Improving Intraoperative Communication in Trauma: The Educational Effect of the Joint DSTC™-DATC™ Courses.

BACKGROUND: Operative management of severe trauma requires excellent communication among team members. The surgeon and anesthesiologist need to interact efficiently, exchanging vital information. The Definitive Surgical Trauma Care (DSTC) and Definitive Anesthesia Trauma Care (DATC) courses provide an excellent opportunity for teamwork training. Our goal was to study the impact of the joint DSTC-DATC courses in candidates' self-reported assessment in communication skills and techniques in a simulated intraoperative trauma scenario. METHODS: Study population consists of 93 candidates (67 surgeons and 26 anesthesiologists) participating in four consecutive joint DSTC-DATC courses in May and June 2019 in Brazil (3) and in Portugal (1). Median age was 30 years; 53 (60%) of subjects were male (46 senior residents and 47 specialists). All participants attended joint lectures, case discussions and surgical skills session, emphasizing intraoperative communication. Post-course survey on several aspects of perioperative communication (responses on a Likert scale) was conducted with participants being asked which aspects of intraoperative communication they valued the most. RESULTS: All participants responded to the survey. Results displayed an increase in the self-assessed importance of team briefing and intraoperative communication, particularly routine periodic communication, rather than only at critical moments. Postoperative team debriefing was also valued as highly relevant. Closed-loop and direct, by-name communication were highly rated. Self-reported communication skills improved significantly during the course. CONCLUSIONS: Joint training in the DSTC-DATC courses improved candidates' perception and skills on proficient intraoperative communication. Further studies should address both the durability of these changes and the potential impact on patient care.

Trauma Leagues-A Novel Option to Attract Medical Students to a Surgical Career.

BACKGROUND: In Brazil, most medical schools do not offer trauma surgery in their undergraduate curriculum. The Trauma Leagues arose in Brazil as an important promoter of trauma education and stimulated activities related to surgical skills and practices. In recent decades, studies have demonstrated that the number of surgical residency applicants has decreased worldwide. Strategies to motivate medical students to choose surgery are needed. OBJECTIVE: To evaluate the impact of participation in the Unicamp Trauma League (UTL) during a 20-year period in the choice for a surgical career. METHODS: The study included 276 students in a Brazilian university hospital who were part of the Trauma League. Research of records in universities and medical societies about the specialties chosen during residency were evaluated. A Likert questionnaire was sent to participants to evaluate the impact of participating in the Trauma League in the student's professional career. RESULTS: The questionnaire was answered by 76% of the participants. Of those, 38.4% chose general surgery. About 55.1% did not know what medical career to choose when joined the league. Participation in the league had an influence on specialty choice in 79.1% of the students. Of those choosing surgery, 93.2% believed that participating in the league had positively influenced their career choice. Overall, 93.1% believed that participating in the league provided knowledge and information that the medical school curriculum was not able to provide. CONCLUSION: Participation in Trauma League has been an effective strategy to encourage medical students to choose a career in general surgery in Campinas, Brazil.

Epidemiology of in-hospital trauma deaths in a Brazilian university hospital.

BACKGROUND: The analysis of patterns of trauma deaths may improve the evaluation of a trauma system and identify areas that may benefit from more resources. The objective of this study was to analyze the epidemiology of trauma deaths in a Brazilian university hospital in order to assess the profile of these fatalities over a 16-year period. METHOD: Retrospective study of time series using database records. The research subjects were in-hospital deaths from external causes during the years 1995, 2000, 2005 and 2010. The following variables were analyzed: cause of injury, trauma scores, time and cause of death. RESULTS: 467 cases were studied, being 325 patients (69.6%) admitted with signs of life and 142 (30.4%) considered dead on arrival. The mean age was 35.35 ± 18.03 years. 85.4% were males. Blunt trauma occurred in 73.0% of cases and penetrating mechanism in 27.0%. There was a significant increase (p < 0.001) in deaths from motorcycle crashes over the years, which went from 7.3% in 1995 to 31.5% in 2010. In contrast, there was a significant decrease (p = 0.030) in firearm-injury victims; from 21.0% in 1995 to 9.6% in 2010. About 60% of deaths occurred less than 24 hours after admission. The main causes of death were lesions of the central nervous system (56.3% of the total), followed by hemorrhagic shock (18.1%) and sepsis/multiple organ dysfunction syndrome (17.1%). The mean Injury Severity Score (ISS) of patients with signs of life was 26.41 ± 9.00, 71.3% of whom had ISS >25. The mean Revised Trauma Score (RTS) was 5.24 ± 2.05. Only 25.8% of the deaths had TRISS <0.50. CONCLUSION: There was a shift in the profile of causes of death from trauma in this university teaching hospital, with a large decrease in penetrating injuries and a higher incidence of deaths of motorcycle riders.

