the study is to analyze the intra-abdominal bacteriology in AA and its relation with clinical outcomes. Results: Patients included were 1431, 806 male (56.3%). The mean/median age was 38.9 (SD ± 18.4) and 35 (range 18-94). Clinical condition at the admission was sepsis in 623 patients (43.5%), severe sepsis and septic shock in 29 (2%) and 10 (0.7%). Peritonitis was localized in 1107 patients (77.4%) and generalized in 324 (22.6%). Adequate source-control and empirical antimicrobial therapy were reported in 95.2% and 88.7% of the patients. 47 isolated bacteria (6.8%) were resistant. Two (4.2%) were health-care-associated infections and 45 (95.7%) were community-acquired infections. Univariate analysis showed factor associated to resistant bacteria was the inadequacy of the empiric antimicrobial therapy (= 0.013); at multivariated analysis factors associated with mortality were age>70 years (= 0.003) and severe sepsis at the admission (= 0.02); factors associated to ICU admission were: severe sepsis (< 0.0001), generalized peritonitis (< 0.0001), malignancy (< 0.0001) and cardiovascular disease (< 0.0001). Conclusion: The evolution of antimicrobial resistance, in common community-acquired infections, combined with lack of new antibiotics development are strictly linked to clinical outcomes. Adequate empirical antimicrobial therapy is fundamental to counteract bacterial resistance.

AIMTo investigate the epidemiology, treatment and outcomes of acute appendicitis (AA) in a large population study.METHODSThis is a retrospective cohort study derived from the administrative dataset of the Bergamo district healthcare system (more than 1 million inhabitants) from 1997 to 2013. Data about treatment, surgery, length of stay were collected. Moreover for each patients were registered data about relapse of appendicitis and hospital admission due to intestinal obstruction.RESULTSFrom 1997 to 2013 in the Bergamo district we collected 16544 cases of AA, with a crude incidence rate of 89/100000 inhabitants per year; mean age was 24.51 +/- 16.17, 54.7% were male and the mean Charlson's comorbidity index was 0.32 +/- 0.92. Mortality was < 0.0001%. Appendectomy was performed in 94.7% of the patients and the mean length of stay was 5.08 +/- 2.88 d; the cumulative hospital stay was 5.19 +/- 3.36 d and 1.2% of patients had at least one further hospitalization due intestinal occlusion. Laparoscopic appendectomy was performed in 48% of cases. Percent of 5.34 the patients were treated conservatively with a mean length of stay of 3.98 +/- 3.96 d; the relapse rate was 23.1% and the cumulative hospital stay during the study period was 5.46 +/- 6.05 d.CONCLUSIONThe treatment of acute appendicitis in Northern Italy is slowly changing, with the large diffusion of laparoscopic approach; conservative treatment of non-complicated appendicitis is still a neglected option, but rich of promising results.