Common bile duct stones management: A network meta-analysis.

BACKGROUND: Timely management is critical for treating symptomatic common bile duct (CBD) stones; however, a single optimal management strategy has yet to be defined in the acute care setting. Consequently, this systematic review and network meta-analysis, comparing one-stage (CBD exploration or intraoperative endoscopic retrograde cholangiopancreatography [ERCP] with simultaneous cholecystectomy) and two-stage (precholecystectomy or postcholecystectomy ERCP) procedures, was undertaken with the main outcomes of interest being postprocedural complications and hospital length of stay (LOS). METHODS: PubMed, SCOPUS, MEDLINE, Embase, and Cochrane Central Register of Controlled Trials were methodically queried for articles from 2010 to 2021. The search terms were a combination of medical subject headings terms and the subsequent terms: gallstone; common bile duct (stone); choledocholithiasis; cholecystitis; endoscopic retrograde cholangiography/ERCP; common bile duct exploration; intraoperative, preoperative, perioperative, and postoperative endoscopic retrograde cholangiography; stone extraction; and one-stage and two-stage procedure. Studies that compared two procedures or more were included, whereas studies not recording complications (bile leak, hemorrhage, pancreatitis, perforation, intra-abdominal infections, and other infections) or LOS were excluded. A network meta-analysis was conducted to compare the four different approaches for managing CBD stones. RESULTS: A total of 16 studies (8,644 participants) addressing the LOS and 41 studies (19,756 participants) addressing postprocedural complications were included in the analysis. The one-stage approaches were associated with a decrease in LOS compared with the two-stage approaches. Common bile duct exploration demonstrated a lower overall risk of complications compared with preoperative ERCP, but there were no differences in the overall risk of complications in the remaining comparisons. However, differences in specific postprocedural complications were detected between the four different approaches managing CBD stones. CONCLUSION: This network meta-analysis suggests that both laparoscopic CBD exploration and intraoperative ERCP have equally good outcomes and provide a preferable single-anesthesia patient pathway with a shorter overall length of hospital stay compared with the two-stage approaches. LEVEL OF EVIDENCE: Systematic Review/Meta Analysis; Level III.

Not only FAST The MUSEC® experience in training surgeons.

For a long time surgeons have been discussing the need to improve their skills in the use of ultrasound (US). However in the recent years it has become evident the importancxe for general aklnd trauma surgeons treating critically-ill patients to learn basic and advanced US. The two last editions (9th and 10th) of the ATLS manual have officially included FAST and e-FAST in the primary assessment of trauma patients, making this tool an essential skill for surgeons. In the acute care setting FAST, e-FAST and other applications have gained a pivotal, evidence-based role in this fields. Nevertheless, surgeons are rarely performing US exams by themselves, losing a major decision-making tool. The Modular Ultrasound ESTES Course (MUSEC®) was developed to provide both fundamental and advanced US training for surgeons in trauma and acute care settings. We are strongly convinced, in the light of the results from both the surveys carried out and the customer satisfaction tests administered to all the participants in the MUSEC courses, that US courses such as these should be part of the general surgery residency programs. KEY WORDS: e-FAST, MUSEC Ultrasound in Emergency Department, Ultrasound Training Trauma Patients.

Enhanced Recovery After Surgery (ERAS) - The Evidence in Geriatric Emergency Surgery: A Systematic Review.

Background: Geriatric surgery is rising and projected to continue at a greater rate. There is already concern about the poor outcomes for the emergency surgery in elderly. How to manage the available resources to improve outcomes in this group of patients is an important object of debate. OBJECTIVES: We aimed to determine the feasibility and safety of applying ERAS pathways to emergency elderly surgical patients. METHOD: Two searches were undertaken for ERAS protocols in elderly patients and emergency surgery, in order to gather evidence in relation to ERAS in geriatric emergency patients. Primary outcomes were postoperative complications, mortality, hospital length of stay and readmission rates. Results: Eighteen studies were included. The majority of patients were older than 70. Elderly patients had fewer postoperative complications and a reduced hospitalization with ERAS compared to conventional care. Emergency surgical patients also had fewer postoperative complications with ERAS compared to conventional care. Hospital stay was reduced in 2 out of 3 studies for emergency surgery. Conclusions: ERAS can be safely applied to elderly and emergency patients with a reduction in postoperative complications, hospitalization and readmission rates. There is evidence to suggest that ERAS is feasible and beneficial for geriatric emergency patients.

Seat Belt Syndrome and the Submarine Effect: A Case Report.

The seatbelt sign is indicative of severe internal lesions in as many as 30% of cases. In the "submarine effect" the body slides below the belt, acting like hinge. "Seatbelt syndrome" describes the presence of the seat belt sign plus an intra-abdominal or spinal injury. We present the case of a driver in a car accident in whom severe soft tissue and visceral lesions were caused by a two-point seat-belt reproducing a complete "seatbelt syndrome".

Enhanced Recovery after Emergency Surgery: A Systematic Review.

OBJECTIVE: To evaluate the current scientific evidence for the applicability, safety and effectiveness of pathways of enhanced recovery after emergency surgery (ERAS). METHODS: We undertook a search using PubMed and Cochrane databases for ERAS protocols in emergency cases. The search generated 65 titles; after eliminating the papers not meeting search criteria, we selected 4 cohort studies and 1 randomized clinical trial (RCT). Data extracted for analysis consisted of: patient age, type of surgery performed, ERAS elements implemented, surgical outcomes in terms of postoperative complications, mortality, length of stay (LOS) and readmission rate. RESULTS: The number of ERAS items applied was good, ranging from 11 to 18 of the 20 recommended by the ERAS Society. The implementation resulted in fewer postoperative complications. LOS for ES patients was shorter when compared to conventional care. Mortality, specifically reported in three studies, was equal or lower with ERAS. Readmission rates varied widely and were generally higher for the intervention group but without statistical significance. CONCLUSIONS: The studies reviewed agreed that ERAS in emergency surgery (ES) was feasible and safe with generally better outcomes. Lower compliance with some of the ERAS items shows the need for the protocol to be adapted to ES patients. More evidence is clearly required as to what can improve outcomes and how this can be formulated into an effective care pathway for the heterogeneous ES patient.