Cesena guidelines: WSES consensus statement on laparoscopic-first approach to general surgery emergencies and abdominal trauma.

BACKGROUND: Laparoscopy is widely adopted across nearly all surgical subspecialties in the elective setting. Initially finding indication in minor abdominal emergencies, it has gradually become the standard approach in the majority of elective general surgery procedures. Despite many technological advances and increasing acceptance, the laparoscopic approach remains underutilized in emergency general surgery and in abdominal trauma. Emergency laparotomy continues to carry a high morbidity and mortality. In recent years, there has been a growing interest from emergency and trauma surgeons in adopting minimally invasive surgery approaches in the acute surgical setting. The present position paper, supported by the World Society of Emergency Surgery (WSES), aims to provide a review of the literature to reach a consensus on the indications and benefits of a laparoscopic-first approach in patients requiring emergency abdominal surgery for general surgery emergencies or abdominal trauma. 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 54 experts then critically revised the manuscript and discussed it in detail, to develop a consensus on a position statement. RESULTS: A total of 323 studies (systematic review and meta-analysis, randomized clinical trial, retrospective comparative cohort studies, case series) have been selected from an initial pool of 7409 studies. Evidence demonstrates several benefits of the laparoscopic approach in stable patients undergoing emergency abdominal surgery for general surgical emergencies or abdominal trauma. The selection of a stable patient seems to be of paramount importance for a safe adoption of a laparoscopic approach. In hemodynamically stable patients, the laparoscopic approach was found to be safe, feasible and effective as a therapeutic tool or helpful to identify further management steps and needs, resulting in improved outcomes, regardless of conversion. Appropriate patient selection, surgeon experience and rigorous minimally invasive surgical training, remain crucial factors to increase the adoption of laparoscopy in emergency general surgery and abdominal trauma. CONCLUSIONS: The WSES expert panel suggests laparoscopy as the first approach for stable patients undergoing emergency abdominal surgery for general surgery emergencies and abdominal trauma.

Biliary Sepsis Due to Recurrent Acute Calculus Cholecystitis (ACC) in a High Surgical-Risk Elderly Patient: An Unexpected Complication.

Acute calculus cholecystitis (ACC) is increasing in frequency within an ageing population, in which biliary tract infection, including cholecystitis and cholangitis, is the second most common cause of sepsis, with higher morbidity and mortality rates. Patient's critical conditions, such as septic shock or anaesthesiology contraindication, may be reasons to avoid laparoscopic cholecystectomy-the first-line treatment of ACC-preferring gallbladder drainage. It can aid in patient's stabilization with also the benefit of identifying the causative organism to establish a targeted antibiotic therapy, especially in patients at high risk for antimicrobial resistance such as healthcare-associated infection. Nevertheless, a recent randomized clinical trial showed that laparoscopic cholecystectomy can reduce the rate of major complications compared with percutaneous catheter drainage in critically ill patients too. On the other hand, among the possibilities to control biliary sepsis in non-operative management of ACC, according to recent meta-analysis, endoscopic gallbladder drainage showed better clinical success rate, and it is gaining popularity because of the potential advantage of allowing gallstones clearance to reduce recurrences of ACC. However, complications that may arise, although rare, can worsen an already weak clinical condition, as happened to the high surgical-risk elderly patient taken into account in our case report.

Adherence to Guidelines Influenced the Mortality, Hospital Stay, and Health Care System Costs in Patients With Acute Pancreatitis.

OBJECTIVES: The primary end point was the compliance rate with guidelines. The secondaries were mortality, hospital stay, and costs. METHODS: This study included 1904 patients with acute pancreatitis (AP): group A, diagnosed before 2013, and group B, after 2013. RESULTS: The compliance rate was 0.6%. The compliance rates increased for fluid resuscitation (3.3% vs 13.7%, P < 0.001), for antibiotics use (21.9% vs 28.1%, P = 0.002), for oral feeding (55.0% vs 49.7%, P = 0.007), and for correct use of endoscopic retrograde cholangiopancreatography (ERCP) (83% vs 91.9%, P < 0.001). Compliance to severity assessment with computed tomography (odds ratio [OR], 0.4; P = 0.029), parenteral nutrition recommendations (OR, 0.3; P = 0.009), and early surgery (OR, 0.3; P = 0.010) reduced the mortality. Compliance to antibiotic therapy (OR, 0.6; P < 0.001), correct use of parenteral nutrition (OR, 0.3; P < 0.001), correct use of ERCP (OR, 0.5; P < 0.001), and early surgery (OR, 0.3; P = 0.010) reduced hospital stay. The compliance reduced the costs for parenteral nutrition (P < 0.001), correct use of ERCP (P = 0.011), and surgery (P = 0.010). CONCLUSIONS: The adherence to guidelines for AP was low. Compliance could reduce mortality, prolonged hospital stay, and costs.