Pub Date : 2025-06-07DOI: 10.1186/s13017-025-00622-6
Gabriele Fanciulli, Giuliana Favara, Andrea Maugeri, Martina Barchitta, Antonella Agodi, Guido Basile
Acute cholecystitis (AC) is a common and serious condition characterized by gallbladder inflammation, most often caused by cystic duct obstruction due to gallstones. Although laparoscopic cholecystectomy (CC) is the preferred surgical treatment, percutaneous cholecystostomy (PC) is frequently considered for high-risk surgical patients. The optimal management strategy for these patients remains a topic of debate. These systematic review and meta-analysis aim to provide an updated evaluation of studies comparing the clinical outcomes of AC patients treated with PC versus those undergoing CC, as well as the outcomes of CC alone versus PC followed by CC. A literature search was carried out across Web of Science, Medline, Embase, and PubMed up to April 2024. Observational studies comparing patients undergoing PC versus CC, as well as CC versus PC followed by CC, and reporting mortality, morbidity, and readmission were included. Data extraction and quality assessment were independently performed by two reviewers, with bias risk evaluated using the Newcastle-Ottawa Quality Scale. The pooled odds ratio (OR) was obtained through meta-analyses by using STATA software (Version 18). A total of 27 studies were included, with 16 comparing PC versus CC and 11 assessing PC followed by CC versus CC alone. Meta-analyses revealed that CC was associated with significantly lower mortality (OR = 0.26; 95% CI = 0.14–0.48) and readmission rates (OR = 0.37; 95% CI = 0.18–0.75) compared to PC. The benefits of laparoscopic cholecystectomy over percutaneous cholecystostomy were particularly evident for mortality (OR = 0.17; 95% CI = 0.09–0.33), while a non-significant trend towards reduced readmission rates was also observed (OR = 0.28; 95% CI = 0.07–1.13). However, PC was identified as a viable alternative in high-risk surgical patients. Studies examining PC followed by CC versus CC alone showed diverse results, with some indicating reduced surgical complications and improved outcomes, while others reported no significant benefits. This work highlights that CC is associated with better outcomes, including lower mortality and readmission rates, compared to both PC alone and PC followed by CC. The combined approach did not show a significant advantage over immediate CC. Further research with larger studies and standardized protocols is needed to refine treatment strategies for high-risk AC patients.
急性胆囊炎（Acute cholecystitis， AC）是一种常见而严重的疾病，以胆囊炎症为特征，最常由胆结石引起的胆囊管阻塞引起。虽然腹腔镜胆囊切除术（CC）是首选的手术治疗方法，但经皮胆囊造口术（PC）经常被考虑用于高危手术患者。这些患者的最佳管理策略仍然是一个有争议的话题。这些系统综述和荟萃分析旨在提供最新的研究评估，比较AC患者接受PC治疗与接受CC治疗的临床结果，以及单纯CC治疗与PC后CC治疗的结果。截至2024年4月，在Web of Science、Medline、Embase和PubMed上进行了文献检索。观察性研究比较了接受PC和CC的患者，以及CC和PC之后的CC，并报告了死亡率、发病率和再入院率。数据提取和质量评估由两名审稿人独立完成，偏倚风险采用纽卡斯尔-渥太华质量量表进行评估。采用STATA软件（Version 18）进行meta分析，得出合并优势比（OR）。共纳入27项研究，其中16项比较PC与CC， 11项评估PC后CC与单独CC。荟萃分析显示，CC与显著降低的死亡率相关(OR = 0.26；95% CI = 0.14-0.48)和再入院率(OR = 0.37；95% CI = 0.18-0.75)。腹腔镜胆囊切除术比经皮胆囊造口术在死亡率上的优势尤为明显(OR = 0.17；95% CI = 0.09-0.33)，同时也观察到再入院率降低的非显著趋势(OR = 0.28；95% ci = 0.07-1.13)。然而，在高危手术患者中，PC被认为是可行的选择。研究显示，与单纯行癌相比，行癌后行癌的研究结果不同，一些研究表明手术并发症减少，预后改善，而另一些研究则没有明显的好处。这项工作强调，与单独的PC和PC后CC相比，CC有更好的结果，包括更低的死亡率和再入院率，联合方法没有显示出比立即CC有显著优势，需要进一步的大规模研究和标准化方案来完善高危AC患者的治疗策略。
{"title":"Comparing percutaneous treatment and cholecystectomy outcomes in acute cholecystitis patients: a systematic review and meta-analysis","authors":"Gabriele Fanciulli, Giuliana Favara, Andrea Maugeri, Martina Barchitta, Antonella Agodi, Guido Basile","doi":"10.1186/s13017-025-00622-6","DOIUrl":"https://doi.org/10.1186/s13017-025-00622-6","url":null,"abstract":"Acute cholecystitis (AC) is a common and serious condition characterized by gallbladder inflammation, most often caused by cystic duct obstruction due to gallstones. Although laparoscopic cholecystectomy (CC) is the preferred surgical treatment, percutaneous cholecystostomy (PC) is frequently considered for high-risk surgical patients. The optimal management strategy for these patients remains a topic of debate. These systematic review and meta-analysis aim to provide an updated evaluation of studies comparing the clinical outcomes of AC patients treated with PC versus those undergoing CC, as well as the outcomes of CC alone versus PC followed by CC. A literature search was carried out across Web of Science, Medline, Embase, and PubMed up to April 2024. Observational studies comparing patients undergoing PC versus CC, as well as CC versus PC followed by CC, and reporting mortality, morbidity, and readmission were included. Data extraction and quality assessment were independently performed by two reviewers, with bias risk evaluated using the Newcastle-Ottawa Quality Scale. The pooled odds ratio (OR) was obtained through meta-analyses by using STATA software (Version 18). A total of 27 studies were included, with 16 comparing PC versus CC and 11 assessing PC followed by CC versus CC alone. Meta-analyses revealed that CC was associated with significantly lower mortality (OR = 0.26; 95% CI = 0.14–0.48) and readmission rates (OR = 0.37; 95% CI = 0.18–0.75) compared to PC. The benefits of laparoscopic cholecystectomy over percutaneous cholecystostomy were particularly evident for mortality (OR = 0.17; 95% CI = 0.09–0.33), while a non-significant trend towards reduced readmission rates was also observed (OR = 0.28; 95% CI = 0.07–1.13). However, PC was identified as a viable alternative in high-risk surgical patients. Studies examining PC followed by CC versus CC alone showed diverse results, with some indicating reduced surgical complications and improved outcomes, while others reported no significant benefits. This work highlights that CC is associated with better outcomes, including lower mortality and readmission rates, compared to both PC alone and PC followed by CC. The combined approach did not show a significant advantage over immediate CC. Further research with larger studies and standardized protocols is needed to refine treatment strategies for high-risk AC patients.","PeriodicalId":48867,"journal":{"name":"World Journal of Emergency Surgery","volume":"170 1","pages":""},"PeriodicalIF":8.0,"publicationDate":"2025-06-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144237427","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-06-07DOI: 10.1186/s13017-025-00630-6
Zhao Huang, Penglong Zhao, Bingmei Qiu, Chuan Gao, Zhao Chen, Nan Yang, Yang Xu, Zhiqiang Zou, Yi Shen, Liwen Hu
Spontaneous esophageal rupture (SER) is a rare and severe emergency with high mortality, and the treatment algorithm remains controversial. This retrospective study analyzed SER cases that underwent VATS debridement and drainage in Jinling Hospital from January 2014 to July 2024. Patients were divided into Lavage-Drainage and Drainage groups based on whether they received a lavage tube cathetering through the esophageal fistula under gastroscope. Preoperative fluid resuscitation, thoracoscopic mediastinotomy, and thoracic debridement were performed. Post-operative management included fasting, enteral nutrition, anti-infective agents, and fluid and electrolyte balance maintenance. Monitoring indicators included vital signs, laboratory test results, postoperative complications, and other relevant factors. A total of 24 patients were enrolled, with 11 in the Lavage-Drainage group and 13 in the Drainage group. The Lavage-Drainage group had lower 30-day mortality, fewer complications and adverse events, and a faster reduction in inflammatory factors, but a higher cost. There was no significant difference in the length of mechanical ventilation, hospital stay, and ICU stay. The Lavage-Drainage approach enhanced the drainage efficiency, reduced the inflammation level, and improved the prognosis of SER. However, this study has some limitations, and further multi-center prospective studies are needed to optimize the treatment and reduce costs.
