Publications by authors named "Walter L Biffl"

174 Publications

Diagnosis and management of small bowel obstruction in virgin abdomen: a WSES position paper.

World J Emerg Surg 2021 Jul 3;16(1):36. Epub 2021 Jul 3.

Department of Surgery, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.

Background: Small bowel obstruction (SBO) is a common surgical emergency, causing high morbidity and healthcare costs. The majority of SBOs are caused by adhesions that result from previous surgeries. Bowel obstruction, however, also occurs in patients without previous operation or known pathology, a so called virgin abdomen. It is unknown if small bowel obstruction in the virgin abdomen (SBO-VA) can be managed according to the same principles as other cases of small bowel obstruction. The aim of this position paper is to evaluate the available evidence on etiology and management of small bowel obstruction in the virgin abdomen.

Methods: This is a narrative review with scoping aspects. Clinical topics covered in this review include epidemiology and etiology of SBO-VA, diagnosis and imaging, initial assessment, the role of surgical management in SBO-VA, and the role of non-operative management in SBO-VA.

Results: Our scoping search revealed seven original studies reporting original patient data related to SBO-VA. All the included studies are retrospective cohorts, with populations ranging between 44 and 103 patients with SBO-VA. Adhesions were found to be the cause of the obstruction in approximately half of the reported cases of SBO-VA. A relatively high number of cases of SBO-VA were managed surgically with studies reporting 39-83%. However, in cases where a trial of non-operative management was started, this was generally successful.

Conclusion: The data available suggest that etiology and treatment results for patients with SBO-VA are largely comparable to the results in patients with SBO after previous abdominal surgery. We therefore propose that patients with a virgin abdomen could be treated according to existing guidelines for SBO and adhesive small bowel obstruction.
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http://dx.doi.org/10.1186/s13017-021-00379-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8254282PMC
July 2021

2020 WSES guidelines for the detection and management of bile duct injury during cholecystectomy.

World J Emerg Surg 2021 Jun 10;16(1):30. Epub 2021 Jun 10.

Rothschild Hospital, AP-HP, Paris, and Université de Paris, Paris, France.

Bile duct injury (BDI) is a dangerous complication of cholecystectomy, with significant postoperative sequelae for the patient in terms of morbidity, mortality, and long-term quality of life. BDIs have an estimated incidence of 0.4-1.5%, but considering the number of cholecystectomies performed worldwide, mostly by laparoscopy, surgeons must be prepared to manage this surgical challenge. Most BDIs are recognized either during the procedure or in the immediate postoperative period. However, some BDIs may be discovered later during the postoperative period, and this may translate to delayed or inappropriate treatments. Providing a specific diagnosis and a precise description of the BDI will expedite the decision-making process and increase the chance of treatment success. Subsequently, the choice and timing of the appropriate reconstructive strategy have a critical role in long-term prognosis. Currently, a wide spectrum of multidisciplinary interventions with different degrees of invasiveness is indicated for BDI management. These World Society of Emergency Surgery (WSES) guidelines have been produced following an exhaustive review of the current literature and an international expert panel discussion with the aim of providing evidence-based recommendations to facilitate and standardize the detection and management of BDIs during cholecystectomy. In particular, the 2020 WSES guidelines cover the following key aspects: (1) strategies to minimize the risk of BDI during cholecystectomy; (2) BDI rates in general surgery units and review of surgical practice; (3) how to classify, stage, and report BDI once detected; (4) how to manage an intraoperatively detected BDI; (5) indications for antibiotic treatment; (6) indications for clinical, biochemical, and imaging investigations for suspected BDI; and (7) how to manage a postoperatively detected BDI.
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http://dx.doi.org/10.1186/s13017-021-00369-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8190978PMC
June 2021

Drug and alcohol positivity of traumatically injured patients related to COVID-19 stay-at-home orders.

Am J Drug Alcohol Abuse 2021 Jun 4:1-7. Epub 2021 Jun 4.

Department of Surgery, University of California, Irvine, CA, USA.

: COVID-19 related stay-at-home (SAH) orders created many economic and social stressors, possibly increasing the risk of drug/alcohol abuse in the community and trauma population.: Describe changes in alcohol/drug use in traumatically injured patients after SAH orders in California and evaluate demographic or injury pattern changes in alcohol or drug-positive patients.: A retrospective analysis of 11 trauma centers in Southern California (1/1/2020-6/30/2020) was performed. Blood alcohol concentration, urine toxicology results, demographics, and injury characteristics were collected. Patients were grouped based on injury date - before SAH (PRE-SAH), immediately after SAH (POST-SAH), and a historical comparison (3/19/2019-6/30/2019) (CONTROL) - and compared in separate analyses. Groups were compared using chi-square tests for categorical variables and Mann-Whitney U tests for continuous variables.: 20,448 trauma patients (13,634 male, 6,814 female) were identified across three time-periods. The POST-SAH group had higher rates of any drug (26.2% vs. 21.6% and 24.7%, OR = 1.26 and 1.08, < .001 and = .035), amphetamine (10.4% vs. 7.5% and 9.3%, OR = 1.43 and 1.14, < .001 and = .023), tetrahydrocannabinol (THC) (13.8% vs. 11.0% and 11.4%, OR = 1.30 and 1.25, < .001 and < .001), and 3,4-methylenedioxy methamphetamine (MDMA) (0.8% vs. 0.4% and 0.2%, OR = 2.02 and 4.97, = .003 and < .001) positivity compared to PRE-SAH and CONTROL groups. Alcohol concentration and positivity were similar between groups ( > .05).: This Southern California multicenter study demonstrated increased amphetamine, MDMA, and THC positivity in trauma patients after SAH, but no difference in alcohol positivity or blood concentration. Drug prevention strategies should continue to be adapted within and outside of hospitals during a pandemic.
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http://dx.doi.org/10.1080/00952990.2021.1904967DOI Listing
June 2021

Don't Mess with the Pancreas! A Multicenter Analysis of the Management of Low-Grade Pancreatic Injuries.