Applying enhanced recovery principles to emergency laparotomy in penetrating abdominal trauma: a case-matched study.

PURPOSE: The implementation of enhanced recovery after surgery programs (ERPs) has significantly improved outcomes within various surgical specialties. However, the suitability of ERPs in trauma surgery remains unclear. This study aimed to (1) design and implement an ERP for trauma laparotomy patients; (2) assess its safety, feasibility, and efficacy; and (3) compare the outcomes of the proposed ERP with conventional practices. METHODS: This case-matched study prospectively enrolled hemodynamically stable patients undergoing emergency laparotomy after penetrating trauma. Patients receiving the proposed ERP were compared to historical controls who had received conventional treatment from two to eight years prior to protocol implementation. Cases were matched for age, sex, injury mechanism, extra-abdominal injuries, and trauma scores. Assessment of intervention effects were modelled using regression analysis for outcome measures, including length of hospital stay (LOS), postoperative complications, and functional recovery parameters. RESULTS: Thirty-six consecutive patients were enrolled in the proposed ERP and matched to their 36 historical counterparts, totaling 72 participants. A statistically significant decrease in LOS, representing a 39% improvement in average LOS was observed. There was no difference in the incidence of postoperative complications. Opioid consumption was considerably lower in the ERP group (p < 0.010). Time to resumption of oral liquid and solid intake, as well as to the removal of nasogastric tubes, urinary catheters, and abdominal drains was significantly earlier among ERP patients (p < 0.001). CONCLUSION: The implementation of a standardized ERP for the perioperative care of penetrating abdominal trauma patients yielded a significant reduction in LOS without increasing postoperative complications. These findings demonstrate that ERPs principles can be safely applied to selected trauma patients.

Are we ready for "green surgery" to promote environmental sustainability in the operating room? Results from the WSES STAR investigation.

BACKGROUND: The importance of environmental sustainability is acknowledged in all sectors, including healthcare. To meet the United Nations Sustainable Development Goals 2030 Agenda, healthcare will need a paradigm shift toward more environmentally sustainable practices that will also impact clinical decision-making. The study investigates trauma and emergency surgeons' perception, acceptance, and employment of environmentally friendly habits. METHODS: An online survey based on the most recent literature regarding environmental sustainability in healthcare and surgery was created by a multidisciplinary committee and endorsed by the World Society of Emergency Surgery (WSES). The survey was advertised to the 917 WSES members through the society's website and Twitter/X profile. RESULTS: 450 surgeons from 55 countries participated in the survey. Results underline both a generally positive attitude toward environmental sustainability but also a lack of knowledge about several concepts and practices, especially concerning the potential contribution to patient care. DISCUSSION: The topic of environmental sustainability in healthcare and surgery is still in its infancy. There is a clear lack of salient guidance and knowledge, and there is a critical need for governments, institutions, health agencies, and scientific societies to promote, disseminate, and report environmentally friendly initiatives and their potential impacts while employing an interdisciplinary approach.

The European Trauma Course: Transforming systems through training.

