Erratum to: 2016 WSES guidelines on acute calculous cholecystitis

[This corrects the article DOI: 10.1186/s13017-016-0082-5.].

2016 WSES guidelines on acute calculous cholecystitis

Acute calculus cholecystitis is a very common disease with several area of uncertainty. The World Society of Emergency Surgery developed extensive guidelines in order to cover grey areas. The diagnostic criteria, the antimicrobial therapy, the evaluation of associated common bile duct stones, the identification of “high risk” patients, the surgical timing, the type of surgery, and the alternatives to surgery are discussed. Moreover the algorithm is proposed: as soon as diagnosis is made and after the evaluation of choledocholitiasis risk, laparoscopic cholecystectomy should be offered to all patients exception of those with high risk of morbidity or mortality. These Guidelines must be considered as an adjunctive tool for decision but they are not substitute of the clinical judgement for the individual patient.

Decompressive laparotomy for abdominal compartment syndrome

Background

The effect of decompressive laparotomy on outcomes in patients with abdominal compartment syndrome has been poorly investigated. The aim of this prospective cohort study was to describe the effect of decompressive laparotomy for abdominal compartment syndrome on organ function and outcomes.

Methods

This was a prospective cohort study in adult patients who underwent decompressive laparotomy for abdominal compartment syndrome. The primary endpoints were 28‐day and 1‐year all‐cause mortality. Changes in intra‐abdominal pressure (IAP) and organ function, and laparotomy‐related morbidity were secondary endpoints.

Results

Thirty‐three patients were included in the study (20 men). Twenty‐seven patients were surgical admissions treated for abdominal conditions. The median (i.q.r.) Acute Physiology And Chronic Health Evaluation (APACHE) II score was 26 (20–32). Median IAP was 23 (21–27) mmHg before decompressive laparotomy, decreasing to 12 (9–15), 13 (8–17), 12 (9–15) and 12 (9–14) mmHg after 2, 6, 24 and 72 h. Decompressive laparotomy significantly improved oxygenation and urinary output. Survivors showed improvement in organ function scores, but non‐survivors did not. Fourteen complications related to the procedure developed in eight of the 33 patients. The abdomen could be closed primarily in 18 patients. The overall 28‐day mortality rate was 36 per cent (12 of 33), which increased to 55 per cent (18 patients) at 1 year. Non‐survivors were no different from survivors, except that they tended to be older and on mechanical ventilation.

Conclusion

Decompressive laparotomy reduced IAP and had an immediate effect on organ function. It should be considered in patients with abdominal compartment syndrome.

Improves organ function

Recommendations for research from the International Conference of Experts on Intra-abdominal Hypertension and Abdominal Compartment Syndrome

OBJECTIVE

Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) have been increasingly recognized in the critically ill over the past decade, and the number of published studies has exploded in recent years. Interpretation of the results and comparison of these studies is difficult, because of incomplete and inconsistent reporting of data and statistics.

DESIGN

An international consensus group of multidisciplinary specialists convened at the third World Congress on Abdominal Compartment Syndrome to develop recommendations for research related to the diagnosis and management of IAH and ACS.

METHODS

Prior to the conference the authors developed a blueprint for consensus definitions and treatment guidelines which were refined both during and after the conference.

RESULTS

Three major types of studies were identified (measurement techniques, epidemiology, and interventions), each with different needs regarding methodology, reporting of data and statistical analysis.

CONCLUSIONS

These recommendations are proposed to guide clinical research in the field of IAH and ACS.

Penetrating esophageal injuries: multicenter study of the American Association for the Surgery of Trauma

OBJECTIVE

The purpose of this study was to define the period of time after which delays in management incurred by investigations cause increased morbidity and mortality. The outcome study is intended to correlate time with death from esophageal causes, overall complications, esophageal related complications, and surgical intensive care unit length of stay.

METHODS

This was a retrospective multicenter study involving 34 trauma centers in the United States, under the auspices of the American Association for the Surgery of Trauma Multi-institutional Trials Committee over a span of 10.5 years. Patients surviving to reach the operating room (OR) were divided into two groups: those that underwent diagnostic studies to identify their injuries (preoperative evaluation group) and those that went immediately to the OR (no preoperative evaluation group). Statistical methods included Fisher's exact test, Student's T test, and logistic regression analysis.