J Trauma Acute Care Surg 2021 May 25. Epub 2021 May 25.

Introduction: Current guidelines recommend nonoperative management (NOM) of low-grade (AAST-OIS grade I-II) pancreatic injuries (LGPIs), and drainage rather than resection for those undergoing operative management, but they are based on low quality evidence. The purpose of this study was to review the contemporary management and outcomes of LGPIs and identify risk factors for morbidity.

Methods: Multicenter retrospective review of diagnosis, management, and outcomes of adult pancreatic injuries from 2010-2018. The primary outcome was pancreas-related complications (PRCs). Predictors of PRCs were analyzed using multivariate logistic regression.

Results: 29 centers submitted data on 728 patients with LGPI (76% male; mean age 38; 37% penetrating; 51% grade I; median ISS 24). Among 24-hour survivors, definitive management was NOM in 31%, surgical drainage alone in 54%, resection in 10%, and pancreatic debridement or suturing in 5%. The incidence of PRCs was 21% overall, and was 42% after resection, 26% after drainage, and 4% after NOM. On multivariate analysis, independent risk factors for PRC were other intra-abdominal injury (OR 2.30; 1.16, 15.28), low volume (OR 2.88; 1.65, 5.06), and penetrating injury (OR 3.42; 1.80, 6.58). Resection was very close to significance (OR 2.06; 0.97, 4.34) (p = 0.0584).

Conclusion: The incidence of PRCs is significant after LGPIs. Patients who undergo pancreatic resection have PRC rates equivalent to patients resected for HGPIs. Those who underwent surgical drainage had slightly lower PRC rate, but only 4% of those who underwent NOM had PRCs. In patients with LGPIs, resection should be avoided. The NOM strategy should be employed whenever possible and studied prospectively, particularly in penetrating trauma.

Level Of Evidence: Level III, Retrospective Diagnostic/Therapeutic Study.
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http://dx.doi.org/10.1097/TA.0000000000003293DOI Listing
May 2021

COVID-19 in trauma: a propensity-matched analysis of COVID and non-COVID trauma patients.

Eur J Trauma Emerg Surg 2021 May 25. Epub 2021 May 25.

Department of Surgery, University of California, Irvine (UCI), 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA.

Purpose: There is mounting evidence that surgical patients with COVID-19 have higher morbidity and mortality than patients without COVID-19. Infection is prevalent amongst the trauma population, but any effect of COVID-19 on trauma patients is unknown. We aimed to evaluate the effect of COVID-19 on a trauma population, hypothesizing increased mortality and pulmonary complications for COVID-19-positive (COVID) trauma patients compared to propensity-matched COVID-19-negative (non-COVID) patients.

Methods: A retrospective analysis of trauma patients presenting to 11 Level-I and II trauma centers in California between 1/1/2019-6/30/2019 and 1/1/2020-6/30/2020 was performed. A 1:2 propensity score model was used to match COVID to non-COVID trauma patients using age, blunt/penetrating mechanism, injury severity score, Glasgow Coma Scale score, systolic blood pressure, respiratory rate, and heart rate. Outcomes were compared between the two groups.

Results: A total of 20,448 trauma patients were identified during the study period. 53 COVID trauma patients were matched with 106 non-COVID trauma patients. COVID patients had higher rates of mortality (9.4% vs 1.9%, p = 0.029) and pneumonia (7.5% vs. 0.0%, p = 0.011), as well as a longer mean length of stay (LOS) (7.47 vs 3.28 days, p < 0.001) and intensive care unit LOS (1.40 vs 0.80 days, p = 0.008), compared to non-COVID patients.

Conclusion: This multicenter retrospective study found increased rates of mortality and pneumonia, as well as a longer LOS, for COVID trauma patients compared to a propensity-matched cohort of non-COVID patients. Further studies are warranted to validate these findings and to elucidate the underlying pathways responsible for higher mortality in COVID trauma patients.
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http://dx.doi.org/10.1007/s00068-021-01699-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8143988PMC
May 2021

Trauma resource pit stop: increasing efficiency in the evaluation of lower severity trauma patients.

Trauma Surg Acute Care Open 2021 28;6(1):e000670. Epub 2021 Apr 28.

Trauma Service, Scripps Memorial Hospital La Jolla, La Jolla, California, USA.

Background: Overtriage of trauma patients is unavoidable and requires effective use of hospital resources. A 'pit stop' (PS) was added to our lowest tier trauma resource (TR) triage protocol where the patient stops in the trauma bay for immediate evaluation by the emergency department (ED) physician and trauma nursing. We hypothesized this would allow for faster diagnostic testing and disposition while decreasing cost.

Methods: We performed a before/after retrospective comparison after PS implementation. Patients not meeting trauma activation (TA) criteria but requiring trauma center evaluation were assigned as a TR for an expedited PS evaluation. A board-certified ED physician and trauma/ED nurse performed an immediate assessment in the trauma bay followed by performance of diagnostic studies. Trauma surgeons were readily available in case of upgrade to TA. We compared patient demographics, Injury Severity Score, time to physician evaluation, time to CT scan, hospital length of stay, and in-hospital mortality. Comparisons were made using 95% CI for variance and SD and unpaired t-tests for two-tailed p values, with statistical difference, p<0.05.