The European Trauma Course (ETC) exemplifies an innovative approach to multispecialty trauma education. This initiative was started as a collaborative effort among the European Society for Emergency Medicine, the European Society for Trauma and Emergency Surgery, and the European Society of Anaesthesiology under the auspices of the European Resuscitation Council. With the robust support of these societies, the project has evolved into the independent European Trauma Course Organisation. Over the past 15 years, the ETC has transcended traditional training by integrating team dynamics and non-technical skills into a scenario-based simulation course, helping to shape trauma care practice and education. A distinctive feature of the ETC is its training of doctors and allied healthcare professionals, fostering a collaborative and holistic approach to trauma care. The ETC stands out for its unique team-teaching approach, which has gained widespread recognition as the standard for in-hospital trauma care training not only in Europe but also beyond. Since its inception ETC has expanded geographically from Finland to Sudan and from Brazil to the Emirates, training nearly 20,000 healthcare professionals and shaping trauma care practice and education across 25 countries. Experiencing exponential growth, the ETC continues to evolve, reflecting its unmet demand in trauma team education. This review examines the evolution of the ETC, its innovative team-teaching methodology, national implementation strategies, current status, and future challenges. It highlights its impact on trauma care, team training, and the effect on other life support courses in various countries.

The 2023 WSES guidelines on the management of trauma in elderly and frail patients.

BACKGROUND: The trauma mortality rate is higher in the elderly compared with younger patients. Ageing is associated with physiological changes in multiple systems and correlated with frailty. Frailty is a risk factor for mortality in elderly trauma patients. We aim to provide evidence-based guidelines for the management of geriatric trauma patients to improve it and reduce futile procedures. METHODS: Six working groups of expert acute care and trauma surgeons reviewed extensively the literature according to the topic and the PICO question assigned. Statements and recommendations were assessed according to the GRADE methodology and approved by a consensus of experts in the field at the 10th international congress of the WSES in 2023. RESULTS: The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage, including drug history, frailty assessment, nutritional status, and early activation of trauma protocol to improve outcomes. Acute trauma pain in the elderly has to be managed in a multimodal analgesic approach, to avoid side effects of opioid use. Antibiotic prophylaxis is recommended in penetrating (abdominal, thoracic) trauma, in severely burned and in open fractures elderly patients to decrease septic complications. Antibiotics are not recommended in blunt trauma in the absence of signs of sepsis and septic shock. Venous thromboembolism prophylaxis with LMWH or UFH should be administrated as soon as possible in high and moderate-risk elderly trauma patients according to the renal function, weight of the patient and bleeding risk. A palliative care team should be involved as soon as possible to discuss the end of life in a multidisciplinary approach considering the patient's directives, family feelings and representatives' desires, and all decisions should be shared. CONCLUSIONS: The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage based on assessing frailty and early activation of trauma protocol to improve outcomes. Geriatric Intensive Care Units are needed to care for elderly and frail trauma patients in a multidisciplinary approach to decrease mortality and improve outcomes.

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.

Bladder injuries after external trauma: 20 years experience report in a population-based cross-sectional view.

OBJECTIVES: Report 20 years experience of bladder injuries after external trauma. METHODS: Gender, age, mechanism/location of damage, associated injuries, systolic blood pressure (SBP), Revised Trauma Score (RTS), Injury Severity Score (ISS), Trauma Injury Severity Score (TRISS), complications, and length of stay (LOS) were analyzed in a prospective collected bladder injuries AAST-OIS grade ≥ II database (American Association for the Surgery of Trauma Organ Injury Scaling) from 1990 to 2009 in a trauma reference center. RESULTS: Among 2,575 patients experiencing laparotomy for trauma, 111 (4.3 %) presented bladder ruptures grade ≥ II, being 83.8 % (n = 93) males, mean age 31.5 years old (± 11.2). Blunt mechanism accounted for 50.5 % (n = 56)-motor vehicle crashes 47.3 % (n = 26), pedestrians hit by a car (29.1 %). Gunshot wounds represented 87.3 % of penetrating mechanism. The most frequent injury was grade IV (51 patients, 46 %). The mean ISS was 23.8 (± 11.2), TRISS 0.90 (± 0.24), and RTS 7.26 (± 1.48). Severity (AAST-OIS), mechanism (blunt/penetrating), localization of the bladder injury (intra/extraperitoneal, associated), and neither concomitant rectum lesion were related to complications, LOS, or death. Mortality rate was 10.8 %. ISS > 25 (p = 0.0001), SBP <90 mmHg (p = 0.0001), RTS <7.84 (p = 0.0001), and pelvic fracture (p = 0.0011) were highly associated with grim prognosis and death with hazard ratios of 5.46, 2.70, 2.22, and 2.06, respectively. CONCLUSIONS: Trauma scores and pelvic fractures impact survival in bladder trauma. The mortality rate has remained stable for the last two decades.

