Damage control resuscitation may lead to postoperative intra-abdominal hypertension or abdominal compartment syndrome. These conditions may result in a vicious, self-perpetuating cycle leading to severe physiologic derangements and multiorgan failure unless interrupted by abdominal (surgical or other) decompression. Further, in some clinical situations, the abdomen cannot be closed due to the visceral edema, the inability to control the compelling source of infection or the necessity to re-explore (as a “planned second-look” laparotomy) or complete previously initiated damage control procedures or in cases of abdominal wall disruption. The open abdomen in trauma and non-trauma patients has been proposed to be effective in preventing or treating deranged physiology in patients with severe injuries or critical illness when no other perceived options exist. Its use, however, remains controversial as it is resource consuming and represents a non-anatomic situation with the potential for severe adverse effects. Its use, therefore, should only be considered in patients who would most benefit from it. Abdominal fascia-to-fascia closure should be done as soon as the patient can physiologically tolerate it. All precautions to minimize complications should be implemented.

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The open abdomen in trauma and non-trauma patients: WSES guidelines

D-dimer is a soluble fibrin degradation product deriving from the plasmin-mediated degradation of cross-linked fibrin. D-dimer can hence be considered a biomarker of activation of coagulation and fibrinolysis, and it is routinely used for ruling out venous thromboembolism (VTE). D-dimer is increasingly used to assess the risk of VTE recurrence and to help define the optimal duration of anticoagulation treatment in patients with VTE, for diagnosing disseminated intravascular coagulation, and for screening medical patients at increased risk of VTE. This review is aimed at (1) revising the definition of D-dimer; (2) discussing preanalytical variables affecting the measurement of D-dimer; (3) reviewing and comparing assay performance and some postanalytical variables (e.g. different units and age-adjusted cutoffs); and (4) discussing the use of D-dimer measurement across different clinical settings.

D-dimer: Preanalytical, analytical, postanalytical variables, and clinical applications

Objectives: To analyze the concept of “case series” in the medical literature compared with case reports. Methods: A PubMed search for articles published during 2009 which had “case series” in their title was performed. A total number of 621 articles were retrieved. 586 papers were included in the analysis and 35 were excluded (18 were commentary letters, 5 were not in English, and twelve could not be retrieved by our Library). The number of patients and category of these articles were analyzed. Results: The median (range) of the number of cases of articles having “case series” in their title was 7 (1-6432) cases. 186/ 586 articles had less than 5 cases (31.7%, 95% CI (28.3-35.1%)). The median (range) of the number of cases of articles having “case report” as their publication type was 4 (1-178) cases. Out of the 219 articles categorized as case reports 114 (52.1%, 95% CI (45.6-58.6%)) had less than five cases. Conclusions: The concept of “case series” is not well defined in the literature and does not reflect a specific research design. We suggest that a case series should have more than four patients while four paitents or less should be reported individually as case reports.

/pdf/clinical-case-series-a-concept-analysis-384lchnr6s.pdf

Clinical "case series": a concept analysis.

The open abdomen (OA) is defined as intentional decision to leave the fascial edges of the abdomen un-approximated after laparotomy (laparostomy). The abdominal contents are potentially exposed and therefore must be protected with a temporary coverage, which is referred to as temporal abdominal closure (TAC). OA use remains widely debated with many specific details deserving detailed assessment and clarification. To date, in patients with intra-abdominal emergencies, the OA has not been formally endorsed for routine utilization; although, utilization is seemingly increasing. Therefore, the World Society of Emergency Surgery (WSES), Abdominal Compartment Society (WSACS) and the Donegal Research Academy united a worldwide group of experts in an international consensus conference to review and thereafter propose the basis for evidence-directed utilization of OA management in non-trauma emergency surgery and critically ill patients. In addition to utilization recommendations, questions with insufficient evidence urgently requiring future study were identified.