Results: There were 994 TAs and 474 TRs in the first 9 months after implementation. TR's preanalysis versus postanalysis of the TR group shows similar mean door to physician evaluation times (6.9 vs. 8.6 minutes, p=0.1084). Mean door to CT time significantly decreased (67.7 vs. 50 minutes, p<0.001). 346 (73%) TR patients were discharged from ED; 2 (0.4%) were upgraded on arrival. When admitted, TR patients were older (61.4 vs. 47.2 years, p<0.0001) and more often involved in a same-level fall (59.5% vs. 20.1%, p<0.0001). Undertriage was calculated using the Cribari matrix at 3.2%.

Discussion: PS implementation allowed for faster door to CT time for trauma patients not meeting activation criteria without mobilizing trauma team resources. This approach is safe, feasible, and simultaneously decreases hospital cost while improving allocation of trauma team resources.

Level Of Evidence: Level II, economic/decision therapeutic/care management study.
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http://dx.doi.org/10.1136/tsaco-2020-000670DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8094379PMC
April 2021

WSES-AAST guidelines: management of inflammatory bowel disease in the emergency setting.

World J Emerg Surg 2021 May 11;16(1):23. Epub 2021 May 11.

Department of Surgical Sciences, Policlinico Sant'Orsola Malpighi, Bologna, Italy.

Background: Despite the current therapeutic options for the treatment of inflammatory bowel disease, surgery is still frequently required in the emergency setting, although the number of cases performed seems to have decreased in recent years. The World Society of Emergency Surgery decided to debate in a consensus conference of experts, the main pertinent issues around the management of inflammatory bowel disease in the emergent situation, with the need to provide focused guidelines for acute care and emergency surgeons.

Method: A group of experienced surgeons and gastroenterologists were nominated to develop the topics assigned and answer the questions addressed by the Steering Committee of the project. Each expert followed a precise analysis and grading of the studies selected for review. Statements and recommendations were discussed and voted at the Consensus Conference of the 6th World Society of Emergency Surgery held in Nijmegen (The Netherlands) in June 2019.

Conclusions: Complicated inflammatory bowel disease requires a multidisciplinary approach because of the complexity of this patient group and disease spectrum in the emergency setting, with the aim of obtaining safe surgery with good functional outcomes and a decreasing stoma rate where appropriate.
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http://dx.doi.org/10.1186/s13017-021-00362-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8111988PMC
May 2021

COVID-19 pandemic: the second phase, are we ready now? An emergency surgeons' manifesto.

Minerva Surg 2021 06 14;76(3):289-290. Epub 2021 Apr 14.

Department of Trauma and Emergency Surgery, University Hospital of Parma, Parma, Italy.

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http://dx.doi.org/10.23736/S2724-5691.21.08699-5DOI Listing
June 2021

The coronavirus disease 2019 (COVID-19) stay-at-home order's unequal effects on trauma volume by insurance status in Southern California.

Surgery 2021 Mar 5. Epub 2021 Mar 5.

University of California, Irvine (UCI), Department of Surgery, Orange, CA.

Background: The rapid spread of coronavirus disease 2019 in the United States led to a variety of mandates intended to decrease population movement and "flatten the curve." However, there is evidence some are not able to stay-at-home due to certain disadvantages, thus remaining exposed to both coronavirus disease 2019 and trauma. We therefore sought to identify any unequal effects of the California stay-at-home orders between races and insurance statuses in a multicenter study utilizing trauma volume data.

Methods: A posthoc multicenter retrospective analysis of trauma patients presenting to 11 centers in Southern California between the dates of January 1, 2020, and June 30, 2020, and January 1, 2019, and June 30, 2019, was performed. The number of trauma patients of each race/insurance status was tabulated per day. We then calculated the changes in trauma volume related to stay-at-home orders for each race/insurance status and compared the magnitude of these changes using statistical resampling.

Results: Compared to baseline, there was a 40.1% drop in total trauma volume, which occurred 20 days after stay-at-home orders. During stay-at-home orders, the average daily trauma volume of patients with Medicaid increased by 13.7 ± 5.3%, whereas the volume of those with Medicare, private insurance, and no insurance decreased. The average daily trauma volume decreased for White, Black, Asian, and Latino patients with the volume of Black and Latino patients dropping to a similar degree compared to White patients.

Conclusion: This retrospective multicenter study demonstrated that patients with Medicaid had a paradoxical increase in trauma volume during stay-at-home orders, suggesting that the most impoverished groups remain disproportionately exposed to trauma during a pandemic, further exacerbating existing health disparities.
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http://dx.doi.org/10.1016/j.surg.2021.02.060DOI Listing
March 2021

A multicenter trial of current trends in the diagnosis and management of high-grade pancreatic injuries.

J Trauma Acute Care Surg 2021 05;90(5):776-786

From the Scripps Memorial Hospital La Jolla (WLB, FZZ, MC, KBS), La Jolla, CA; Maine Medical Center (BM), Portland, ME; Memorial Hermann Hospital (MM), Houston, TX; University of Oklahoma (JL), Oklahoma City, OK; Ryder Trauma Center (SB), Miami, FL; University of California-San Diego (JW), San Diego, CA; San Francisco General Hospital (RC, LK), San Francisco, CA; University of Calgary (CCGB), Calgary, Alberta, Canada; University of California-Irvine (JN), Irvine, CA; North Memorial Health Hospital (MW), Robbinsdale, MN; University of California-Davis (GJJ), Sacramento, CA; Grady Memorial Hospital (SRT), Atlanta, GA; Hadassah- Hebrew University Medical Center (MB), Jerusalem, Israel; Grant Medical Center (CS), Columbus, OH; Ernest E. Moore Shock Trauma Center at Denver Health (EEM), Denver, CO.