RESULTS

The study involved 405 patients: 355 male patients (86.5%) and 50 female patients (13.5%). The mean Revised Trauma Score was 6.3, the mean Injury Severity Score was 28, and the mean time interval to the OR was 6.5 hours. There were associated injuries in 356 patients (88%), and an overall complication rate of 53.5%. Overall mortality was 78 of 405 (19%). Three hundred forty-six patients survived to reach the OR: 171 in the preoperative evaluation group and 175 in the no preoperative evaluation group. No statistically significant differences were noted in the two groups in the following parameters: number of patients, age, Injury Severity Score, admission blood pressure, anatomic location of injury (cervical or thoracic), surgical management (primary repair, resection and anastomosis, resection and diversion, flaps), number of associated injuries, and mortality. Average length of time to the OR was 13 hours in the preoperative evaluation group versus 1 hour in the no preoperative evaluation group (p < 0.001). Overall complications occurred in 134 in the preoperative evaluation group versus 87 in the no preoperative evaluation group (p < 0.001), and 74 (41%) esophageal related complications occurred in the preoperative evaluation group versus 32 (19%) in the no preoperative evaluation group (p = 0.003). Mean surgical intensive care unit length of stay was 11 days in the preoperative evaluation group versus 7 days in the no preoperative evaluation group (p = 0.012). Logistic regression analysis identified as independent risk factors for the development of esophageal related complications included time delays in preoperative evaluation (odds ratio, 3.13), American Association for the Surgery of Trauma Organ Injury Scale grade >2 (odds ratio, 2.62), and resection and diversion (odds ratio, 4.47).

CONCLUSION

Esophageal injuries carry a high morbidity and mortality. Increased esophageal related morbidity occurs with the diagnostic workup and its inherent delay in operative repair of these injuries. For centers practicing selective management of penetrating neck injuries and transmediastinal gunshot wounds, rapid diagnosis and definitive repair should be made a high priority.

Effect of hemorrhage on superior mesenteric artery flow during increased intra-abdominal pressures

BACKGROUND

Elevations in intra-abdominal pressure (IAP) adversely affect organ function. Prior hemorrhage and resuscitation exacerbates the cardiac and pulmonary effects of IAP. We have recently shown that superior mesenteric artery flow (SMAF) is reduced with increasing IAP. This study was designed to determine whether and how hemorrhage and resuscitation affects SMAF with increasing IAP.

METHODS

Ten pigs were divided into two groups after placement of a Doppler flow probe around the proximal SMA and insertion of a pulmonary artery (PA) catheter. Group 1 underwent intraperitoneal infusion of fluid to increase IAP to 10, 20, 30, and 40 mm Hg followed by a 20-minute equilibration period at each IAP. Group 2 was hemorrhaged 20% of circulating volume followed by standard resuscitation. After equilibration, this group had IAP increased in the same manner as group 1. Cardiac output (CO), PA pressures, and SMAF were recorded 1 hour after laparotomy and after equilibration at each IAP. Comparisons were made using repeated measures of analysis of variance, Student's t test, and linear regression analysis.

RESULTS

In group 2, a reduction in SMAF was noted at 30 and 40 mm Hg of IAP when compared with baseline (p = 0.009). This reduction was not seen in group 1. There was also a significant (p = 0.001) reduction in CO between baseline and all levels of increased IAP in group 2. This decrease was again not seen in group 1. The correlation between CO and SMAF in group 2 was r = 0.74, r2 = 0.55, p = 0.0001. There was no significant correlation between CO and SMAF in group 1.

CONCLUSION

SMAF and CO are reduced with increasing IAP to a greater degree when preceded by hemorrhage and resuscitation. Although there is a strong correlation between the reductions in CO and SMAF, the reduction in SMAF is greater than the reduction in CO. This finding suggests that optimizing cardiac function alone during periods of even moderate levels of increased IAP may be inadequate to normalize SMAF. This lends further support for early abdominal decompression in the treatment of trauma patients with increased IAP.

Penetrating ureteric injuries

Injury to the ureter is relatively rare. We retrospectively reviewed our experience with 21 cases of ureteric injury from penetrating trauma at the Lincoln Medical Center. Two injuries resulted from stab wounds and 19 from gunshot wounds. Total ureteric disruption occurred in 14 cases, partial transection in four and contusion in three. Preoperative screening was unreliable in accurately predicting the injury with hematuria being present in 66 per cent of cases. Similarly, intravenous urogram was diagnostic in 14 per cent and suspicious in another 42 per cent. Most injuries were diagnosed intraoperatively and exploration of the retro peritoneum remains the only definitive method of excluding ureteric injuries. Most patients were critically ill (mean ISS 27) due to associated injuries (90 per cent). Neither peritoneal contamination associated with hollow viscous injuries nor hypotension adversely affected the healing of ureteric anastomoses. Anastomotic leak developed in three (14 per cent) cases and one of them required operative correction. Another two patients developed infections related to the urinary tract.