{"title":"Effects of the lavage through fistula in treatment of spontaneous esophageal rupture by combined thoracoscopic and gastroscopic management","authors":"Zhao Huang, Penglong Zhao, Bingmei Qiu, Chuan Gao, Zhao Chen, Nan Yang, Yang Xu, Zhiqiang Zou, Yi Shen, Liwen Hu","doi":"10.1186/s13017-025-00630-6","DOIUrl":"https://doi.org/10.1186/s13017-025-00630-6","url":null,"abstract":"Spontaneous esophageal rupture (SER) is a rare and severe emergency with high mortality, and the treatment algorithm remains controversial. This retrospective study analyzed SER cases that underwent VATS debridement and drainage in Jinling Hospital from January 2014 to July 2024. Patients were divided into Lavage-Drainage and Drainage groups based on whether they received a lavage tube cathetering through the esophageal fistula under gastroscope. Preoperative fluid resuscitation, thoracoscopic mediastinotomy, and thoracic debridement were performed. Post-operative management included fasting, enteral nutrition, anti-infective agents, and fluid and electrolyte balance maintenance. Monitoring indicators included vital signs, laboratory test results, postoperative complications, and other relevant factors. A total of 24 patients were enrolled, with 11 in the Lavage-Drainage group and 13 in the Drainage group. The Lavage-Drainage group had lower 30-day mortality, fewer complications and adverse events, and a faster reduction in inflammatory factors, but a higher cost. There was no significant difference in the length of mechanical ventilation, hospital stay, and ICU stay. The Lavage-Drainage approach enhanced the drainage efficiency, reduced the inflammation level, and improved the prognosis of SER. However, this study has some limitations, and further multi-center prospective studies are needed to optimize the treatment and reduce costs.","PeriodicalId":48867,"journal":{"name":"World Journal of Emergency Surgery","volume":"138 1","pages":""},"PeriodicalIF":8.0,"publicationDate":"2025-06-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144237426","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
In Japan—particularly in the Hokkaido region—a limited number of dedicated trauma surgeons often compels general surgeons to serve as frontline providers of trauma care. However, their ability to perform critical trauma procedures and their level of confidence remain unclear. Understanding this gap is vital for guiding targeted training programs aimed at improving patient outcomes. Although conducted in one region, these findings may inform strategies in other remote or resource-limited settings worldwide, where timely surgical intervention significantly affects survival. Therefore, the objective of this study was to evaluate the experience and confidence of general surgeons in Hokkaido in performing 35 essential trauma procedures. This prospective observational study surveyed all general surgeons and surgical residents working in hospitals that regularly perform surgical procedures in Hokkaido. Participants provided demographic information, trauma training history, and self-assessed confidence and experience in performing 35 procedures identified via a previous Delphi study. Confidence was defined as a Likert scale rating of 4 or 5. Comparisons were made between respondents with and without advanced trauma training (e.g., ATOM, DSTC) and between those who had managed more than 50 trauma cases versus fewer than 50. Of 730 eligible participants, 444 completed the survey (62.2%). Over half (57.9%) reported fewer than 10 lifetime trauma surgeries, and 64.4% had not managed a trauma case in the past year. Only six procedures were rated confidently (≥ 4) by more than half the respondents, including endotracheal intubation, chest tube placement, and selected gastrointestinal procedures. Subgroup analyses indicated that surgeons generally had higher confidence in procedures related to their subspecialty, whereas less frequent or advanced trauma skills remained areas of concern. Surgeons with advanced trauma training or a higher trauma case volume (> 50) demonstrated significantly greater confidence in multiple trauma-specific skills. General surgeons in Hokkaido lack confidence in most essential trauma procedures, particularly those encountered infrequently. Although these findings originate from one region, they underscore training gaps potentially relevant to other remote or resource-limited areas, where frontline trauma care demands targeted, high-yield interventions to improve outcomes.