Background: Outcomes following pancreatic trauma have not improved significantly over the past two decades. A 2013 Western Trauma Association algorithm highlighted emerging data that might improve the diagnosis and management of high-grade pancreatic injuries (HGPIs; grades III-V). We hypothesized that the use of magnetic resonance cholangiopancreatography, pancreatic duct stenting, operative drainage versus resection, and nonoperative management of HGPIs increased over time.

Methods: Multicenter retrospective review of diagnosis, management, and outcomes of adult pancreatic injuries from 2010 to 2018 was performed. Data were analyzed by grade and time period (PRE, 2010-2013; POST, 2014-2018) using various statistical tests where appropriate.

Results: Thirty-two centers reported data on 515 HGPI patients. A total of 270 (53%) had penetrating trauma, and 58% went directly to the operating room without imaging. Eighty-nine (17%) died within 24 hours. Management and outcomes of 426 24-hour survivors were evaluated. Agreement between computed tomography and operating room grading was 38%. Magnetic resonance cholangiopancreatography use doubled in grade IV/V injuries over time but was still low.Overall HGPI treatment and outcomes did not change over time. Resection was performed in 78% of grade III injuries and remained stable over time, while resection of grade IV/V injuries trended downward (56% to 39%, p = 0.11). Pancreas-related complications (PRCs) occurred more frequently in grade IV/V injuries managed with drainage versus resection (61% vs. 32%, p = 0.0051), but there was no difference in PRCs for grade III injuries between resection and drainage.Pancreatectomy closure had no impact on PRCs. Pancreatic duct stenting increased over time in grade IV/V injuries, with 76% used to treat PRCs.

Conclusion: Intraoperative and computed tomography grading are different in the majority of HGPI cases. Resection is still used for most patients with grade III injuries; however, drainage may be a noninferior alternative. Drainage trended upward for grade IV/V injuries, but the higher rate of PRCs calls for caution in this practice.

Level Of Evidence: Retrospective diagnostic/therapeutic study, level III.
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http://dx.doi.org/10.1097/TA.0000000000003080DOI Listing
May 2021

The management of surgical patients in the emergency setting during COVID-19 pandemic: the WSES position paper.

World J Emerg Surg 2021 03 22;16(1):14. Epub 2021 Mar 22.

Department of Emergency and Trauma Surgery, Parma University Hospital, Parma, Italy.

Background: Since the COVID-19 pandemic has occurred, nations showed their unpreparedness to deal with a mass casualty incident of this proportion and severity, which resulted in a tremendous number of deaths even among healthcare workers. The World Society of Emergency Surgery conceived this position paper with the purpose of providing evidence-based recommendations for the management of emergency surgical patients under COVID-19 pandemic for the safety of the patient and healthcare workers.

Method: A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis Protocols (PRISMA-P) through the MEDLINE (PubMed), Embase and SCOPUS databases. Synthesis of evidence, statements and recommendations were developed in accordance with the GRADE methodology.

Results: Given the limitation of the evidence, the current document represents an effort to join selected high-quality articles and experts' opinion.

Conclusions: The aim of this position paper is to provide an exhaustive guidelines to perform emergency surgery in a safe and protected environment for surgical patients and for healthcare workers under COVID-19 and to offer the best management of COVID-19 patients needing for an emergency surgical treatment. We recommend screening for COVID-19 infection at the emergency department all acute surgical patients who are waiting for hospital admission and urgent surgery. The screening work-up provides a RT-PCR nasopharyngeal swab test and a baseline (non-contrast) chest CT or a chest X-ray or a lungs US, depending on skills and availability. If the COVID-19 screening is not completed we recommend keeping the patient in isolation until RT-PCR swab test result is not available, and to manage him/she such as an overt COVID patient. The management of COVID-19 surgical patients is multidisciplinary. If an immediate surgical procedure is mandatory, whether laparoscopic or via open approach, we recommend doing every effort to protect the operating room staff for the safety of the patient.
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http://dx.doi.org/10.1186/s13017-021-00349-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7983964PMC
March 2021

The WSES: what do we see in the future?

World J Emerg Surg 2021 03 20;16(1):13. Epub 2021 Mar 20.

Department of Emergency and Trauma Surgery, University Hospital of Parma, Parma, Italy.

We present the New Year letter from the WSES board to wish everyone a new year full of positive surprises and good news, despite COVID-19 pandemic.We confirm the WSES primary aim: to promote education in emergency surgery putting together all the world experts on emergency surgery without restrictions or boundaries, in inclusivity, equality, and equal opportunities. This will be the year of innovations and WSES will assess the application of artificial intelligence technologies in emergency and trauma surgery.Thank you All for trusting us with your collaboration.
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http://dx.doi.org/10.1186/s13017-021-00358-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7980739PMC
March 2021

The WSES: what do we see in the future?

World J Emerg Surg 2021 03 20;16(1):13. Epub 2021 Mar 20.

Department of Emergency and Trauma Surgery, University Hospital of Parma, Parma, Italy.

