Fulminant Emphysematous Pancreatitis: Diagnosis Time Counts.

Emphysematous pancreatitis (EP), a severe form of necrotizing infection of the pancreas, is an extremely rare medical emergency with high rates of mortality. It is characterized by intraparenchymal pancreatic or peri-pancreatic air due to either monomicrobial or polymicrobial infection with gas-forming bacteria or due to entero-pancreatic fistula. EP is classified according to timing from disease onset when air bubble signs were detected on computed tomography (CT) scan, as early onset (within 2 weeks from disease onset) or late (more than 2 weeks from disease onset). While most cases of acute pancreatitis are resolved with supportive care alone, clinical outcomes of EP, especially the early onset subtype, are very poor with high rates of morbidity and mortality. These two case reports present the clinical features, diagnostic investigations, and management of two patients admitted to our hospital with early onset fulminant EP, each investigated and managed with different approaches. The first patient underwent a more conservative treatment, with diagnosis being made 52 h following admission, and thus, intensive care unit (ICU) admission and surgery were postponed, while the second patient was diagnosed a few hours following presentation with earlier ICU admission. In this article, we will present the critical importance of early diagnosis of the aforementioned rare entity of severe pancreatitis and will consider the consequences of rapid diagnosis on disease course, morbidity and mortality.

Intractable Postoperative Pancreatic Fistula: Undefined Type of Pancreatic Fistula Managed by Puestow-Like Procedure.

Pancreatoduodenectomy (PD) is a very complex and highly challenging operation for surgeons worldwide. It is the surgical procedure of choice for the management of benign and malignant diseases of the periampullary region. Although mortality rate following this complicated surgery has fallen to 1-3%, morbidity rate following PD remains high, with almost 30-40% of patients developing at least one complication. Postoperative pancreatic fistula (POPF) is one of the most common complications following PD. Therefore, Pancreatico-enteric anastomosis has been regarded as the "Achilles heel" of the modern, one-stage PD procedure. According to the International Study Group of Pancreatic Surgery (ISGPS), three types of POPF are recognized nowadays: biochemical leak, previously known as grade A POPF, grade B and grade C, with the latter being the most dangerous. Most POPFs, especially of the biochemical leak and grade B heal with non-operative management to recur later and present as an intra-abdominal abscess or pseudocyst, necessitating management by means of interventional radiology, endoscopy or surgery. These types of fistulas are undefined and occasionally intractable. Herein, we present two patients who presented with the aforementioned type of pancreatic fistula following duct occlusion PD. The first patient, a 53-year-old female patient, suffered from intolerance to oral feeding, severe weight loss and recurrent hospital admission, while the second patient, a 72-year-old patient, suffered from recurrent bouts of abdominal sepsis. Their management involved step-up approach, starting with non-operative management, followed by percutaneous drainage and operative treatment in the form of Puestow-like procedure (longitudinal pancreatojejunostomy), as a recourse due to the inadequacy of preceding therapeutic modalities.

The role of RObotic surgery in EMergency setting (ROEM): protocol for a multicentre, observational, prospective international study on the use of robotic platform in emergency surgery.

BACKGROUND: Robotic surgery has gained widespread acceptance in elective interventions, yet its role in emergency procedures remains underexplored. While the 2021 WSES position paper discussed limited studies on the application of robotics in emergency general surgery, it recommended strict patient selection, adequate training, and improved platform accessibility. This prospective study aims to define the role of robotic surgery in emergency settings, evaluating intraoperative and postoperative outcomes and assessing its feasibility and safety. METHODS: The ROEM study is an observational, prospective, multicentre, international analysis of clinically stable adult patients undergoing robotic surgery for emergency treatment of acute pathologies including diverticulitis, cholecystitis, and obstructed hernias. Data collection includes patient demographics and intervention details. Furthermore, data relating to the operating theatre team and the surgical instruments used will be collected in order to conduct a cost analysis. The study plans to enrol at least 500 patients from 50 participating centres, with each centre having a local lead and collaborators. All data will be collected and stored online through a secure server running the Research Electronic Data Capture (REDCap) web application. Ethical considerations and data governance will be paramount, requiring local ethical committee approvals from participating centres. DISCUSSION: Current literature and expert consensus suggest the feasibility of robotic surgery in emergencies with proper support. However, challenges include staff training, scheduling conflicts with elective surgeries, and increased costs. The ROEM study seeks to contribute valuable data on the safety, feasibility, and cost-effectiveness of robotic surgery in emergency settings, focusing on specific pathologies. Previous studies on cholecystitis, abdominal hernias, and diverticulitis provide insights into the benefits and challenges of robotic approaches. It is necessary to identify patient populations that benefit most from robotic emergency surgery to optimize outcomes and justify costs.

The Operating Room management for emergency Surgical Activity (ORSA) study: a WSES international survey.

BACKGROUND: Despite advances and improvements in the management of surgical patients, emergency and trauma surgery is associated with high morbidity and mortality. This may be due in part to delays in definitive surgical management in the operating room (OR). There is a lack of studies focused on OR prioritization and resource allocation in emergency surgery. The Operating Room management for emergency Surgical Activity (ORSA) study was conceived to assess the management of operating theatres and resources from a global perspective among expert international acute care surgeons. METHOD: The ORSA study was conceived as an international web survey. The questionnaire was composed of 23 multiple-choice and open questions. Data were collected over 3 months. Participation in the survey was voluntary and anonymous. RESULTS: One hundred forty-seven emergency and acute care surgeons answered the questionnaire; the response rate was 58.8%. The majority of the participants come from Europe. One hundred nineteen surgeons (81%; 119/147) declared to have at least one emergency OR in their hospital; for the other 20/147 surgeons (13.6%), there is not a dedicated emergency operating room. Forty-six (68/147)% of the surgeons use the elective OR to perform emergency procedures during the day. The planning of an emergency surgical procedure is done by phone by 70% (104/147) of the surgeons. CONCLUSIONS: There is no dedicated emergency OR in the majority of hospitals internationally. Elective surgical procedures are usually postponed or even cancelled to perform emergency surgery. It is a priority to validate an effective universal triaging and scheduling system to allocate emergency surgical procedures. The new Timing in Acute Care Surgery (TACS) was recently proposed and validated by a Delphi consensus as a clear and reproducible triage tool to timely perform an emergency surgical procedure according to the clinical severity of the surgical disease. The new TACS needs to be prospectively validated in clinical practice. Logistics have to be assessed using a multi-disciplinary approach to improve patients' safety, optimise the use of resources, and decrease costs.

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.

Strategies to prevent blood loss and reduce transfusion in emergency general surgery, WSES-AAST consensus paper.

Emergency general surgeons often provide care to severely ill patients requiring surgical interventions and intensive support. One of the primary drivers of morbidity and mortality is perioperative bleeding. In general, when addressing life threatening haemorrhage, blood transfusion can become an essential part of overall resuscitation. However, under all circumstances, indications for blood transfusion must be accurately evaluated. When patients decline blood transfusions, regardless of the reason, surgeons should aim to provide optimal care and respect and accommodate each patient's values and target the best outcome possible given the patient's desires and his/her clinical condition. The aim of this position paper was to perform a review of the existing literature and to provide comprehensive recommendations on organizational, surgical, anaesthetic, and haemostatic strategies that can be used to provide optimal peri-operative blood management, reduce, or avoid blood transfusions and ultimately improve patient outcomes.