{"title":"How confident are the general surgeons in Hokkaido region in performing essential trauma skills: a cross-sectional questionnaire survey","authors":"Kazuyuki Hirose, Saseem Poudel, Soichi Murakami, Yo Kurashima, Nagato Sato, Hiroyasu Tojima, Isao Yokota, Kazufumi Okada, Toshiaki Shichinohe, Satoshi Hirano","doi":"10.1186/s13017-025-00623-5","DOIUrl":"https://doi.org/10.1186/s13017-025-00623-5","url":null,"abstract":"In Japan—particularly in the Hokkaido region—a limited number of dedicated trauma surgeons often compels general surgeons to serve as frontline providers of trauma care. However, their ability to perform critical trauma procedures and their level of confidence remain unclear. Understanding this gap is vital for guiding targeted training programs aimed at improving patient outcomes. Although conducted in one region, these findings may inform strategies in other remote or resource-limited settings worldwide, where timely surgical intervention significantly affects survival. Therefore, the objective of this study was to evaluate the experience and confidence of general surgeons in Hokkaido in performing 35 essential trauma procedures. This prospective observational study surveyed all general surgeons and surgical residents working in hospitals that regularly perform surgical procedures in Hokkaido. Participants provided demographic information, trauma training history, and self-assessed confidence and experience in performing 35 procedures identified via a previous Delphi study. Confidence was defined as a Likert scale rating of 4 or 5. Comparisons were made between respondents with and without advanced trauma training (e.g., ATOM, DSTC) and between those who had managed more than 50 trauma cases versus fewer than 50. Of 730 eligible participants, 444 completed the survey (62.2%). Over half (57.9%) reported fewer than 10 lifetime trauma surgeries, and 64.4% had not managed a trauma case in the past year. Only six procedures were rated confidently (≥ 4) by more than half the respondents, including endotracheal intubation, chest tube placement, and selected gastrointestinal procedures. Subgroup analyses indicated that surgeons generally had higher confidence in procedures related to their subspecialty, whereas less frequent or advanced trauma skills remained areas of concern. Surgeons with advanced trauma training or a higher trauma case volume (> 50) demonstrated significantly greater confidence in multiple trauma-specific skills. General surgeons in Hokkaido lack confidence in most essential trauma procedures, particularly those encountered infrequently. Although these findings originate from one region, they underscore training gaps potentially relevant to other remote or resource-limited areas, where frontline trauma care demands targeted, high-yield interventions to improve outcomes.","PeriodicalId":48867,"journal":{"name":"World Journal of Emergency Surgery","volume":"59 1","pages":""},"PeriodicalIF":8.0,"publicationDate":"2025-06-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144218929","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-06-04DOI: 10.1186/s13017-025-00619-1
Meng Cui, Yiqing Jia, Zhaoyang Chen, Jie Qu, Zonghong Zhu, Yan Xu, Shuyuan Liu, Ruifeng Chen, Yi Shan
To compare primary closure (PC) with delayed/no closure (DC/NC), and compare prophylactic use of antibiotics (PUA) with no use of antibiotics (NUA) in the treatment of traumatic wounds caused by mammals by a systematic review and meta-analysis. PubMed and Embase databases were searched for eligible randomized clinical trials (RCTs) and observational studies. Qualities of RCTs were assessed according to Cochrane risk of bias tool, qualities of observational studies were assessed according to Newcastle–Ottawa Scale. Primary outcomes included the incidence of wound infection or poor wound healing and the rate of wound cosmesis satisfaction. The relative risks (RRs) of RCTs, odds ratios (ORs) of observational studies and their 95% confidence interval (CI) were extracted directly from included studies or calculated according to the 2 × 2 table obtained by the incidence. The sensitivity analysis, meta-regression and subgroup analysis were performed to identify clinical factors that caused the heterogeneity between studies. Of 26 included studies, 17 studies (8 RCTs and 9 observational studies, 8091 patients) compared PC with DC/NC and 14 studies (7 RCTs and 7 observational studies, 2508 patients) compared PUA with NUA. The pooled OR of all studies (PC versus DC/NC) for wound infection or poor wound healing was 0.79 (95%CI: 0.54, 1.17), the pooled RR of RCTs for wound infection was 0.73 (0.51, 1.06). The pooled OR for cosmesis satisfaction was 3.68 (1.27, 10.68) of 2 studies (PC versus DC) that did not use the negative pressure sealing drainage technique. Subgroup analysis demonstrated that the pooled OR was significant under specific clinical conditions: (1) comparison of PC and DC (pooled OR: 0.49 [0.27, 0.90]), (2) prophylactic use of antibiotics (0.56 [0.33, 0.94]), (3) no use of antibiotics (0.63 [0.41, 0.98]), (4) wounds located in limbs/trunk (0.41 [0.23, 0.73]), (5) time to the first medical presentation (TTP) ≤ 10 h (0.59 [0.39, 0.89]). While the pooled OR (PC versus NC) was not significant (0.84 [0.51, 1.37]). The pooled OR of all studies for wound infection (PUA versus NUA) was 0.73 (95%CI: 0.46, 1.17), the pooled RR of RCTs for wound infection was 0.81 (0.46, 1.44). No included studies (PUA versus NUA) reported the outcome of wound cosmesis. Subgroup analysis demonstrated that the pooled OR was significant under specific clinical conditions: (1) injury caused by other type of mammals other than dog (pooled OR: 0.24 [0.06–0.98]), (2) wounds located in face/head (0.13 [0.03, 0.52]). Regardless of whether prophylactic antibiotics are used or not, compared to delayed closure, primary closure should be given priority in treating traumatic wounds caused by mammals which can decrease the incidence of wound infection or poor wound healing and obtain the better wound cosmesis, but it does not show the superiority compared to no closure, unless under some specific clinical conditions. Prophylactic use of antibiotics may not benefit in prevention of wo
