Venous Leg Ulcer Clinical Practice Guidelines: What is AGREEd?

OBJECTIVE: The aim was to evaluate the quality of current venous leg ulcer (VLU) clinical practice guidelines (CPGs) to assist healthcare professionals in choosing an accessible high quality CPG to advise their practice, and to identify areas for improvement in future versions of current CPGs. METHODS: A systematic review of PubMed, Embase, online CPG databases, and reference lists of included CPGs was carried out. Full text CPGs published no earlier than 1998 reporting evidence based recommendations on VLU diagnosis and management in English were included. CPGs that were only available if purchased were excluded. Two reviewers identified eligible CPGs, extracted data, and assessed the quality independently using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument. Significant scoring discrepancies were discussed with a third reviewer. RESULTS: Fourteen eligible CPGs were identified (1999-2016). The majority of CPGs originated from Europe or North America. Overall, there was good inter-reviewer reliability of scores with an intraclass correlation coefficient of 0.986 (95% confidence interval 0.979-0.991). No single CPG achieved the highest score in all six domains. Significant methodological heterogeneity was observed across VLU CPGs; however, consistently, poor performance was noted in domain 5, concerning CPG applicability. CONCLUSION: Four CPGs were considered of adequate quality for clinical use. Consolidation of efforts to drive high quality, comprehensive VLU CPGs is necessary to reduce the number of and heterogeneity seen in currently published guidelines. Elements of methodological quality are lacking and a structured approach with use of checklists and CPG creation tools, such as AGREE II or others, may bolster rigour in future VLU CPGs.

Operative management of acute abdomen after bariatric surgery in the emergency setting: the OBA guidelines.

BACKGROUND: Patients presenting with acute abdominal pain that occurs after months or years following bariatric surgery may present for assessment and management in the local emergency units. Due to the large variety of surgical bariatric techniques, emergency surgeons have to be aware of the main functional outcomes and long-term surgical complications following the most performed bariatric surgical procedures. The purpose of these evidence-based guidelines is to present a consensus position from members of the WSES in collaboration with IFSO bariatric experienced surgeons, on the management of acute abdomen after bariatric surgery focusing on long-term complications in patients who have undergone laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass. METHOD: A working group of experienced general, acute care, and bariatric surgeons was created to carry out a systematic review of the literature following the Preferred Reporting Items for Systematic Review and Meta-analysis Protocols (PRISMA-P) and to answer the PICO questions formulated after the Operative management in bariatric acute abdomen survey. The literature search was limited to late/long-term complications following laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass. CONCLUSIONS: The acute abdomen after bariatric surgery is a common cause of admission in emergency departments. Knowledge of the most common late/long-term complications (> 4 weeks after surgical procedure) following sleeve gastrectomy and Roux-en-Y gastric bypass and their anatomy leads to a focused management in the emergency setting with good outcomes and decreased morbidity and mortality rates. A close collaboration between emergency surgeons, radiologists, endoscopists, and anesthesiologists is mandatory in the management of this group of patients in the emergency setting.

Advice of General Practitioner, of Surgeon, of Endocrinologist, and Self-determination: the Italian Road to Bariatric Surgery.

PURPOSE: Bariatric surgery (BS) is considered the most efficient treatment for severe obesity. International guidelines recommend multidisciplinary approach to BS (general practitioners, endocrinologists, surgeons, psychologists, or psychiatrists), and access to BS should be the final part of a protocol of treatment of obesity. However, there are indications that general practitioners (GPs) are not fully aware of the possible benefits of BS, that specialty physicians are reluctant to refer their patients to surgeons, and that patients with obesity choose self-management of their own obesity, including internet-based choices. There are no data on the pathways chosen by physicians and patients to undergo BS in the real world in Italy. METHODS: An exploratory exam was performed for 6 months in three pilot regions (Lombardy, Lazio, Campania) in twenty-three tertiary centers for the treatment of morbid obesity, to describe the real pathways to BS in Italy. RESULTS: Charts of 2686 patients (788 men and 1895 women, 75.5% in the age range 30-59 years) were evaluated by physicians and surgeons of the participating centers. A chronic condition of obesity was evident for the majority of patients, as indicated by duration of obesity, by presence of several associated medical problems, and by frequency of previous dietary attempts to weight loss. The vast majority (75.8%) patients were self-presenting or referred by bariatric surgeons, 24.2% patients referred by GPs and other specialists. Self-presenting patients were younger, more educated, more professional, and more mobile than patients referred by other physicians. Patients above the age of 40 years or with a duration of obesity greater than 10 years had a higher prevalence of all associated medical problems. CONCLUSIONS: The majority of patients referred to a tertiary center for the treatment of morbid obesity have a valid indication for BS. Most patients self-refer to the centers, with a minority referred by a GP or by specialists. Self-presenting patients are younger, more educated, more professional, and more mobile than patients referred by other physicians. Older patients and with a longer duration of obesity are probably representative of the conservative approach to BS, often regarded as the last resort in an endless story.

