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1.  Analysis and injury paterns of walnut tree falls in central anatolia of turkey 
Introduction
Falls are the second most common cause of injury-associated mortality worldwide. This study aimed to analysis the injuries caused by falls from walnut tree and assess their mortality and morbidity risk.
Methods
This is a retrospective hospital-based study of patients presenting to emergency department (ED) of Ahi Evran Univercity between September and October 2012. For each casualty, we computed the ISS (defined as the sum of the squares of the highest Abbreviated Injury Scale (AIS) score in each of the three most severely injured body regions). Severe injury was defined as ISS ≥ 16. The duration of hospital stay and final outcome were recorded. Statistical comparisons were carried out with Chi-Square test for categorical data and non-parametric spearman correlation tests were used to test the association between variables. A p value less than 0.05 was considered to be statistically significant.
Results
Fifty-four patients admitted to our emergency department with fall from walnut tree. Fifty (92.6%) patients were male. The mean age was 48 ± 14 years. Spinal region (44.4%) and particularly lumbar area (25.9%) sustained the most of the injuries among all body parts. Wedge compression fractures ranked first among all spinal injuries. Extremities injuries were the second most common injury. None of the patients died. Morbidity rate was 9.25%.
Conclussion
Falls from walnut trees are a significant health problem. Preventive measures including education of farmers and agricultural workers and using mechanized methods for harvesting walnut will lead to a dramatic decrease in mortality and morbidity caused by falls from walnut trees.
doi:10.1186/1749-7922-9-42
PMCID: PMC4085373
Emergency; Falls; Walnut
2.  Establishment and implementation of an effective rule for the interpretation of computed tomography scans by emergency physicians in blunt trauma 
Introduction
Computed tomography (CT) can detect subtle organ injury and is applicable to many body regions. However, its interpretation requires significant skill. In our hospital, emergency physicians (EPs) must interpret emergency CT scans and formulate a plan for managing most trauma cases. CT misinterpretation should be avoided, but we were initially unable to completely accomplish this. In this study, we proposed and implemented a precautionary rule for our EPs to prevent misinterpretation of CT scans in blunt trauma cases.
Methods
We established a simple precautionary rule, which advises EPs to interpret CT scans with particular care when a complicated injury is suspected per the following criteria: 1) unstable physiological condition; 2) suspicion of injuries in multiple regions of the body (e.g., brain injury plus abdominal injury); 3) high energy injury mechanism; and 4) requirement for rapid movement to other rooms for invasive treatment. If a patient meets at least one of these criteria, the EP should exercise the precautions laid out in our newly established rule when interpreting the CT scan. Additionally, our rule specifies that the EP should request real-time interpretation by a radiologist in difficult cases. We compared the accuracy of EPs’ interpretations and resulting patient outcomes in blunt trauma cases before (January 2011, June 2012) and after (July 2012, January 2013) introduction of the rule to evaluate its efficacy.
Results
Before the rule’s introduction, emergency CT was performed 1606 times for 365 patients. We identified 44 cases (2.7%) of minor misinterpretation and 40 (2.5%) of major misinterpretation. After introduction, CT was performed 820 times for 177 patients. We identified 10 cases (1.2%) of minor misinterpretation and two (0.2%) of major misinterpretation. Real-time support by a radiologist was requested 104 times (12.7% of all cases) and was effective in preventing misinterpretation in every case. Our rule decreased both minor and major misinterpretations in a statistically significant manner. In particular, it conspicuously decreased major misinterpretations.
Conclusion
Our rule was easy to practice and effective in preventing EPs from missing major organ injuries. We would like to propose further large-scale multi-center trials to corroborate these results.
doi:10.1186/1749-7922-9-40
PMCID: PMC4085233
Blunt trauma; Computed tomography; Rule; Misinterpretation
3.  Lemierre’s disease: a case with bilateral iliopsoas abscesses and a literature review 
Lemierre’s disease is characterized by sepsis, often with an oropharyngeal source, secondary septic emboli and internal jugular vein thrombosis (Lancet 1:701–3, 1936. Clin Microbiol Rev 20(4):622–59, 2007). Septic emboli affecting many bodily sites have been reported, including the lungs, joints, bones, and brain. The case report describes an unusual case of Lemierre’s disease in a 64 year old gentleman causing profound sepsis, acute kidney injury, bilateral iliopsoas abscesses and a right hand abscess. To our knowledge, this is the first reported case of Lemierre’s disease in the context of bilateral psoas abscesses, and highlights the ambiguity surrounding the definition of Lemierre’s disease. The clinical literature review highlights the difficulty in definitively diagnosing the condition and offers some suggestions for recognising and refining the diagnostic criterion of Lemierre’s.