We present the New Year letter from the WSES board to wish everyone a new year full of positive surprises and good news, despite COVID-19 pandemic.We confirm the WSES primary aim: to promote education in emergency surgery putting together all the world experts on emergency surgery without restrictions or boundaries, in inclusivity, equality, and equal opportunities. This will be the year of innovations and WSES will assess the application of artificial intelligence technologies in emergency and trauma surgery.Thank you All for trusting us with your collaboration.
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http://dx.doi.org/10.1186/s13017-021-00358-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7980739PMC
March 2021

2020 World Society of Emergency Surgery updated guidelines for the diagnosis and treatment of acute calculus cholecystitis.

World J Emerg Surg 2020 11 5;15(1):61. Epub 2020 Nov 5.

Department of Surgery, College of Medicine, UAE University, Al Ain, UAE.

Background: Acute calculus cholecystitis (ACC) has a high incidence in the general population. The presence of several areas of uncertainty, along with the availability of new evidence, prompted the current update of the 2016 WSES (World Society of Emergency Surgery) Guidelines on ACC.

Materials And Methods: The WSES president appointed four members as a scientific secretariat, four members as an organization committee and four members as a scientific committee, choosing them from the expert affiliates of WSES. Relevant key questions were constructed, and the task force produced drafts of each section based on the best scientific evidence from PubMed and EMBASE Library; recommendations were developed in order to answer these key questions. The quality of evidence and strength of recommendations were reviewed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria (see https://www.gradeworkinggroup.org/ ). All the statements were presented, discussed and voted upon during the Consensus Conference at the 6th World Congress of the World Society of Emergency Surgery held in Nijmegen (NL) in May 2019. A revised version of the statements was voted upon via an online questionnaire until consensus was reached.

Results: The pivotal role of surgery is confirmed, including in high-risk patients. When compared with the WSES 2016 guidelines, the role of gallbladder drainage is reduced, despite the considerable technical improvements available. Early laparoscopic cholecystectomy (ELC) should be the standard of care whenever possible, even in subgroups of patients who are considered fragile, such as the elderly; those with cardiac disease, renal disease and cirrhosis; or those who are generally at high risk for surgery. Subtotal cholecystectomy is safe and represents a valuable option in cases of difficult gallbladder removal.

Conclusions, Knowledge Gaps And Research Recommendations: ELC has a central role in the management of patients with ACC. The value of surgical treatment for high-risk patients should lead to a distinction between high-risk patients and patients who are not suitable for surgery. Further evidence on the role of clinical judgement and the use of clinical scores as adjunctive tools to guide treatment of high-risk patients and patients who are not suitable for surgery is required. The development of local policies for safe laparoscopic cholecystectomy is recommended.
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http://dx.doi.org/10.1186/s13017-020-00336-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7643471PMC
November 2020

Management of intra-abdominal-infections: 2017 World Society of Emergency Surgery guidelines summary focused on remote areas and low-income nations.

Int J Infect Dis 2020 Oct 31;99:140-148. Epub 2020 Jul 31.

Department of Emergency Surgery, Maggiore Hospital, Parma, Italy.

Background: Most remote areas have restricted access to healthcare services and are too small and remote to sustain specialist services. In 2017, the World Society of Emergency Surgery (WSES) published guidelines for the management of intra-abdominal infections. Many hospitals, especially those in remote areas, continue to face logistical barriers, leading to an overall poorer adherence to international guidelines.

Methods: The aim of this paper is to report and amend the 2017 WSES guidelines for the management of intra-abdominal infections, extending these recommendations for remote areas and low-income countries. A literature search of the PubMed/MEDLINE databases was conducted covering the period up until June 2020.

Results: The critical shortages of healthcare workers and material resources in remote areas require the use of a robust triage system. A combination of abdominal signs and symptoms with early warning signs may be used to screen patients needing immediate acute care surgery. A tailored diagnostic step-up approach based on the hospital's resources is recommended. Ultrasound and plain X-ray may be useful diagnostic tools in remote areas. The source of infection should be totally controlled as soon as possible.

Conclusions: The cornerstones of effective treatment for intra-abdominal infections in remote areas include early diagnosis, prompt resuscitation, early source control, and appropriate antimicrobial therapy. Standardization in applying the guidelines is mandatory to adequately manage intra-abdominal infections.
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http://dx.doi.org/10.1016/j.ijid.2020.07.046DOI Listing
October 2020

Disparities in triage and management of the homeless and the elderly trauma patient.

Inj Epidemiol 2020 Jul 13;7(1):39. Epub 2020 Jul 13.

Trauma Service, Scripps Memorial Hospital La Jolla, 9888 Genesee Ave., LJ601, La Jolla, CA, 92037, USA.

Background: Trauma systems are designed to provide specialized treatment for the most severely injured. As populations change, it is imperative for trauma centers to remain dynamic to provide the best care to all members of the community.

Methods: A retrospective review of all trauma patients treated at one Level II trauma center in Southern CA over 5 years. Three cohorts of patients were studied: geriatric (> 65 years), the homeless, and all other trauma patients. Triage, hospitalization, and outcomes were collected and analyzed.

Results: Of 8431 patients treated, 30% were geriatric, 3% homeless and 67% comprised all other patients. Trauma activation criteria was met for 84% of all other trauma patients, yet only 61% of homeless and geriatric patients combined. Injury mechanism for homeless included falls (38%), pedestrian/bicycle related (27%) and assaults (24%), often while under the influence of alcohol and drugs. Average length of hospital stay (LOS) was greater for homeless and geriatric patients and frequently attributed to discharge planning challenges. Both the homeless and geriatric groups demonstrated increased complications, comorbidities, and death rates.