通过系统综述和meta分析，比较初次缝合（PC）与延迟/无缝合（DC/NC），比较预防性使用抗生素（PUA）与不使用抗生素（NUA）治疗哺乳动物创伤性伤口的效果。检索PubMed和Embase数据库，查找符合条件的随机临床试验（rct）和观察性研究。随机对照试验质量采用Cochrane偏倚风险评估工具评估，观察性研究质量采用Newcastle-Ottawa量表评估。主要结局包括伤口感染或愈合不良的发生率和伤口美容的满意率。rct的相对危险度（RRs）、观察性研究的优势比（ORs）及其95%置信区间（CI）直接从纳入的研究中提取或根据发病率得到的2 × 2表计算。通过敏感性分析、meta回归和亚组分析确定导致研究间异质性的临床因素。在纳入的26项研究中，17项研究（8项随机对照试验和9项观察性研究，8091例患者）比较了PC与DC/NC， 14项研究（7项随机对照试验和7项观察性研究，2508例患者）比较了PUA与NUA。所有研究（PC vs DC/NC）伤口感染或伤口愈合不良的合并OR为0.79 (95%CI: 0.54, 1.17)，伤口感染的rct合并RR为0.73（0.51,1.06）。未使用负压密封引流技术的2项研究（PC与DC）美容满意度的综合OR为3.68（1.27,10.68）。亚组分析显示，在特定的临床条件下，汇总OR (1) PC与DC的比较（汇总OR: 0.49[0.27, 0.90]），(2)预防性使用抗生素（0.56[0.33,0.94]），(3)未使用抗生素（0.63[0.41,0.98]），(4)肢体/躯干伤口（0.41[0.23,0.73]），(5)首次就诊时间(TTP)≤10 h（0.59[0.39, 0.89]）。而合并OR （PC vs NC）不显著（0.84[0.51,1.37]）。所有伤口感染研究（PUA vs NUA）的合并OR为0.73 (95%CI: 0.46, 1.17)，伤口感染的rct合并RR为0.81（0.46,1.44）。没有纳入的研究（PUA与NUA）报道伤口美容的结果。亚组分析表明，在特定的临床条件下，混合OR具有显著性：(1)除狗以外的其他哺乳动物造成的损伤（混合OR: 0.24[0.06-0.98]），(2)面部/头部损伤（0.13[0.03,0.52]）。无论是否使用预防性抗生素，在哺乳动物创伤性创面治疗中，与延迟缝合相比，应优先考虑一次缝合，可减少创面感染或愈合不良的发生率，获得更好的创面美容效果，但除非在某些特定的临床条件下，与不缝合相比并不表现出优势。预防性使用抗生素可能不利于预防伤口感染，除非在特定的临床条件下，例如由除狗以外的哺乳动物造成的伤口或位于面部/头部的伤口。
{"title":"Primary closure and prophylactic antibiotics for treatment of traumatic wounds caused by mammals, a systematic review and meta-analysis","authors":"Meng Cui, Yiqing Jia, Zhaoyang Chen, Jie Qu, Zonghong Zhu, Yan Xu, Shuyuan Liu, Ruifeng Chen, Yi Shan","doi":"10.1186/s13017-025-00619-1","DOIUrl":"https://doi.org/10.1186/s13017-025-00619-1","url":null,"abstract":"To compare primary closure (PC) with delayed/no closure (DC/NC), and compare prophylactic use of antibiotics (PUA) with no use of antibiotics (NUA) in the treatment of traumatic wounds caused by mammals by a systematic review and meta-analysis. PubMed and Embase databases were searched for eligible randomized clinical trials (RCTs) and observational studies. Qualities of RCTs were assessed according to Cochrane risk of bias tool, qualities of observational studies were assessed according to Newcastle–Ottawa Scale. Primary outcomes included the incidence of wound infection or poor wound healing and the rate of wound cosmesis satisfaction. The relative risks (RRs) of RCTs, odds ratios (ORs) of observational studies and their 95% confidence interval (CI) were extracted directly from included studies or calculated according to the 2 × 2 table obtained by the incidence. The sensitivity analysis, meta-regression and subgroup analysis were performed to identify clinical factors that caused the heterogeneity between studies. Of 26 included studies, 17 studies (8 RCTs and 9 observational studies, 8091 patients) compared PC with DC/NC and 14 studies (7 RCTs and 7 observational studies, 2508 patients) compared PUA with NUA. The pooled OR of all studies (PC versus DC/NC) for wound infection or poor wound healing was 0.79 (95%CI: 0.54, 1.17), the pooled RR of RCTs for wound infection was 0.73 (0.51, 1.06). The pooled OR for cosmesis satisfaction was 3.68 (1.27, 10.68) of 2 studies (PC versus DC) that did not use the negative pressure sealing drainage technique. Subgroup analysis demonstrated that the pooled OR was significant under specific clinical conditions: (1) comparison of PC and DC (pooled OR: 0.49 [0.27, 0.90]), (2) prophylactic use of antibiotics (0.56 [0.33, 0.94]), (3) no use of antibiotics (0.63 [0.41, 0.98]), (4) wounds located in limbs/trunk (0.41 [0.23, 0.73]), (5) time to the first medical presentation (TTP) ≤ 10 h (0.59 [0.39, 0.89]). While the pooled OR (PC versus NC) was not significant (0.84 [0.51, 1.37]). The pooled OR of all studies for wound infection (PUA versus NUA) was 0.73 (95%CI: 0.46, 1.17), the pooled RR of RCTs for wound infection was 0.81 (0.46, 1.44). No included studies (PUA versus NUA) reported the outcome of wound cosmesis. Subgroup analysis demonstrated that the pooled OR was significant under specific clinical conditions: (1) injury caused by other type of mammals other than dog (pooled OR: 0.24 [0.06–0.98]), (2) wounds located in face/head (0.13 [0.03, 0.52]). Regardless of whether prophylactic antibiotics are used or not, compared to delayed closure, primary closure should be given priority in treating traumatic wounds caused by mammals which can decrease the incidence of wound infection or poor wound healing and obtain the better wound cosmesis, but it does not show the superiority compared to no closure, unless under some specific clinical conditions. Prophylactic use of antibiotics may not benefit in prevention of wo","PeriodicalId":48867,"journal":{"name":"World Journal of Emergency Surgery","volume":"62 1","pages":""},"PeriodicalIF":8.0,"publicationDate":"2025-06-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144211271","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-06-02DOI: 10.1186/s13017-025-00618-2
Paula Ferrada, Saima Shafique, Megan Brenner, Clay Burlew, Fausto Catena, Julia Coleman, Jamie Coleman, Demetrios Demetriades, Marc Demoya, Salomone Di Saverio, Sharmila Dissanaike, Tom Dransfield, Joseph DuBose, Juan Duchesne, Adel Elkbuli, Esteban Foianini, Josephine Gambardella, Alberto Garcia, Amy Goldberg, Eric Goralnick, John Holcomb, Messing Jonathan, Bellal Joseph, Lenworth Jacobs, Jeffrey Kerby, Robert Lawerance, Stefan Leichtle, Charles Lucas, Gustavo Machain, Jana Macleod, Zoe Maher, Matthew Martin, Napoleon Mendez, Carlos Menegozzo, Ilenia Merlini, Nicholas Namias, Mayur Narayan, Carlos Ordonez, Pablo Ottolino, Mayur Patel, Zaffer A. Qasim, Martha Quiodettis, LeAnne Sitari Young, Ashanti Ratnasekera, David Rayburn, Juan Salamea, Babak Sarani, Thomas Scalea, Mark Seamon, David Spain, Portia Steele, Sharven Taghavi, Leah Tatebe, Felipe Vega, George Velmahos, Tanya Zakrison, Walter L. Biffl, Dimitrios Damaskos, Federico Coccolini, Carlo Vallicelli, Ernest E. Moore, L..