The need for red blood cell transfusions in the emergency department as a risk factor for failure of non-operative management of splenic trauma: a multicenter prospective study.

INTRODUCTION: The majority of patients with splenic trauma undergo non-operative management (NOM); around 15% of these cases fail NOM and require surgery. The aim of the current study is to assess whether the hemodynamic status of the patient represents a risk factor for failure of NOM (fNOM) and if this may be considered a relevant factor in the decision-making process, especially in Centers where AE (angioembolization), intensive monitoring and 24-h-operating room are not available. Furthermore, the presence of additional risk factors for fNOM was investigated. MATERIALS AND METHODS: This is a multicentre prospective observational study, including patients presenting with blunt splenic trauma older than 17 years, managed between 2014 and 2016 in two Italian trauma centres (ASST Papa Giovanni XXIII in Bergamo and Sant'Anna University Hospital in Ferrara-Italy). The risk factors for fNOM were analyzed with univariate and multivariate analyses. RESULTS: In total, 124 patients were included in the study. In univariate analysis, the risk factors for fNOM were AAST grade > 3 (fNOM 37.5% vs 9.1%, p = 0.024), and the need of red blood cell (RBC) transfusion in the emergency department (ED) (fNOM 42.9% vs 8.9%, p = 0.011). Multivariate analysis showed that the only significant risk factor for fNOM was the need for RBC transfusion in the ED (p = 0.049). CONCLUSIONS: The current study confirms the contraindication to NOM in case of hemodynamically instability in case of splenic trauma, as indicated by the most recent guidelines; attention should be paid to patients with transient hemodynamic stability, including patients who require transfusion of RBC in the ED. These patients could benefit from AE; in centers where AE, intensive monitoring and an 24-h-operating room are not available, this particular subgroup of patients should probably be treated with operative management.

The World Society of Emergency Surgery (WSES) spleen trauma classification: a useful tool in the management of splenic trauma.

Background: The World Society of Emergency Surgery (WSES) spleen trauma classification meets the need of an evolution of the current anatomical spleen injury scale considering both the anatomical lesions and their physiologic effect. The aim of the present study is to evaluate the efficacy and trustfulness of the WSES classification as a tool in the decision-making process during spleen trauma management. Methods: Multicenter prospective observational study on adult patients with blunt splenic trauma managed between 2014 and 2016 in two Italian trauma centers (ASST Papa Giovanni XXIII in Bergamo and Sant'Anna University Hospital in Ferrara). Risk factors for operative management at the arrival of the patient and as a definitive treatment were analyzed. Moreover, the association between the different WSES grades of injury and the definitive management was analyzed. Results: One hundred twenty-four patients were included. At multivariate analysis, a WSES splenic injury grade IV is a risk factor for the operative management both at the arrival of the patients and as a definitive treatment. WSES splenic injury grade III is a risk factor for angioembolization. Conclusions: The WSES classification is a good and reliable tool in the decision-making process in splenic trauma management.

Splenic trauma: WSES classification and guidelines for adult and pediatric patients.

Spleen injuries are among the most frequent trauma-related injuries. At present, they are classified according to the anatomy of the injury. The optimal treatment strategy, however, should keep into consideration the hemodynamic status, the anatomic derangement, and the associated injuries. The management of splenic trauma patients aims to restore the homeostasis and the normal physiopathology especially considering the modern tools for bleeding management. Thus, the management of splenic trauma should be ultimately multidisciplinary and based on the physiology of the patient, the anatomy of the injury, and the associated lesions. Lastly, as the management of adults and children must be different, children should always be treated in dedicated pediatric trauma centers. In fact, the vast majority of pediatric patients with blunt splenic trauma can be managed non-operatively. This paper presents the World Society of Emergency Surgery (WSES) classification of splenic trauma and the management guidelines.

IROA: International Register of Open Abdomen, preliminary results.