Penetrating cardiac trauma: 20-y experience from a university teaching hospital.

BACKGROUND: Penetrating traumas, including gunshot and stab wounds, are the major causes of cardiac trauma. Our aim was to describe and compare the variables between patients with penetrating cardiac trauma in the past 20 y in a university hospital, identifying risk factors for morbidity and death. METHODS: Review of trauma registry data followed by descriptive statistical analysis comparing the periods 1990-1999 (group 1, 54 cases) and 2000-2009 (group 2, 39 cases). Clinical data at hospital admission, Injury Severity Score (ISS), Glasgow Coma Scale (GCS), and Revised Trauma Score (RTS) were recorded. RESULTS: The incidences of penetrating cardiac injuries were steady within the period of study in the chosen metropolitan area. The two groups were similar regarding age, mechanism of trauma (gunshot × stab), and ISS. Group 1 showed lower systolic blood pressure at admission (mean 87 versus 109 mm Hg), lower GCS (12.9 versus 14.1), lower RTS (6.4 versus 7.3), higher incidence of grade IV-V cardiac lesions (74% versus 48.7%), and were less likely to survive (0.83 versus 0.93). The major risk factor for death was gunshot wound (13 times higher than stab wound), systolic blood pressure < 90 mm Hg, GCS < 8, RTS < 7.84, associated injuries, grade IV-V injury, and ISS > 25. We observed a tendency in mortality reduction from 20.3% to 10.3% within the period of observation. CONCLUSIONS: Several associated factors for mortality and morbidity were identified. In the last decade, patients were admitted in better physiological condition, perhaps reflecting an improvement on prehospital treatment. We observed a trend toward a lower mortality rate.

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.

Worldwide snapshot of trauma team structure and training: an international survey.

INTRODUCTION: Trauma teams (TTs) are a key tool in trauma care, as they bring a multidisciplinary approach to the trauma patient, improving outcomes. Excellent teamwork (TW) requires not only individual skills but also training at non-technical skills (NTS). Although there is evidence supporting TTs, there is little information regarding how they are organized and trained. With this study, we intend to assess the reality of TTs all over the world, focusing on how they are organized and trained. MATERIALS AND METHODS: We composed a 42-question sheet on Google Forms, in four different languages (English, Polish, Portuguese, and Spanish). The questions regarded the respondents' background, and their respective hospitals' trauma patient management, TT features and its training, NTS and TW. The survey was shared on social media, through the International Assessment Group of Online Surgical & Trauma Education community, and the European Society of Trauma and Emergency Surgery. Statistical analysis was performed on Statistical Package for the Social Sciences (SPSS®) version 27. RESULTS: We obtained 296 answers from 52 different countries, with 6 having at least 10 answers (Brazil, Portugal, Poland, Spain, Italy, and USA). While the majority of the respondents (97%) agreed that TTs can improve outcomes, only 61% have a TT in their hospital, with 69% of these being dedicated TTs. General surgery (76%), trauma surgery (68%), and anesthesia (66%) were the three most common specialties in the teams. Teams performed briefings and debriefings with a frequency of, at least, "often" in only 49% and 38%, respectively. Only 50% and 33% of the respondents stated that their hospital provided trauma management courses focusing on individual technical skills, and TT training courses, respectively. The Advanced Trauma Life Support (85%), the Definitive Surgical and Anesthetic Trauma Care (38%), and the European Trauma Course (31%) were the three trauma management courses of choice. Regarding TT training courses, the European Trauma Course (52%) and local/in-house (42%) courses were the most common ones. Most participants (93%) stated that NTS were highly important in trauma care. However, only 60% of the respondents had postgraduate training on NTS and TW, and only 24% had this type of training on an undergraduate level. CONCLUSION: The number of TTs worldwide does not match their relevance in trauma care. Institutions are not providing enough trauma courses, particularly TT training courses and NTS teaching. Implementing TT should include promotion of team courses, as well as team briefings and debriefings.