Hemorrhage is one of the leading causes of preventable death in trauma patients. For decades, the Airway-Breathing-Circulation (ABC) approach has been the cornerstone of trauma care. However, emerging evidence suggests that prioritizing airway management in exsanguinating patients may worsen hypotension and increase mortality. This systematic review and meta-analysis aim to evaluate the effectiveness of the Circulation-Airway-Breathing (CAB) approach compared to the traditional ABC sequence in improving survival in trauma patients with severe hemorrhage. A systematic review was conducted in accordance with the PRISMA guidelines. Databases including PubMed and Ovid MEDLINE, SCOPUS, web of science and EMBASE were searched for studies published up to September 2024. Eligible studies included observational and comparative studies reporting outcomes of trauma patients with exsanguinating hemorrhage. The Newcastle–Ottawa Scale was used for risk of bias assessment. A meta-analysis was performed using a random-effects model to calculate pooled odds ratios (OR) for mortality, with 95% confidence intervals (CI). Subgroup analysis was conducted to compare the ABC and CAB approaches in prospective and retrospective studies. Six studies (N = 11,855 patients) met the inclusion criteria. The meta-analysis revealed a significant increase in mortality associated with the ABC approach (pooled OR: 3.65, 95% CI: 1.74–7.65). Subgroup analysis of prospective cohort studies found an even higher mortality risk (POR: 9.99, 95% CI: 5.59–17.85) when compared with POR of retrospective studies (POR: 2.42, 95%CI: 1.08–5.36). High heterogeneity (I2 = 92%) was observed across the studies, likely due to variations in patient populations and resuscitation protocols. Prioritizing circulation over airway management in trauma patients with exsanguinating injuries significantly reduces mortality compared to the traditional ABC approach. The present consensus paper, conducted according to the WSES methodology3, aims to provide a review of the literature comparing the CAB approach to the traditional ABC sequence in trauma patients with exsanguinating hemorrhage, to develop a shared consensus statement based on the currently available evidence
{"title":"Prioritizing circulation over airway to improve survival in trauma patients with exsanguinating injuries: a world society of emergency surgery-panamerican trauma consensus statement","authors":"Paula Ferrada, Saima Shafique, Megan Brenner, Clay Burlew, Fausto Catena, Julia Coleman, Jamie Coleman, Demetrios Demetriades, Marc Demoya, Salomone Di Saverio, Sharmila Dissanaike, Tom Dransfield, Joseph DuBose, Juan Duchesne, Adel Elkbuli, Esteban Foianini, Josephine Gambardella, Alberto Garcia, Amy Goldberg, Eric Goralnick, John Holcomb, Messing Jonathan, Bellal Joseph, Lenworth Jacobs, Jeffrey Kerby, Robert Lawerance, Stefan Leichtle, Charles Lucas, Gustavo Machain, Jana Macleod, Zoe Maher, Matthew Martin, Napoleon Mendez, Carlos Menegozzo, Ilenia Merlini, Nicholas Namias, Mayur Narayan, Carlos Ordonez, Pablo Ottolino, Mayur Patel, Zaffer A. Qasim, Martha Quiodettis, LeAnne Sitari Young, Ashanti Ratnasekera, David Rayburn, Juan Salamea, Babak Sarani, Thomas Scalea, Mark Seamon, David Spain, Portia Steele, Sharven Taghavi, Leah Tatebe, Felipe Vega, George Velmahos, Tanya Zakrison, Walter L. Biffl, Dimitrios Damaskos, Federico Coccolini, Carlo Vallicelli, Ernest E. Moore, L..","doi":"10.1186/s13017-025-00618-2","DOIUrl":"https://doi.org/10.1186/s13017-025-00618-2","url":null,"abstract":"Hemorrhage is one of the leading causes of preventable death in trauma patients. For decades, the Airway-Breathing-Circulation (ABC) approach has been the cornerstone of trauma care. However, emerging evidence suggests that prioritizing airway management in exsanguinating patients may worsen hypotension and increase mortality. This systematic review and meta-analysis aim to evaluate the effectiveness of the Circulation-Airway-Breathing (CAB) approach compared to the traditional ABC sequence in improving survival in trauma patients with severe hemorrhage. A systematic review was conducted in accordance with the PRISMA guidelines. Databases including PubMed and Ovid MEDLINE, SCOPUS, web of science and EMBASE were searched for studies published up to September 2024. Eligible studies included observational and comparative studies reporting outcomes of trauma patients with exsanguinating hemorrhage. The Newcastle–Ottawa Scale was used for risk of bias assessment. A meta-analysis was performed using a random-effects model to calculate pooled odds ratios (OR) for mortality, with 95% confidence intervals (CI). Subgroup analysis was conducted to compare the ABC and CAB approaches in prospective and retrospective studies. Six studies (N = 11,855 patients) met the inclusion criteria. The meta-analysis revealed a significant increase in mortality associated with the ABC approach (pooled OR: 3.65, 95% CI: 1.74–7.65). Subgroup analysis of prospective cohort studies found an even higher mortality risk (POR: 9.99, 95% CI: 5.59–17.85) when compared with POR of retrospective studies (POR: 2.42, 95%CI: 1.08–5.36). High heterogeneity (I2 = 92%) was observed across the studies, likely due to variations in patient populations and resuscitation protocols. Prioritizing circulation over airway management in trauma patients with exsanguinating injuries significantly reduces mortality compared to the traditional ABC approach. The present consensus paper, conducted according to the WSES methodology3, aims to provide a review of the literature comparing the CAB approach to the traditional ABC sequence in trauma patients with exsanguinating hemorrhage, to develop a shared consensus statement based on the currently available evidence","PeriodicalId":48867,"journal":{"name":"World Journal of Emergency Surgery","volume":"7 1","pages":""},"PeriodicalIF":8.0,"publicationDate":"2025-06-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144193281","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-06-02DOI: 10.1186/s13017-025-00616-4
Karri Kase, Annika Reintam Blaser, Merli Koitmäe, Peep Talving, Kadri Tamme, Stefan Acosta, Martin Björck, Miklosh Bala, Zsolt Bodnar, Martin Cahenzli, Dumitru Casian, Zaza Demetrashvili, Mario D’Oria, Virginia Durán Muñoz-Cruzado, Alastair Forbes, Morten Vetrhus, Moran Hellerman Itzhaki, Kristoffer Lein, Matthias Lindner, Cecilia I. Loudet, Dimitrios Damaskos, Alexandre Nuzzo, Sten Saar, Maximilian Scheiterle, Joel Starkopf, Anna-Liisa Voomets, Kenneth Voon, Mohammad Alif Yunus, Marko Murruste, Yves Castier, Maxime Ronot, Alan Biloslavo, Lucia Paiano, Gunnar Elke, Denise Nagel, David I. Radke, Jacqueline Vilca Becerra, María Elina Abeleyra, Benjamin Hess, Mikhail Kirov, Tatjana Semenkova, Anton Nikonov, Alexey Smetkin, Geir Ivar Nedredal, Øivind Irtun, Oded Cohen-Arazi, Asaf Keda, Gheorghe Rojnoveanu, Tatiana Malcova, Felipe Pareja Ciuró, Anabel García-Leon, Carlos Javier García-Sánchez, Lim Jia Hui, Loy Yuan Ling, Ilya Kagan, Pierre Singer, Edgar Lipping, Ana Tvaladze, Dami..