Conclusions: Homeless trauma patients reflect similar challenges in care as with the elderly, requiring additional resources and more complex case management. It is prudent to identify and understand the issues surrounding patients transported to our trauma center requiring a higher level of care yet are under-triaged upon arrival to the Emergency Department. Although a monthly review is done for all under-triaged patients, and geriatric patients are acknowledged to be a cohort continually having delays, the homeless cohort continues to be under-triaged. The admitted homeless trauma patient has similar complex case management issues as the elderly related to pre-existing health issues and challenges with discharge planning, both which can add to longer lengths of hospital stay as compared to other trauma patients. Given the lack of social support that is endemic to both populations, these cohorts represent a unique challenge to trauma centers. Further research into specialized care is required to determine best practices to address disparities evident in the homeless and elderly, and to promote health equity in marginalized populations.
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http://dx.doi.org/10.1186/s40621-020-00262-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7358191PMC
July 2020

WSES guidelines updates.

World J Emerg Surg 2020 06 10;15(1):39. Epub 2020 Jun 10.

Emergency and Trauma Surgery, Maggiore Hospital, Parma, Italy.

The World Society of Emergency Surgery promotes training and continuing medical education in the field of emergency surgery and trauma. One of the most important activities of the society is the development of guidelines. The debate about the process of developing and updating guidelines is very active with no clear consensus and different policies among scientific societies. The present commentary provides the position of the World Society of Emergency Surgery on guideline development process and their update.
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http://dx.doi.org/10.1186/s13017-020-00318-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7288408PMC
June 2020

Syncope, "mechanical falls", and the trauma surgeon.

J Trauma Acute Care Surg 2020 09;89(3):e64-e68

From the Trauma Department (W.L.B., T.D.), and Department of Emergency Medicine (A.F.), Scripps Memorial Hospital La Jolla, La Jolla; and Department of Pediatric Physical Medicine and Rehabilitation (S.E.B.), Rady Children's Hospital, University of California San Diego, San Diego, California.

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http://dx.doi.org/10.1097/TA.0000000000002812DOI Listing
September 2020

2020 update of the WSES guidelines for the management of acute colonic diverticulitis in the emergency setting.

World J Emerg Surg 2020 05 7;15(1):32. Epub 2020 May 7.

Trauma Service, Inkosi Albert Luthuli Central Hospital and Department of Surgery, Nelson R Mandela School of Clinical Medicine, Durban, South Africa.

Acute colonic diverticulitis is one of the most common clinical conditions encountered by surgeons in the acute setting. An international multidisciplinary panel of experts from the World Society of Emergency Surgery (WSES) updated its guidelines for management of acute left-sided colonic diverticulitis (ALCD) according to the most recent available literature. The update includes recent changes introduced in the management of ALCD. The new update has been further integrated with advances in acute right-sided colonic diverticulitis (ARCD) that is more common than ALCD in select regions of the world.
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http://dx.doi.org/10.1186/s13017-020-00313-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7206757PMC
May 2020

ACR Appropriateness Criteria® Major Blunt Trauma.

J Am Coll Radiol 2020 May;17(5S):S160-S174

Specialty Chair, University of Alabama at Birmingham, Birmingham, Alabama.

This review assesses the appropriateness of various imaging studies for adult major blunt trauma or polytrauma in the acute setting. Trauma is the leading cause of mortality for people in the United States <45 years of age, and the fourth leading cause of death overall. Imaging, in particular CT, plays a critical role in the management of these patients, and a number of indications are discussed in this publication, including patients who are hemodynamically stable or unstable; patients with additional injuries to the face, extremities, chest, bowel, or urinary system; and pregnant patients. Excluded from consideration in this review are penetrating traumatic injuries, burns, and injuries to pediatric patients. Patients with suspected injury to the head and spine are also discussed more specifically in other appropriateness criteria documents. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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http://dx.doi.org/10.1016/j.jacr.2020.01.024DOI Listing
May 2020

COVID-19 the showdown for mass casualty preparedness and management: the Cassandra Syndrome.

World J Emerg Surg 2020 04 9;15(1):26. Epub 2020 Apr 9.

Emergency and Trauma Surgery, Maggiore Hospital, Parma, Italy.

Since December 2019, the world is potentially facing one of the most difficult infectious situations of the last decades. COVID-19 epidemic warrants consideration as a mass casualty incident (MCI) of the highest nature. An optimal MCI/disaster management should consider all four phases of the so-called disaster cycle: mitigation, planning, response, and recovery. COVID-19 outbreak has demonstrated the worldwide unpreparedness to face a global MCI.This present paper thus represents a call for action to solicitate governments and the Global Community to actively start effective plans to promote and improve MCI management preparedness in general, and with an obvious current focus on COVID-19.
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http://dx.doi.org/10.1186/s13017-020-00304-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7145275PMC
April 2020

The Operative management in Bariatric Acute abdomen (OBA) Survey: long-term complications of bariatric surgery and the emergency surgeon's point of view.

World J Emerg Surg 2020 01 6;15(1). Epub 2020 Jan 6.

Department of Emergency and Trauma Surgery, Parma University Hospital, Parma, Italy.

Background: The number of bariatric procedures is increasing worldwide. No consensus or guidelines about the emergency management of long-term complications following bariatric surgery are currently available. The aim of this study is to investigate by a web survey how an emergency surgeon approaches this unique group of patients in an emergency medical scenario and to report their personal experience.

Method: An international web survey was sent to 197 emergency surgeons with the aim to collect data about emergency surgeons' experience in the management of patients admitted in the emergency department for acute abdominal pain after bariatric surgery. The survey was conceived as a questionnaire composed by 26 (multiple choice and open) questions and approved by a steering committee.