https://link.springer.com/content/pdf/10.1186/s13017-017-0146-1.pdf

The role of open abdomen in non-trauma patient: WSES Consensus Paper

Laparotomy remains the gold standard for diagnosis of acute mesenteric ischemia (AMI), but is often unhelpful or too late due to non-specific clinical and radiological signs. This systematic review and meta-analysis aims to evaluate the diagnostic accuracy of the novel serological biomarkers intestinal fatty acid-binding protein (I-FABP), α-glutathione S-transferase (α-GST), D-lactate, ischemia modified albumin (IMA), and citrulline to detect AMI. A systematic search of electronic databases was performed to identify all published diagnostic accuracy studies on I-FABP, α-GST, D-lactate, IMA, and citrulline. Articles were selected based on pre-defined inclusion and exclusion criteria. Risk of bias and applicability were assessed. Two-by-two contingency tables were constructed to calculate accuracy standards. Summary estimates were computed using random-effects models. The search yielded 1925 papers, 21 were included in the final analysis. Pooled sensitivity and specificity for investigated biomarkers were: I-FABP (Uden); 79.0 (95% CI 66.5-88.5) and 91.3 (87.0-94.6), I-FABP (Osaka); 75.0 (67.9-81.2) and 79.2 (76.2-82.0), D-lactate; 71.7 (58.6-82.5) and 74.2 (69.0-79.0), α-GST; 67.8 (54.2-79.5) and 84.2 (75.3-90.9), IMA; 94.7 (74.0-99.9) and 86.4 (65.1-97.1), respectively. One study investigated accuracy standards for citrulline: sensitivity 39% and specificity 100%. The novel serological biomarkers I-FABP, α-GST, IMA, and citrulline may offer improved diagnostic accuracy of acute mesenteric ischemia; however, further research is required to specify threshold values and accuracy standards for different aetiological forms.

/pdf/diagnostic-accuracy-of-novel-serological-biomarkers-to-2w19occuy1.pdf

Diagnostic accuracy of novel serological biomarkers to detect acute mesenteric ischemia: a systematic review and meta-analysis

Acute mesenteric ischaemia (AMI) accounts for about 1:1000 acute hospital admissions. Untreated, AMI will cause mesenteric infarction, intestinal necrosis, an overwhelming inflammatory response and death. Early intervention can halt and reverse this process leading to a full recovery, but the diagnosis of AMI is difficult and failure to recognize AMI before intestinal necrosis has developed is responsible for the high mortality of the disease. Early diagnosis and prompt treatment are the goals of modern therapy, but there are no randomized controlled trials to guide treatment and the published literature contains a high ratio of reviews to original data. Much of that data comes from case reports and often small, retrospective series with no clearly defined treatment criteria. A study group of the European Society for Trauma and Emergency Surgery (ESTES) was formed in 2013 with the aim of developing guidelines for the management of AMI. A comprehensive literature search was performed using the Medical Subject Heading (MeSH) thesaurus keywords “mesenteric ischaemia”, “bowel ischaemia” and “bowel infarction”. The bibliographies of relevant articles were screened for additional publications. After an initial systematic review of the literature by the whole group, a steering group formulated questions using a modified Delphi process. The evidence was then reviewed to answer these questions, and recommendations formulated and agreed by the whole group. The resultant recommendations are presented in this paper. The aim of these guidelines is to provide recommendations for practice that will lead to improved outcomes for patients.

/pdf/estes-guidelines-acute-mesenteric-ischaemia-2dgq8gmr6j.pdf

ESTES guidelines: acute mesenteric ischaemia.

Background Ultrasound is widely accepted as a valuable diagnostic tool for detecting intra-abdominal and intrathoracic bleeding in trauma patients. Nevertheless, many doctors are reluctant to use it because they do not have sufficient training. This study aimed to define intra-abdominal and intratho

Establishment of a teaching animal model for sonographic diagnosis of trauma.