Can trauma leagues contribute to better cognitive performance and technical skills of medical students? The experience of the Unicamp trauma league.

PURPOSE: Trauma leagues (TLs) are extracurricular programs that offer medical students supervised exposure to trauma and acute care surgery, mentorship, and participation in other academic activities. TLs are fully approved medical schools, and currently, over 100 TLs exist in Brazil. We hypothesized that the performance/competence of medical students who participated in TLs was superior compared to non-participants. This study evaluated and compared the cognitive performance and technical skills of the two groups. METHODS: This retrospective cohort study evaluated the performance of TL medical students to non-TL alumni from 2005 to 2017, using the students' academic performance coefficient, Clinical Competence Assessment, and Progress Test results. SigmaPlot 12.0 software was used to perform statistical analyses, including Mann-Whitney comparison tests and the Kruskal-Wallis test to confirm the data. RESULTS: Of the 1366 medical students who graduated from a Brazilian university, 966 were included, with 17.9% having participated in TL. Compared to non-TL participants, TL students demonstrated better cognitive performance according to the performance coefficient (p = 0.017) and Progress Test result (p < 0.001), and higher achievement in the Clinical Competence Assessment (p < 0.001). CONCLUSION: The academic performance of TL students was superior to that of non-TL students at the University of Campinas (Unicamp), suggesting a positive impact of TL in the preparation of future doctors. The study findings suggest that participation in TL at Unicamp was beneficial in preparing better doctors and should be considered by medical schools worldwide. EVIDENCE LEVEL: II (Retrospective cohort).

Assessing and managing frailty in emergency laparotomy: a WSES position paper.

Many countries are facing an aging population. As people live longer, surgeons face the prospect of operating on increasingly older patients. Traditional teaching is that with older age, these patients face an increased risk of mortality and morbidity, even to a level deemed too prohibitive for surgery. However, this is not always true. An active 90-year-old patient can be much fitter than an overweight, sedentary 65-year-old patient with comorbidities. Recent literature shows that frailty-an age-related cumulative decline in multiple physiological systems, is therefore a better predictor of mortality and morbidity than chronological age alone. Despite recognition of frailty as an important tool in identifying vulnerable surgical patients, many surgeons still shun objective tools. The aim of this position paper was to perform a review of the existing literature and to provide recommendations on emergency laparotomy and in frail patients. This position paper was reviewed by an international expert panel composed of 37 experts who were asked to critically revise the manuscript and position statements. The position paper was conducted according to the WSES methodology. We shall present the derived statements upon which a consensus was reached, specifying the quality of the supporting evidence and suggesting future research directions.

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.

2023 WSES guidelines for the prevention, detection, and management of iatrogenic urinary tract injuries (IUTIs) during emergency digestive surgery.

Iatrogenic urinary tract injury (IUTI) is a severe complication of emergency digestive surgery. It can lead to increased postoperative morbidity and mortality and have a long-term impact on the quality of life. The reported incidence of IUTIs varies greatly among the studies, ranging from 0.3 to 1.5%. Given the high volume of emergency digestive surgery performed worldwide, there is a need for well-defined and effective strategies to prevent and manage IUTIs. Currently, there is a lack of consensus regarding the prevention, detection, and management of IUTIs in the emergency setting. The present guidelines, promoted by the World Society of Emergency Surgery (WSES), were developed following a systematic review of the literature and an international expert panel discussion. The primary aim of these WSES guidelines is to provide evidence-based recommendations to support clinicians and surgeons in the prevention, detection, and management of IUTIs during emergency digestive surgery. The following key aspects were considered: (1) effectiveness of preventive interventions for IUTIs during emergency digestive surgery; (2) intra-operative detection of IUTIs and appropriate management strategies; (3) postoperative detection of IUTIs and appropriate management strategies and timing; and (4) effectiveness of antibiotic therapy (including type and duration) in case of IUTIs.