Children who are shot: a 30-year experience

Three data sets describe the pattern of gunshot injuries to children from 1960 to 1993: The Harlem Hospital pediatric trauma registry (HHPTR), the northern Manhattan injury surveillance system (NMISS) a population-based study, and the National Pediatric Trauma Registry (NPTR). A small case-control study compares the characteristics of injured children with a control group. Before 1970 gunshot injuries to Harlem children were rare. In 1971 an initial rise in pediatric gunshot admissions occurred, and by 1988 pediatric gunshot injuries at Harlem Hospital had peaked at 33. Population-based data through NMISS showed that the gunshot rate for Central Harlem children 10 to 16 years of age rose from 64.6 per 100,000 in 1986 to 267.6 per 100,000 in 1987, a 400% increase. The case fatality for children admitted to Harlem Hospital (1960 to 1993) was 3%, usually because of brain injury, but the majority of deaths occurred before hospitalization. During the same period, felony drug arrests in Harlem increased by 163%. The neighboring South Bronx experienced the same increase in gunshot wound admissions and felony arrests from 1986 to 1993. The NPTR showed a similar injury pattern for other communities in the United States. In a case-control analysis. Harlem adolescents who had sustained gunshot wounds were more likely to have dropped out of school, to have lived in a household without a biological parent, to have experienced parental death, and to have known of a relative or friend who had been shot than community adolescents treated for other medical or surgical problems.(ABSTRACT TRUNCATED AT 250 WORDS)

Guaiac testing in the diagnosis of rectal trauma: what is its value?

Rectal examination with guaiac testing is a standard part of the emergency department evaluation of acutely traumatized patients. Its major role is in the recognition of occult bowel injury. We questioned its efficacy in detecting occult rectal injury in patients with penetrating trauma. We reviewed the charts of 19 patients with suspected rectal injury. Ten injuries were to the abdomen, nine to the buttock, and three to the thigh. Guaiac testing was 69% (11/16) sensitive and 33% (1/3) specific. Rigid sigmoidoscopy was 100% (12/12) sensitive and 67% (2/3) specific. Sensitivity was 100% (8/8) when the two were combined. Our findings suggest that guaiac testing is not accurate enough to rule out the presence of occult rectal injury. The result of guaiac testing must not influence the decision to further evaluate patients with high-risk injuries.

Percutaneous tracheostomy after trauma and critical illness

A method of percutaneous tracheostomy (PT) using a tracheostome, which permits insertion of a full-sized cuffed tracheostomy tube, was evaluated in 61 critically ill or injured patients (89% had trauma). Of the 54 trauma patients, 65% had brain injuries, 14% had injuries to the cervical spinal cord, 33% had face or jaw injuries, and 15% had lung injuries. The indications for PT were coma (46%), acute airway obstruction (5%), face or jaw injury (20%), pneumonitis (39%), adult respiratory distress syndrome (12%), and sepsis (21%). Tracheostomy was done in 51% of all cases specifically for managing pulmonary secretions, in 37% for prolonged intubation, and in 25% for neurologic lesions. The tracheostomy was done as an emergency in 5%, as urgent in 28%, and electively in 77%. Percutaneous tracheostomy was successful in 90% of the cases, and in 8% it was converted to a surgical tracheostomy after an initial percutaneous attempt. In 46% it was performed at the bedside, in 46% in the operating room, and in 7% in the emergency suite. A full-sized tracheostomy tube (#6 to #8) was used in all cases and was considered optimal or larger than needed in 87% of cases. With three exceptions the complications of PT were minor, but 30% of the patients died of their primary disease. In one case death occurred because of bronchospasm and cardiac arrest during the PT, but appeared to be independent of the type of tracheostomy. Healing after in-hospital removal (37%) was excellent in 95% of cases and 97% of physicians indicated that they would use the device again.

Indications for barium enema preceding colostomy closure in trauma patients

The need for a barium enema (BE) preceding colostomy closure is controversial. In the process of evaluating the usefulness of BE before closure of colostomies performed for colorectal injuries, we reviewed our experience with 84 trauma patients who underwent BE before colostomy closure. Patients who had their colonic injuries repaired or diverted during the initial procedure did not benefit from the precolostomy closure contrast study. In this group of patients artifacts on BE had to be ruled out by endoscopy or repeat radiography in 9.5% of patients. Barium enema was found beneficial in evaluating colorectal injuries below the peritoneal reflection in one out of 20 patients. However, since the rectal injuries are not usually explored and repaired during the initial procedure, investigation by endoscopy and contrast studies may still be indicated preceding colostomy closure.

Selective conservatism in abdominal stab wounds: the efficacy of serial physical examination

An analysis of 186 consecutive patients with anterior abdominal stab wounds in a 2-year period was carried out to assess the efficacy of serial physical examination as the determining factor for the need for laparotomy. Of 106 patients managed by clinical evaluation, the incidence of negative laparotomy was 0.9% and three patients (2.7%) had an "unnecessary" celiotomy. There were no missed injuries or delayed detection of intraperitoneal visceral trauma. The incidence of negative laparotomy among patients subjected to wound exploration +/- peritoneal lavage (n = 41) was 2.4%, and 39 patients had mandatory laparotomy for evisceration, with a negative celiotomy rate of 20.5%. Our experience supports serial physical examination as a highly effective method of "selective conservatism" of anterior abdominal stab wounds. Mandatory laparotomy for evisceration needs further clarification.