Subspecialisation within general surgery has today reached further than ever. However, on-call time, an unchanged need for broad surgical skills are required to meet the demands of acute surgical disease and trauma. The introduction of a new subspecialty in North America that deals solely with acute care surgery and trauma is an attempt to offer properly trained surgeons also during on-call time. To find out whether such a subspecialty could be helpful in Sweden we analyzed our workload for emergency surgery and trauma. Linkoping University Hospital serves a population of 257 000. Data from 2010 for all patients, diagnoses, times and types of operations, surgeons involved, duration of stay, types of injury and deaths regarding emergency procedures were extracted from a prospectively-collected database and analyzed. There were 2362 admissions, 1559 emergency interventions; 835 were mainly abdominal operations, and 724 diagnostic or therapeutic endoscopies. Of the 1559 emergency interventions, 641 (41.1%) were made outside office hours, and of 453 minor or intermediate procedures (including appendicectomy, cholecystectomy, or proctological procedures) 276 (60.9%) were done during the evenings or at night. Two hundred and fifty-four patients were admitted with trauma and 29 (11.4%) required operation, of whom general surgeons operated on eight (3.1%). Thirteen consultants and 11 senior registrars were involved in 138 bowel resections and 164 cholecystectomies chosen as index operations for standard emergency surgery. The median (range) number of such operations done by each consultant was 6 (3–17) and 6 (1–22). Corresponding figures for senior registrars were 7 (0–11) and 8 (1–39). There was an uneven distribution of exposure to acute surgical problems and trauma among general surgeons. Some were exposed to only a few standard emergency interventions and most surgeons did not operate on a single patient with trauma. Further centralization of trauma care, long-term positions at units for emergency surgery and trauma, and subspecialisation in the fields of emergency surgery and trauma, might be options to solve problems of low volumes.

/pdf/distribution-of-emergency-operations-and-trauma-in-a-swedish-38ymq29kkl.pdf

Distribution of emergency operations and trauma in a Swedish hospital: need for reorganisation of acute surgical care?

One of the challenges of surgery on patients with active SARS-CoV-2(severe acute respiratory syndrome coronavirus 2) infection is the increased risk of postoperative morbidity and mortality.This study will describe and compare the postoperative morbidity and mortality in asymptomatic patients or those with mild infection with those with severe COVID-19 infection undergoing elective or and emergency surgery.This is a retrospective study of 37 COVID19 patients who had the infection 7 days prior to and 30 days after emergency or elective surgery. Patients were divided to two groups. Group1: the asymptomatic or those with mild infection that is diagnosed just before surgery (14 patients). Group 2: those who were admitted to the hospital because of severe COVID-19 and were operated for COVID-19 related complications (23 patients). Morbidity and mortality of both groups was studied.There was no significant difference in gender between the two groups. There were 5 females (2 in group 1, and 3 in group 2) and 32 males (12 in group 1, and 20 in group 2). Mean age for all patients was 49.8years (38 for group 1 and 57 for group2). Median age for all patients was 50 years (37.5 for group 1 and 57 years for group 2). Sepsis developed in 7 patients (1 patient in group 1 and in 6 patients in group 2). Statistically there was no significant difference in occurrence of sepsis between the two groups. There was a significant difference in the intensive care stay between the two groups (higher in group 2). Four deaths were reported in group 1 and fourteen in group 2. Eighteen out of thirty-seven patients died.Severity of COVID-19 infection will prolong the hospitalization and ICU stay in surgical patients with no significant effect on mortality. 

https://doi.org/10.1016/j.amsu.2022.103910

Fawzi Al-Ayoubi

Papers

ESTES guidelines: acute mesenteric ischaemia.

Establishment of a teaching animal model for sonographic diagnosis of trauma.

Distribution of emergency operations and trauma in a Swedish hospital: need for reorganisation of acute surgical care?

Impacts of severity of Covid-19 infection on the morbidity and mortality of surgical patients

Outcome of trauma patients.