Surgical stabilization of rib fractures (SSRF): the WSES and CWIS position paper.

BACKGROUND: Rib fractures are one of the most common traumatic injuries and may result in significant morbidity and mortality. Despite growing evidence, technological advances and increasing acceptance, surgical stabilization of rib fractures (SSRF) remains not uniformly considered in trauma centers. Indications, contraindications, appropriate timing, surgical approaches and utilized implants are part of an ongoing debate. The present position paper, which is endorsed by the World Society of Emergency Surgery (WSES), and supported by the Chest Wall Injury Society, aims to provide a review of the literature investigating the use of SSRF in rib fracture management to develop graded position statements, providing an updated guide and reference for SSRF. METHODS: This position paper was developed according to the WSES methodology. A steering committee performed the literature review and drafted the position paper. An international panel of experts then critically revised the manuscript and discussed it in detail, to develop a consensus on the position statements. RESULTS: A total of 287 studies (systematic reviews, randomized clinical trial, prospective and retrospective comparative studies, case series, original articles) have been selected from an initial pool of 9928 studies. Thirty-nine graded position statements were put forward to address eight crucial aspects of SSRF: surgical indications, contraindications, optimal timing of surgery, preoperative imaging evaluation, rib fracture sites for surgical fixation, management of concurrent thoracic injuries, surgical approach, stabilization methods and material selection. CONCLUSION: This consensus document addresses the key focus questions on surgical treatment of rib fractures. The expert recommendations clarify current evidences on SSRF indications, timing, operative planning, approaches and techniques, with the aim to guide clinicians in optimizing the management of rib fractures, to improve patient outcomes and direct future research.

Goodbye Hartmann trial: a prospective, international, multicenter, observational study on the current use of a surgical procedure developed a century ago.

BACKGROUND: Literature suggests colonic resection and primary anastomosis (RPA) instead of Hartmann's procedure (HP) for the treatment of left-sided colonic emergencies. We aim to evaluate the surgical options globally used to treat patients with acute left-sided colonic emergencies and the factors that leading to the choice of treatment, comparing HP and RPA. METHODS: This is a prospective, international, multicenter, observational study registered on ClinicalTrials.gov. A total 1215 patients with left-sided colonic emergencies who required surgery were included from 204 centers during the period of March 1, 2020, to May 31, 2020. with a 1-year follow-up. RESULTS: 564 patients (43.1%) were females. The mean age was 65.9 ± 15.6 years. HP was performed in 697 (57.3%) patients and RPA in 384 (31.6%) cases. Complicated acute diverticulitis was the most common cause of left-sided colonic emergencies (40.2%), followed by colorectal malignancy (36.6%). Severe complications (Clavien-Dindo ≥ 3b) were higher in the HP group (P < 0.001). 30-day mortality was higher in HP patients (13.7%), especially in case of bowel perforation and diffused peritonitis. 1-year follow-up showed no differences on ostomy reversal rate between HP and RPA. (P = 0.127). A backward likelihood logistic regression model showed that RPA was preferred in younger patients, having low ASA score (≤ 3), in case of large bowel obstruction, absence of colonic ischemia, longer time from admission to surgery, operating early at the day working hours, by a surgeon who performed more than 50 colorectal resections. CONCLUSIONS: After 100 years since the first Hartmann's procedure, HP remains the most common treatment for left-sided colorectal emergencies. Treatment's choice depends on patient characteristics, the time of surgery and the experience of the surgeon. RPA should be considered as the gold standard for surgery, with HP being an exception.

The silent threat: A retrospective study of right-sided traumatic diaphragmatic hernias in a university hospital.

Objectives: In hospital attendance, 75% of diaphragmatic hernias occur on left as opposed to 25% on the right side. Right side hernias are associated with abdominal injuries, mainly the liver. However, right-side injuries are frequently underdiagnosed due to the complexity of associated injuries and high mortality rates. The aim of this study was to perform a retrospective analysis of records from our clinical experience to investigate demographics, TM, diagnosis, morbidity, and mortality associated with right sided TDH. These findings may provide insights into improving the clinical management of patients with this serious injury, potentially reducing morbidity and mortality rates. Material and Methods: Retrospective analysis of the medical records of patients from the trauma database of the Division of Trauma Surgery at University of Campinas in 32-year period was performed. Only records of patients with right sided TDH were included in the analysis. Results: Blunt trauma was the most common mechanism. Diagnoses were made by laparotomy in eight cases, all these cases were hemodynamically unstable. TDH grade III injury occurred in most cases followed by grade IV. Liver injuries were present in almost all cases, most of them high grade, followed by colon and small bowel. Extra-abdominal associated injuries with a predominance of femur fractures, pelvic fractures and hemothorax. Post-operative complications were associated with length of stay in intensive care unit. Pneumonia was the most frequent complication. The overall mortality rate was 16%. Conclusion: Most diagnoses were performed through laparotomy and not by radiologic exams, due to hemodynamic instability on admission. There is underdiagnosis of right-side TDH due to the high-energy trauma mechanism with high grade associated injuries and mortality on pre-hospital.