The optimal strategy for initial treatment of acute occlusion of superior mesenteric artery (SMA) is debated. The aim of the study was to compare the effectiveness, timelines and outcomes of endovascular versus open surgical treatment in patients with acute SMA occlusion. This was a preplanned substudy of the prospective observational multicenter AMESI (Acute MESenteric Ischaemia) study. Patients with SMA occlusion were divided into surgical and endovascular treatment groups. The surgical group included patients initially subjected to open surgical treatment with surgical or hybrid revascularization or intestinal resection only. The endovascular group included patients initially revascularized endovascularly and was further divided according to treatment effectiveness. Patients were also categorized according to revascularization or no revascularization, and subanalysis performed for different revascularization methods. Baseline and outcome comparisons were made using Fisher and Mann–Whitney U tests. Risk-factors for in-hospital mortality were analysed using a logistic regression model. Of 158 patients 107 had surgical and 51 endovascular treatment. The surgical group had higher baseline illness severity scores, higher C-reactive protein and lactate values. The mortality in the endovascular effective, endovascular insufficient as monotherapy and surgical groups was 2.9%, 41.2% and 45.8%, respectively. In multivariable analysis surgery was not an independent risk factor for in-hospital mortality. The rate of arterial embolism was higher in the endovascular revascularization as monotherapy insufficient treatment group (10/17) compared to the endovascular revascularization as monotherapy effective (5/34) and surgical (27/107) groups. We could not identify useful best thresholds for discriminating between effective and insufficient endovascular treatment. Analysis comparing the effect of any revascularization versus no revascularization on in-hospital mortality did not show a clear benefit of revascularization and the method of revascularization did not independently influence mortality. The beneficial effect of endovascular compared to surgical treatment in unadjusted analyses is largely explained by selection of patients. None of the compared management approaches had an independent effect on mortality. The choice between endovascular and surgical treatment should not be based solely on the time elapsed from symptom onset but rather on the patient’s general condition and possibly on the cause of SMA occlusion.
{"title":"Comparison between endovascular and surgical treatment of acute arterial occlusive mesenteric ischemia","authors":"Karri Kase, Annika Reintam Blaser, Merli Koitmäe, Peep Talving, Kadri Tamme, Stefan Acosta, Martin Björck, Miklosh Bala, Zsolt Bodnar, Martin Cahenzli, Dumitru Casian, Zaza Demetrashvili, Mario D’Oria, Virginia Durán Muñoz-Cruzado, Alastair Forbes, Morten Vetrhus, Moran Hellerman Itzhaki, Kristoffer Lein, Matthias Lindner, Cecilia I. Loudet, Dimitrios Damaskos, Alexandre Nuzzo, Sten Saar, Maximilian Scheiterle, Joel Starkopf, Anna-Liisa Voomets, Kenneth Voon, Mohammad Alif Yunus, Marko Murruste, Yves Castier, Maxime Ronot, Alan Biloslavo, Lucia Paiano, Gunnar Elke, Denise Nagel, David I. Radke, Jacqueline Vilca Becerra, María Elina Abeleyra, Benjamin Hess, Mikhail Kirov, Tatjana Semenkova, Anton Nikonov, Alexey Smetkin, Geir Ivar Nedredal, Øivind Irtun, Oded Cohen-Arazi, Asaf Keda, Gheorghe Rojnoveanu, Tatiana Malcova, Felipe Pareja Ciuró, Anabel García-Leon, Carlos Javier García-Sánchez, Lim Jia Hui, Loy Yuan Ling, Ilya Kagan, Pierre Singer, Edgar Lipping, Ana Tvaladze, Dami..","doi":"10.1186/s13017-025-00616-4","DOIUrl":"https://doi.org/10.1186/s13017-025-00616-4","url":null,"abstract":"The optimal strategy for initial treatment of acute occlusion of superior mesenteric artery (SMA) is debated. The aim of the study was to compare the effectiveness, timelines and outcomes of endovascular versus open surgical treatment in patients with acute SMA occlusion. This was a preplanned substudy of the prospective observational multicenter AMESI (Acute MESenteric Ischaemia) study. Patients with SMA occlusion were divided into surgical and endovascular treatment groups. The surgical group included patients initially subjected to open surgical treatment with surgical or hybrid revascularization or intestinal resection only. The endovascular group included patients initially revascularized endovascularly and was further divided according to treatment effectiveness. Patients were also categorized according to revascularization or no revascularization, and subanalysis performed for different revascularization methods. Baseline and outcome comparisons were made using Fisher and Mann–Whitney U tests. Risk-factors for in-hospital mortality were analysed using a logistic regression model. Of 158 patients 107 had surgical and 51 endovascular treatment. The surgical group had higher baseline illness severity scores, higher C-reactive protein and lactate values. The mortality in the endovascular effective, endovascular insufficient as monotherapy and surgical groups was 2.9%, 41.2% and 45.8%, respectively. In multivariable analysis surgery was not an independent risk factor for in-hospital mortality. The rate of arterial embolism was higher in the endovascular revascularization as monotherapy insufficient treatment group (10/17) compared to the endovascular revascularization as monotherapy effective (5/34) and surgical (27/107) groups. We could not identify useful best thresholds for discriminating between effective and insufficient endovascular treatment. Analysis comparing the effect of any revascularization versus no revascularization on in-hospital mortality did not show a clear benefit of revascularization and the method of revascularization did not independently influence mortality. The beneficial effect of endovascular compared to surgical treatment in unadjusted analyses is largely explained by selection of patients. None of the compared management approaches had an independent effect on mortality. The choice between endovascular and surgical treatment should not be based solely on the time elapsed from symptom onset but rather on the patient’s general condition and possibly on the cause of SMA occlusion.","PeriodicalId":48867,"journal":{"name":"World Journal of Emergency Surgery","volume":"9 1","pages":""},"PeriodicalIF":8.0,"publicationDate":"2025-06-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144193283","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
The decline in trauma cases and the increase in non-surgical treatments have reduced opportunities for trauma surgery training. This study examined the effectiveness of Cadaver-Based Educational Seminar for Trauma Surgery (C-BEST) as a lifelong educational tool for novice and experienced clinicians. From 2017 to 2023, 117 clinicians with varying levels of experience participated in the C-BEST program at Hokkaido University. Participants included novice clinicians (median years post-graduation: 5) and experienced clinicians (median years post-graduation: 19). Each participant assessed their confidence in 21 trauma techniques before, immediately after, and 6 months post-course using a self-assessment of confidence levels (SACL) scale. The analysis showed significant improvement in SACL scores immediately after the course, with confidence levels remaining sustained 6 months later. Novice clinicians demonstrated substantial skill acquisition, whereas experienced clinicians reported the reinforcement and refinement of existing skills. C-BEST seems valuable as a training tool for the acquisition and retention of trauma surgery skills, addressing practical needs in trauma care. C-BEST provides an effective and sustained approach to trauma surgery skill development and retention across career stages. Further research on its long-term impact and applicability in diverse clinical settings is recommended.