Results: One hundred seventeen international emergency surgeons decided to join the project and answered to the web survey with a response rate of 59.39%.

Conclusions: The aim of this WSES web survey was to highlight the current management of patients previously submitted to bariatric surgical procedures by ES. Emergency surgeons must be mindful of postoperative bariatric surgery complications. CT scan with oral intestinal opacification may be useful in making a diagnosis if carefully interpreted by the radiologist and the surgeon. In case of inconclusive clinical and radiological findings, when symptoms fail to improve, surgical exploration for bariatric patients presenting acute abdominal pain, by laparoscopy if expertise is available, is mandatory in the first 12-24 h, to have good outcomes and decrease morbidity rate.
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http://dx.doi.org/10.1186/s13017-019-0281-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6945511PMC
January 2020

Perforated and bleeding peptic ulcer: WSES guidelines.

World J Emerg Surg 2020 7;15. Epub 2020 Jan 7.

26Department of General Surgery, Rambam Health Care Campus, Haifa, Israel.

Background: Peptic ulcer disease is common with a lifetime prevalence in the general population of 5-10% and an incidence of 0.1-0.3% per year. Despite a sharp reduction in incidence and rates of hospital admission and mortality over the past 30 years, complications are still encountered in 10-20% of these patients. Peptic ulcer disease remains a significant healthcare problem, which can consume considerable financial resources. Management may involve various subspecialties including surgeons, gastroenterologists, and radiologists. Successful management of patients with complicated peptic ulcer (CPU) involves prompt recognition, resuscitation when required, appropriate antibiotic therapy, and timely surgical/radiological treatment.

Methods: The present guidelines have been developed according to the GRADE methodology. To create these guidelines, a panel of experts was designed and charged by the board of the WSES to perform a systematic review of the available literature and to provide evidence-based statements with immediate practical application. All the statements were presented and discussed during the 5th WSES Congress, and for each statement, a consensus among the WSES panel of experts was reached.

Conclusions: The population considered in these guidelines is adult patients with suspected complicated peptic ulcer disease. These guidelines present evidence-based international consensus statements on the management of complicated peptic ulcer from a collaboration of a panel of experts and are intended to improve the knowledge and the awareness of physicians around the world on this specific topic. We divided our work into the two main topics, bleeding and perforated peptic ulcer, and structured it into six main topics that cover the entire management process of patients with complicated peptic ulcer, from diagnosis at ED arrival to post-discharge antimicrobial therapy, to provide an up-to-date, easy-to-use tool that can help physicians and surgeons during the decision-making process.
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http://dx.doi.org/10.1186/s13017-019-0283-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6947898PMC
March 2021

Unique Epidemiology of Spinal Cord Injury in Hawai'i: Wave-related Incidents.

Hawaii J Health Soc Welf 2019 12;78(12):365-370

Scripps Memorial Hospital La Jolla, La Jolla, CA (WLB).

Spinal cord injury remains one of the most devastating forms of traumatic injury. The purpose of this study was to characterize the clinical characteristics of spinal cord injury patients and the geographic location where the injury occurred in the state of Hawai'i. Spinal cord injury cases from 2009-2017 were identified using the State Trauma Registry, which included demographics, mechanism of injury, and outcomes. In 1170 spinal cord injury cases, the second most frequent etiology was an ocean-wave related incident. Over half of wave related spinal cord injury occurred on ten beaches on four islands. Compared to other mechanisms, patients with wave related spinal cord injury were significantly less likely to be Hawai'i residents (15%), screen positive for alcohol (4%), or have an injury in the lower thoracic or lumbar region (4%). These patients were also less likely to die (1%) and more likely to be discharged to home (66%). Wave related incidents are a major cause of spinal cord injury in Hawai'i, disproportionately affecting visitors. Education focused toward middle-aged male visitors at beaches with moderate to severe shorebreak may reduce the incidence of injury.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6911777PMC
December 2019

WSES consensus conference guidelines: monitoring and management of severe adult traumatic brain injury patients with polytrauma in the first 24 hours.

World J Emerg Surg 2019 29;14:53. Epub 2019 Nov 29.

1Department of Anesthesia and Intensive Care, Parma University Hospital, Via Gramsci 14, 43100 Parma, Italy.

The acute phase management of patients with severe traumatic brain injury (TBI) and polytrauma represents a major challenge. Guidelines for the care of these complex patients are lacking, and worldwide variability in clinical practice has been documented in recent studies. Consequently, the World Society of Emergency Surgery (WSES) decided to organize an international consensus conference regarding the monitoring and management of severe adult TBI polytrauma patients during the first 24 hours after injury. A modified Delphi approach was adopted, with an agreement cut-off of 70%. Forty experts in this field (emergency surgeons, neurosurgeons, and intensivists) participated in the online consensus process. Sixteen recommendations were generated, with the aim of promoting rational care in this difficult setting.
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http://dx.doi.org/10.1186/s13017-019-0270-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6884766PMC
July 2020

Patients with acute cholecystitis should be admitted to a surgical service.

J Trauma Acute Care Surg 2019 10;87(4):870-875

From the Department of Surgery (N.L., L.L.W., W.L.B.) and Center for Outcomes Research and Evaluation (J.A.P., G.Z., A.L.), The Queen's Medical Center, and Department of Surgery, John H. Burns School of Medicine of the University of Hawaii (N.L., L.L.W., W.L.B.), Honolulu, Hawaii.

