Management of complicated diaphragmatic hernia in the acute setting: a WSES position paper.

BACKGROUND: Diaphragmatic hernia (DH) presenting acutely can be a potentially life-threatening condition. Its management continues to be debatable. METHODS: A bibliographic search using major databases was performed using the terms "emergency surgery" "diaphragmatic hernia," "traumatic diaphragmatic rupture" and "congenital diaphragmatic hernia." GRADE methodology was used to evaluate the evidence and give recommendations. RESULTS: CT scan of the chest and abdomen is the diagnostic gold standard to evaluate complicated DH. Appropriate preoperative assessment and prompt surgical intervention are important for a clinical success. Complicated DH repair is best performed via the use of biological and bioabsorbable meshes which have proven to reduce recurrence. The laparoscopic approach is the preferred technique in hemodynamically stable patients without significant comorbidities because it facilitates early diagnosis of small diaphragmatic injuries from traumatic wounds in the thoraco-abdominal area and reduces postoperative complications. Open surgery should be reserved for situations when skills and equipment for laparoscopy are not available, where exploratory laparotomy is needed, or if the patient is hemodynamically unstable. Damage Control Surgery is an option in the management of critical and unstable patients. CONCLUSIONS: Complicated diaphragmatic hernia is a rare life-threatening condition. CT scan of the chest and abdomen is the gold standard for diagnosing the diaphragmatic hernia. Laparoscopic repair is the best treatment option for stable patients with complicated diaphragmatic hernias. Open repair is considered necessary in majority of unstable patients in whom Damage Control Surgery can be life-saving.

Management of intra-abdominal-infections: 2017 World Society of Emergency Surgery guidelines summary focused on remote areas and low-income nations.

BACKGROUND: Most remote areas have restricted access to healthcare services and are too small and remote to sustain specialist services. In 2017, the World Society of Emergency Surgery (WSES) published guidelines for the management of intra-abdominal infections. Many hospitals, especially those in remote areas, continue to face logistical barriers, leading to an overall poorer adherence to international guidelines. METHODS: The aim of this paper is to report and amend the 2017 WSES guidelines for the management of intra-abdominal infections, extending these recommendations for remote areas and low-income countries. A literature search of the PubMed/MEDLINE databases was conducted covering the period up until June 2020. RESULTS: The critical shortages of healthcare workers and material resources in remote areas require the use of a robust triage system. A combination of abdominal signs and symptoms with early warning signs may be used to screen patients needing immediate acute care surgery. A tailored diagnostic step-up approach based on the hospital's resources is recommended. Ultrasound and plain X-ray may be useful diagnostic tools in remote areas. The source of infection should be totally controlled as soon as possible. CONCLUSIONS: The cornerstones of effective treatment for intra-abdominal infections in remote areas include early diagnosis, prompt resuscitation, early source control, and appropriate antimicrobial therapy. Standardization in applying the guidelines is mandatory to adequately manage intra-abdominal infections.

Abdominopelvic trauma: from anatomical to anatomo-physiological classification.

Abdominopelvic trauma has been for decades classified with the AAST-OIS (American Association for the Surgery of Trauma-Organ Injury Scale) classification. It has represented a milestone. At present, the medical evolutions in trauma management allowed an incredible progress in trauma decision-making and treatment. Non-operative trauma management has been widely applied. The interventional radiological procedures and the modern conception of Hybrid and Endovascular Trauma and Bleeding Management (EVTM) led to good results in increasing the rate of patients managed non-operatively, opening new scenarios and options. Even severe anatomical lesions in hemodynamically stable patients can be safely managed non-operatively. The driving issue in deciding for the best treatment is anatomy, as well as physiology, for the patient physiological derangement grade is even more important. The emergency general surgeon must be prepared in those pathophysiological issues that play the pivotal role in the team management of trauma patients. Moreover, the classification of trauma patients cannot only remain anchored to anatomical lesions. The necessity to follow the modern possibilities of treatment imposes addressing trauma using a classification based on anatomical lesions and on the physiological status of the patient.