{"title":"Validation of cadaver-based trauma surgery training for lifelong skill development","authors":"Soichi Murakami, Toshiaki Shichinohe, Yo Kurashima, Kazufumi Okada, Yusuke Tsunetoshi, Ryoji Iizuka, Wataru Ishii, Kenji Kandori, Shinichiro Irabu, Naoki Shinyama, Hiroshi Homma, Masahiko Watanabe, Satoshi Hirano","doi":"10.1186/s13017-025-00608-4","DOIUrl":"https://doi.org/10.1186/s13017-025-00608-4","url":null,"abstract":"The decline in trauma cases and the increase in non-surgical treatments have reduced opportunities for trauma surgery training. This study examined the effectiveness of Cadaver-Based Educational Seminar for Trauma Surgery (C-BEST) as a lifelong educational tool for novice and experienced clinicians. From 2017 to 2023, 117 clinicians with varying levels of experience participated in the C-BEST program at Hokkaido University. Participants included novice clinicians (median years post-graduation: 5) and experienced clinicians (median years post-graduation: 19). Each participant assessed their confidence in 21 trauma techniques before, immediately after, and 6 months post-course using a self-assessment of confidence levels (SACL) scale. The analysis showed significant improvement in SACL scores immediately after the course, with confidence levels remaining sustained 6 months later. Novice clinicians demonstrated substantial skill acquisition, whereas experienced clinicians reported the reinforcement and refinement of existing skills. C-BEST seems valuable as a training tool for the acquisition and retention of trauma surgery skills, addressing practical needs in trauma care. C-BEST provides an effective and sustained approach to trauma surgery skill development and retention across career stages. Further research on its long-term impact and applicability in diverse clinical settings is recommended.","PeriodicalId":48867,"journal":{"name":"World Journal of Emergency Surgery","volume":"9 1","pages":""},"PeriodicalIF":8.0,"publicationDate":"2025-05-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144165150","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-05-28DOI: 10.1186/s13017-025-00624-4
Jingxian Wang, Wei Zhu, Ping Song, Peiyang Zhou, Peng An
The recent study by Thu et al. investigating the interplay between frailty, sarcopenia, and physical status in patients undergoing emergency laparotomy (EmLap) provides valuable insights into preoperative risk stratification. The authors’ efforts to disentangle these complex factors in predicting mortality are commendable, particularly their emphasis on frailty and poor physical status as independent prognostic markers. However, several underappreciated aspects of this relationship warrant further discussion to refine clinical applicability and guide future research (1).
{"title":"Uncharted factors in emergency laparotomy outcomes: a call for holistic assessment","authors":"Jingxian Wang, Wei Zhu, Ping Song, Peiyang Zhou, Peng An","doi":"10.1186/s13017-025-00624-4","DOIUrl":"https://doi.org/10.1186/s13017-025-00624-4","url":null,"abstract":"The recent study by Thu et al. investigating the interplay between frailty, sarcopenia, and physical status in patients undergoing emergency laparotomy (EmLap) provides valuable insights into preoperative risk stratification. The authors’ efforts to disentangle these complex factors in predicting mortality are commendable, particularly their emphasis on frailty and poor physical status as independent prognostic markers. However, several underappreciated aspects of this relationship warrant further discussion to refine clinical applicability and guide future research (1).","PeriodicalId":48867,"journal":{"name":"World Journal of Emergency Surgery","volume":"58 1","pages":""},"PeriodicalIF":8.0,"publicationDate":"2025-05-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144165151","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-05-24DOI: 10.1186/s13017-025-00602-w
Giulia Bonavina, Gianluca Bonitta, Alberto Aiolfi, Noemi Salmeri, Massimo Candiani, Paolo Ivo Cavoretto, Luigi Bonavina, Alessandro Bulfoni
Preventing postpartum haemorrhage remains a high priority worldwide. We aimed to provide all available evidence comparing maternal and neonatal outcomes of different prophylactic endovascular procedures in patients with abnormal placentation. Pubmed, Embase and ClinicalTrials.gov databases were searched from inception to Nov, 2024, using relevant key words. Studies comparing outcomes of women undergoing or not prophylactic endovascular procedures in planned cesarean delivery in patients with antenatally suspected or confirmed PAS, placenta previa or both were included. An arm-based random effect frequentist network meta-analysis was performed. All available maternal and neonatal outcomes were evaluated. Three randomized controlled trials and 59 observational studies were eligible reporting on 6973 women (42.9% did not undergo any endovascular procedure, 26.7% underwent aortic balloon occlusion, REBOA, 16.6%, internal iliac balloon occlusion, PBO-IIA, 5.8%, common iliac artery occlusion, PBO-CIA, placement, and 7.8% underwent uterine artery embolization, UAE). The pooled network analysis showed that all prophylactic endovascular procedures were associated with reduced perioperative blood loss, with proximal balloon occlusion (REBOA) having the strongest effect (SMD −1.80 L, 95%CI −2.38;-1.21; I2 = 97.2%). Also, peripartum hysterectomy rates were significantly lower in women undergoing prophylactic UAE and REBOA compared to the control group; moreover, patients with placenta previa without any prophylactic endovascular procedure had a 4 to fivefold increased risk of peripartum hysterectomy compared to the REBOA group (I2 = 20.6%). REBOA was associated with a significant decrease in massive transfusion rates (I2 = 0%), surgery-related complications (I2 = 0%), ICU admissions (I2 = 40.3%), and units of red blood cells transfused (I2 = 92.8%), compared to PBO-IIA and control groups. The control group versus women undergoing prophylactic UAE showed a significant increase in total operative time (I2 = 96.5%) and Clavien-Dindo grade IV post-operative complications (I2 = 26%), compared to REBOA. All prophylactic endovascular procedures had a comparable risk ratio in terms of units of platelets transfused, maternal mortality, and use of additional post-operative bilateral uterine artery embolization among the treatment groups. As for neonatal outcomes, no significant differences were detected. Although the preponderance of observational studies suggests caution in interpreting the results of this meta-analysis, our findings suggest that prophylactic endovascular interventional procedures, particularly aortic balloon occlusion, may substantially improve clinical outcomes in women with PAS, placenta previa or both. CRD4202457398.