Background: In bowel obstruction and biliary pancreatitis, patients receive more expedient surgical care when admitted to surgical compared with medical services. This has not been studied in acute cholecystitis.

Methods: Retrospective analysis of clinical and cost data from July 2013 to September 2015 for patients with cholecystitis who underwent laparoscopic cholecystectomy in a tertiary care inpatient hospital. One hundred ninety lower-risk (Charlson-Deyo) patients were included. We assessed admitting service, length of stay (LOS), time from admission to surgery, time from surgery to discharge, number of imaging studies, and total cost.

Results: Patients admitted to surgical (n = 106) versus medical (n = 84) service had shorter mean LOS (1.4 days vs. 2.6 days), shorter time from admission to surgery (0.4 days vs. 0.8 days), and shorter time from surgery to discharge (0.8 days vs. 1.1 days). Surgical service patients had fewer CT (38% vs. 56%) and magnetic resonance imaging (MRI) (5% vs. 16%) studies. Cholangiography (30% vs. 25%) and endoscopic retrograde cholangiopancreatography (ERCP) (3 vs. 8%) rates were similar. Surgical service patients had 39% lower median total costs (US $7787 vs. US $12572).

Conclusion: Nonsurgical admissions of patients with cholecystitis are common, even among lower-risk patients. Routine admission to the surgical service should decrease LOS, resource utilization and costs.

Level Of Evidence: Therapeutic/care management, level IV.
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http://dx.doi.org/10.1097/TA.0000000000002415DOI Listing
October 2019

ACR Appropriateness Criteria Suspected Spine Trauma-Child.

J Am Coll Radiol 2019 May;16(5S):S286-S299

Specialty Chair, Riley Hospital for Children Indiana University, Indianapolis, Indiana.

Choosing the appropriate imaging in children with accidental traumatic spine injuries can be challenging because the recommendations based on scientific evidence at this time differ from those applied in adults. This differentiation is due in part to differences in anatomy and physiology of the developing spine. This publication uses scientific evidence and a panel of pediatric experts to summarize best current imaging practices for children with accidental spine trauma. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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http://dx.doi.org/10.1016/j.jacr.2019.02.003DOI Listing
May 2019

Preserve encephalus in surgery of trauma: online survey. (P.E.S.T.O).

World J Emerg Surg 2019;14. Epub 2019 Mar 4.

11Department of Emergency Surgery, Parma University Hospital, Parma, Italy.

Background: Traumatic brain injury (TBI) is a global health problem. Extracranial hemorrhagic lesions needing emergency surgery adversely affect the outcome of TBI. We conducted an international survey regarding the acute phase management practices in TBI polytrauma patients.

Methods: A questionnaire was available on the World Society of Emergency Surgery website between December 2017 and February 2018. The main endpoints were the evaluation of (1) intracranial pressure (ICP) monitoring during extracranial emergency surgery (EES), (2) hemodynamic management without ICP monitoring during EES, (3) coagulation management, and (4) utilization of simultaneous multisystem surgery (SMS).

Results: The respondents were 122 representing 105 trauma centers worldwide. ICP monitoring was utilized in 10-30% of patients at risk of intracranial hypertension (IH) undergoing EES from about a third of the respondents [ = 35 (29%)]. The respondents reported that the safest values of systolic blood pressure during EES in patients at risk of IH were 90-100 mmHg [ = 35 (29%)] and 100-110 mmHg [ = 35 (29%)]. The safest values of mean arterial pressure during EES in patients at risk of IH were > 70 mmHg [ = 44 (36%)] and > 80 mmHg [ = 32 (26%)]. Regarding ICP placement, a large percentage of respondents considered a platelet (PLT) count > 50,000/mm [ = 57 (47%)] and a prothrombin time (PT)/activated partial thromboplastin time (aPTT) < 1.5 times the normal control [ = 73 (60%)] to be the safest parameters. For craniotomy, the majority of respondents considered PLT count > 100,000/mm [ = 67 (55%)] and a PT/aPTT < 1.5 times the normal control [ = 76 (62%)] to be the safest parameters. Almost half of the respondents [ = 53 (43%)], reported that they transfused red blood cells (RBCs)/plasma (P)/PLTs at a ratio of 1/1/1 in TBI polytrauma patients. SMS was performed in 5-19% of patients, requiring both an emergency neurosurgical operation and EES, by almost half of the respondents [ = 49 (40%)].

Conclusions: A great variability in practices during the acute phase management of polytrauma patients with severe TBI was identified. These findings may be helpful for future investigations and educational purposes.
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http://dx.doi.org/10.1186/s13017-019-0229-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6399949PMC
June 2019

2019 update of the WSES guidelines for management of () infection in surgical patients.

World J Emerg Surg 2019;14. Epub 2019 Feb 28.

Vital Care, Inc, Meridian, MS USA.

In the last three decades, infection (CDI) has increased in incidence and severity in many countries worldwide. The increase in CDI incidence has been particularly apparent among surgical patients. Therefore, prevention of CDI and optimization of management in the surgical patient are paramount. An international multidisciplinary panel of experts from the World Society of Emergency Surgery (WSES) updated its guidelines for management of CDI in surgical patients according to the most recent available literature. The update includes recent changes introduced in the management of this infection.
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http://dx.doi.org/10.1186/s13017-019-0228-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6394026PMC
June 2019

The evolving role of laparoscopic lavage and drainage.

J Trauma Acute Care Surg 2019 02;86(2):376

Scripps Memorial Hospital La Jolla La Jolla, California.

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http://dx.doi.org/10.1097/TA.0000000000002145DOI Listing
February 2019
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