Enhanced perioperative care in emergency general surgery: the WSES position paper.

Enhanced perioperative care protocols become the standard of care in elective surgery with a significant improvement in patients' outcome. The key element of the enhanced perioperative care protocol is the multimodal and interdisciplinary approach targeted to the patient, focused on a holistic approach to reduce surgical stress and improve perioperative recovery. Enhanced perioperative care in emergency general surgery is still a debated topic with little evidence available. The present position paper illustrates the existing evidence about perioperative care in emergency surgery patients with a focus on each perioperative intervention in the preoperative, intraoperative and postoperative phase. For each item was proposed and approved a statement by the WSES collaborative group.

Use of Sengstaken-Blakemore intrahepatic balloon: an alternative for liver-penetrating injuries.

BACKGROUND: Severe lesions in the liver are associated with a high mortality rate. Alternative surgical techniques such as the use of an intrahepatic balloon may be effective and reduce mortality in severe hepatic lesions. This study aimed to demonstrate the experience of a university hospital in the use of the Sengstaken-Blakemore balloon in patients with transfixing penetrating hepatic injury as an alternative way to treat these challenging injuries. METHODS: A retrospective study based on the trauma registry of a university hospital was performed. All patients admitted with hepatic penetrating injuries and treated with the Sengstaken-Blakemore balloon within the period 1990-2010 were reviewed. RESULTS: Forty-six patients with transfixing hepatic injuries were treated with the Sengstaken-Blakemore balloon in the study period. The most frequent cause of injury was gunshot wound (87 % of the patients). The mean trauma scores on admission were Revised Trauma Score (RTS) = 7.12 ± 1.46, Injury Severity Score (ISS) = 22.4 ± 9.7, and Abdominal Trauma Index (ATI) = 19.5 ± 11. According to the severity of the hepatic trauma, 71.8 % of patients had grade III, 23.9 % grade IV, and 4.3 % grade V injuries. Associated abdominal injuries were found in 89.1 % of the patients. The most frequent liver-related complications were hepatic abscess postoperative bleeding (8.6 %), biliary fistula (8.6 %), (4.3 %), and biliary peritonitis (2.1 %). Surgical reintervention was necessary in 14 patients (31.1 %). From those 14, only 3 had the balloon removed. The overall morbidity and mortality rates were 56.5 % and 23.9 % (11 patients), respectively. CONCLUSION: The knowledge of alternative surgical techniques is essential in improving survival in patients with severe penetrating hepatic injuries. The use of intrahepatic balloon is a viable surgical strategy.

The role of teamwork and non-technical skills for improving emergency surgical outcomes: an international perspective.

The assurance of patient safety in emergency general surgery remains challenging due to the patients' high-risk underlying conditions and the wide variability in emergency surgical care provided around the globe. The authors of this article convened as an expert panel on patient safety in surgery at the 8th International Conference of the World Society of Emergency Surgery (WSES) in Edinburgh, Scotland, on September 7-10, 2021. This review article represents the proceedings from the expert panel discussions at the WSES congress and was designed to provide an international perspective on optimizing teamwork and non-technical skills in emergency general surgery.

WSES guidelines on blunt and penetrating bowel injury: diagnosis, investigations, and treatment.

The aim of this paper was to review the recent literature to create recommendations for the day-to-day diagnosis and surgical management of small bowel and colon injuries. Where knowledge gaps were identified, expert consensus was pursued during the 8th International Congress of the World Society of Emergency Surgery Annual (September 2021, Edinburgh). This process also aimed to guide future research.