{"title":"Every minute counts: a network meta-analysis comparing the effect of prophylactic endovascular procedures in abnormal placentation","authors":"Giulia Bonavina, Gianluca Bonitta, Alberto Aiolfi, Noemi Salmeri, Massimo Candiani, Paolo Ivo Cavoretto, Luigi Bonavina, Alessandro Bulfoni","doi":"10.1186/s13017-025-00602-w","DOIUrl":"https://doi.org/10.1186/s13017-025-00602-w","url":null,"abstract":"Preventing postpartum haemorrhage remains a high priority worldwide. We aimed to provide all available evidence comparing maternal and neonatal outcomes of different prophylactic endovascular procedures in patients with abnormal placentation. Pubmed, Embase and ClinicalTrials.gov databases were searched from inception to Nov, 2024, using relevant key words. Studies comparing outcomes of women undergoing or not prophylactic endovascular procedures in planned cesarean delivery in patients with antenatally suspected or confirmed PAS, placenta previa or both were included. An arm-based random effect frequentist network meta-analysis was performed. All available maternal and neonatal outcomes were evaluated. Three randomized controlled trials and 59 observational studies were eligible reporting on 6973 women (42.9% did not undergo any endovascular procedure, 26.7% underwent aortic balloon occlusion, REBOA, 16.6%, internal iliac balloon occlusion, PBO-IIA, 5.8%, common iliac artery occlusion, PBO-CIA, placement, and 7.8% underwent uterine artery embolization, UAE). The pooled network analysis showed that all prophylactic endovascular procedures were associated with reduced perioperative blood loss, with proximal balloon occlusion (REBOA) having the strongest effect (SMD −1.80 L, 95%CI −2.38;-1.21; I2 = 97.2%). Also, peripartum hysterectomy rates were significantly lower in women undergoing prophylactic UAE and REBOA compared to the control group; moreover, patients with placenta previa without any prophylactic endovascular procedure had a 4 to fivefold increased risk of peripartum hysterectomy compared to the REBOA group (I2 = 20.6%). REBOA was associated with a significant decrease in massive transfusion rates (I2 = 0%), surgery-related complications (I2 = 0%), ICU admissions (I2 = 40.3%), and units of red blood cells transfused (I2 = 92.8%), compared to PBO-IIA and control groups. The control group versus women undergoing prophylactic UAE showed a significant increase in total operative time (I2 = 96.5%) and Clavien-Dindo grade IV post-operative complications (I2 = 26%), compared to REBOA. All prophylactic endovascular procedures had a comparable risk ratio in terms of units of platelets transfused, maternal mortality, and use of additional post-operative bilateral uterine artery embolization among the treatment groups. As for neonatal outcomes, no significant differences were detected. Although the preponderance of observational studies suggests caution in interpreting the results of this meta-analysis, our findings suggest that prophylactic endovascular interventional procedures, particularly aortic balloon occlusion, may substantially improve clinical outcomes in women with PAS, placenta previa or both. CRD4202457398.","PeriodicalId":48867,"journal":{"name":"World Journal of Emergency Surgery","volume":"33 1","pages":""},"PeriodicalIF":8.0,"publicationDate":"2025-05-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144130299","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Secondary peritonitis is a serious condition with significant morbidity and mortality. Its management requires emergency laparotomy for source control. Vacuum-assisted closure (VAC) and primary abdominal closure (PAC) are the main strategies for managing the laparostomy after source control. Despite the increasing use of VAC, concerns persist regarding its complications and long-term outcomes compared with PAC. This systematic review followed PRISMA 2020 and MOOSE. The Cochrane Risk of Bias (RoB 2) tool, MINORS and GRADE framework assessed study quality and evidence certainty. The protocol was registered in PROSPERO (CRD42022304724). A comprehensive search of MEDLINE, Embase, and the Cochrane Library from January 2004 to August 2024 identified studies reporting postoperative outcomes following VAC or PAC after laparotomy for secondary peritonitis. The included studies had to report at least two key outcomes: mortality, postoperative complications, incisional hernia, secondary fascial closure, and hospital or intensive care unit (ICU) length of stay. Thirty-three studies including 4,520 patients were analyzed. Mortality was 31.1% in VAC and 22.2% in PAC (p = 0.327). Postoperative complications were higher with VAC (71.0% vs. 39.3%, p = 0.001). Incisional hernia rates were similar (21.3% vs. 20.8%, p = 0.958). Secondary fascial closure rate was significantly lower with VAC (58.1% vs. 85.9%, p < 0.001). VAC patients had longer ICU stays (21.1 vs. 9.7 days, p = 0.04), while hospital stay did not differ. Most studies had a high risk of bias, and GRADE assessment showed low to very low evidence certainty. VAC therapy was associated with more postoperative complications, a lower fascial closure rate, and a longer ICU length of stay compared with PAC. Thirty-day mortality rates did not differ between the approaches. However, most of studies included were subject to serious risk of bias and a low level of certainty in evidence.
继发性腹膜炎是一种严重的疾病，发病率和死亡率都很高。其管理需要紧急剖腹手术来控制源头。真空辅助闭合（VAC）和初级腹部闭合（PAC）是源头控制后处理剖腹造口的主要策略。尽管VAC的使用越来越多，但与PAC相比，人们对其并发症和长期预后的担忧仍然存在。该系统综述是在PRISMA 2020和MOOSE之后进行的。Cochrane偏倚风险（RoB 2）工具、minor和GRADE框架评估了研究质量和证据确定性。该协议已在PROSPERO （CRD42022304724）中注册。2004年1月至2024年8月对MEDLINE、Embase和Cochrane图书馆进行了全面检索，确定了报告继发性腹膜炎剖腹手术后VAC或PAC术后结果的研究。纳入的研究必须报告至少两个关键结果：死亡率、术后并发症、切口疝、继发性筋膜闭合和住院或重症监护病房（ICU）的住院时间。共分析了33项研究，包括4520名患者。VAC组死亡率为31.1%，PAC组死亡率为22.2% （p = 0.327）。VAC组术后并发症较高（71.0% vs 39.3%, p = 0.001）。切口疝发生率相似（21.3% vs. 20.8%, p = 0.958）。二次筋膜闭合率明显低于VAC组（58.1%比85.9%,p < 0.001）。VAC患者在ICU的住院时间更长（21.1天vs 9.7天，p = 0.04），而住院时间无差异。大多数研究具有高偏倚风险，GRADE评估显示低至极低的证据确定性。与PAC相比，VAC治疗与更多的术后并发症、更低的筋膜闭合率和更长的ICU住院时间相关。30天死亡率在两种方法之间没有差异。然而，纳入的大多数研究存在严重的偏倚风险，证据的确定性较低。
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