BACKGROUND: No definitive data about open abdomen (OA) epidemiology and outcomes exist. The World Society of Emergency Surgery (WSES) and the Panamerican Trauma Society (PTS) promoted the International Register of Open Abdomen (IROA). METHODS: A prospective observational cohort study including patients with an OA treatment. Data were recorded on a web platform (Clinical Registers®) through a dedicated website: www.clinicalregisters.org. RESULTS: Four hundred two patients enrolled. Adult patients: 369 patients; Mean age: 57.39±18.37; 56% male; Mean BMI: 36±5.6. OA indication: Peritonitis (48.7%), Trauma (20.5%), Vascular Emergencies/Hemorrhage (9.4%), Ischemia (9.1%), Pancreatitis (4.2%),Post-operative abdominal-compartment-syndrome (3.9%), Others (4.2%). The most adopted Temporary-abdominal-closure systems were the commercial negative pressure ones (44.2%). During OA 38% of patients had complications; among them 10.5% had fistula. Definitive closure: 82.8%; Mortality during treatment: 17.2%. Mean duration of OA: 5.39(±4.83) days; Mean number of dressing changes: 0.88(±0.88). After-closure complications: (49.5%) and Mortality: (9%). No significant associations among TACT, indications, mortality, complications and fistula. A linear correlationexists between days of OA and complications (Pearson linear correlation = 0.326 p<0.0001) and with the fistula development (Pearson = 0.146 p= 0.016). Pediatric patients: 33 patients. Mean age: 5.91±(3.68) years; 60% male. Mortality: 3.4%; Complications: 44.8%; Fistula: 3.4%. Mean duration of OA: 3.22(±3.09) days. CONCLUSION: Temporary abdominal closure is reliable and safe. The different techniques account for different results according to the different indications. In peritonitis commercial negative pressure temporary closure seems to improve results. In trauma skin-closure and Bogotà-bag seem to improve results. TRIAL REGISTRATION: ClinicalTrials.gov NCT02382770.

Erratum to: IROA: International Register of Open Abdomen, preliminary results.

[This corrects the article DOI: 10.1186/s13017-017-0123-8.].

Benign multicystic mesothelioma of peritoneum complicating acute appendicitis in a man: a case report.

BACKGROUND: Benign multicystic mesothelioma is a rare pathology. Few cases are reported in the medical literature and acute presentation is extremely uncommon. CASE PRESENTATION: We describe an acute clinical presentation of the neoplasm that revealed itself with signs and symptoms attributable to acute appendicitis in a 41-year-old white man. Abdominal echography and computed tomography scans demonstrated the presence of a mass in direct contiguity with cecal fundus, but diagnosis remained unclear. Our patient underwent surgery and complete removal of the neoplasm. Only a definitive histological examination defined the nature of the lesion. No signs of relapse were demonstrated 1 year after the operation. CONCLUSIONS: We showed that an acute presentation of a benign neoplasm represents a diagnostic and therapeutic challenge for the surgeon, because of the difficult differential diagnosis that acute presentation can sometimes pose and the trouble that an emergence treatment can imply.

An approach to complicated diverticular disease. A retrospective study in an Acute Care Surgery service recently established.

AIM: Acute diverticulitis is a frequent disease in the Western Countries. The increase number of patients admitted in the Surgery Departments led the necessity of new Scores and Classifications in order to clarify, in absence of clear guidelines, the best treatments to offer in the different situations. METHODS: A retrospective study of ninety-nine patients treated in our Department from June 2010 and March 2015. RESULTS: In our study 41 patients were treated conservatively, the remaining 58 were operated, 56 laparotomic and 2 laparoscopic. 5 patients submitted US guided drainage of abscess which failed in 2 cases. 25 submitted Hartmann's Procedure (HP), 29 Primary Resection and Anastomosis (PRA), 3 Contemporary Closure of Perforated Diverticula (CC) and just 2 Laparoscopic Peritoneal Lavage and Drainage (LPL). We related different Hinchey groups and up-groups with the treatments approached, identifying patients risk factors, ASA score and complications. DISCUSSION: The treatment of perforated diverticulitis is debated. CT scan is becoming an useful instrument to make a correct diagnosis. Hinchey I and II patients are preferentially treated conservatively except in cases of complicated presentations. Hinchey III and IV are necessarily treated with surgical approach. We analyze the different types of intervention currently approached. CONCLUSION: We believe in PRA in Hinchey III and IV selected patients, HP is the gold standard in higher ASA scores patients but the low number of stoma reversal remains an open problem. Many studies are ongoing concerning LPL and now there are insufficient data to think of a widespread use of this technique. Key words: CT scan, Diverticular Disease, Hartmann's Procedure, Intr-abdominal abscess, Laparoscopic Peritoneal Lavage and Drainage (LPL), Peritonitis, Primary Resection and Anastomosis (PRAHinchey Classification, US and CT guided drainage.