doi:10.1186/1749-7922-9-38
PMCID: PMC4046005  PMID: 24904685
Lemierre; Fusobacterium; Fusobacterium Necrophorum; Bilateral; Iliopsoas abscess
4.  Complicated intra-abdominal infections worldwide: the definitive data of the CIAOW Study 
Sartelli, Massimo | Catena, Fausto | Ansaloni, Luca | Coccolini, Federico | Corbella, Davide | Moore, Ernest E | Malangoni, Mark | Velmahos, George | Coimbra, Raul | Koike, Kaoru | Leppaniemi, Ari | Biffl, Walter | Balogh, Zsolt | Bendinelli, Cino | Gupta, Sanjay | Kluger, Yoram | Agresta, Ferdinando | Saverio, Salomone Di | Tugnoli, Gregorio | Jovine, Elio | Ordonez, Carlos A | Whelan, James F | Fraga, Gustavo P | Gomes, Carlos Augusto | Pereira, Gerson Alves | Yuan, Kuo-Ching | Bala, Miklosh | Peev, Miroslav P | Ben-Ishay, Offir | Cui, Yunfeng | Marwah, Sanjay | Zachariah, Sanoop | Wani, Imtiaz | Rangarajan, Muthukumaran | Sakakushev, Boris | Kong, Victor | Ahmed, Adamu | Abbas, Ashraf | Gonsaga, Ricardo Alessandro Teixeira | Guercioni, Gianluca | Vettoretto, Nereo | Poiasina, Elia | Díaz-Nieto, Rafael | Massalou, Damien | Skrovina, Matej | Gerych, Ihor | Augustin, Goran | Kenig, Jakub | Khokha, Vladimir | Tranà, Cristian | Kok, Kenneth Yuh Yen | Mefire, Alain Chichom | Lee, Jae Gil | Hong, Suk-Kyung | Lohse, Helmut Alfredo Segovia | Ghnnam, Wagih | Verni, Alfredo | Lohsiriwat, Varut | Siribumrungwong, Boonying | El Zalabany, Tamer | Tavares, Alberto | Baiocchi, Gianluca | Das, Koray | Jarry, Julien | Zida, Maurice | Sato, Norio | Murata, Kiyoshi | Shoko, Tomohisa | Irahara, Takayuki | Hamedelneel, Ahmed O | Naidoo, Noel | Adesunkanmi, Abdul Rashid Kayode | Kobe, Yoshiro | Ishii, Wataru | Oka, Kazuyuki | Izawa, Yoshimitsu | Hamid, Hytham | Khan, Iqbal | Attri, AK | Sharma, Rajeev | Sanjuan, Juan | Badiel, Marisol | Barnabé, Rita
The CIAOW study (Complicated intra-abdominal infections worldwide observational study) is a multicenter observational study underwent in 68 medical institutions worldwide during a six-month study period (October 2012-March 2013). The study included patients older than 18 years undergoing surgery or interventional drainage to address complicated intra-abdominal infections (IAIs).
1898 patients with a mean age of 51.6 years (range 18-99) were enrolled in the study. 777 patients (41%) were women and 1,121 (59%) were men. Among these patients, 1,645 (86.7%) were affected by community-acquired IAIs while the remaining 253 (13.3%) suffered from healthcare-associated infections. Intraperitoneal specimens were collected from 1,190 (62.7%) of the enrolled patients.
827 patients (43.6%) were affected by generalized peritonitis while 1071 (56.4%) suffered from localized peritonitis or abscesses.
The overall mortality rate was 10.5% (199/1898).
According to stepwise multivariate analysis (PR = 0.005 and PE = 0.001), several criteria were found to be independent variables predictive of mortality, including patient age (OR = 1.1; 95%CI = 1.0-1.1; p < 0.0001), the presence of small bowel perforation (OR = 2.8; 95%CI = 1.5-5.3; p < 0.0001), a delayed initial intervention (a delay exceeding 24 hours) (OR = 1.8; 95%CI = 1.5-3.7; p < 0.0001), ICU admission (OR = 5.9; 95%CI = 3.6-9.5; p < 0.0001) and patient immunosuppression (OR = 3.8; 95%CI = 2.1-6.7; p < 0.0001).
doi:10.1186/1749-7922-9-37
PMCID: PMC4039043  PMID: 24883079
5.  Blunt cerebrovascular injury in rugby and other contact sports: case report and review of the literature 
Contact sports have long been a part of human existence. The two earliest recorded organized contact games, both of which still exist, include Royal Shrovetide Football played since the 12th century in England and Caid played since 1308 AD in Ireland. Rugby is the premier contact sport played throughout the world with the very popular derivative American football being the premier contact sport of the North American continent.
American football in the USA has on average 1,205,037 players at the high school and collegiate level per year while rugby in the USA boasts a playing enrollment of 457,983 at all levels.
Recent media have highlighted injury in the context of competitive contact sports including their long-term sequelae such as chronic traumatic encephalopathy (CTE) that had previously been underappreciated. Blunt cerebrovascular injury (BCVI) has become a recognized injury pattern for trauma; however, a paucity of data regarding this injury can be found in the sports trauma literature.
We present a case of an international level scrum-half playing Rugby Union at club level for a local non-professional team, in which a player sustained a fatal BCVI followed by a discussion of the literature surrounding sport related BCVI.
doi:10.1186/1749-7922-9-36
PMCID: PMC4036724  PMID: 24872841
6.  Giant extra-hepatic thrombosed portal vein aneurysm: a case report and review of the literature 
Background
Extrahepatic Portal vein aneurysm (EPVA) is a rare finding that may be associated with different complications, e.g. thrombosis, rupture, portal hypertension and compression of adjacent structures. It is being diagnosed more frequently with the advent of modern cross-sectional imaging. Our review of the English literature disclosed 13 cases of thrombosed EPVA.
Case presentation
A 50-years-old woman presented with acute abdominal pain but no other symptom. She had no relevant medical history. Palpation of the right upper quadrant showed tenderness. Laboratory tests were unremarkable. A computed tomography showed portal vein aneurysm measuring 88 × 65 mm with thrombosis extending to the superior mesenteric and splenic vein. The patient was treated conservatively with anticoagulation therapy. She was released after two weeks and followed on an outpatient basis. At two months, she reported decreased abdominal pain and her physical examination was normal. A computed tomography was performed showing a decreased thrombosis size and extent, measuring 80 × 55 mm.
Conclusions
Although rare, surgeons should be made aware of this entity. Complications are various. Conservative therapy should be chosen in first intent in most cases. We reported the case of the second largest thrombosed extra-hepatic PVA described in the literature, treated by anticoagulation therapy with a good clinical and radiological response.
doi:10.1186/1749-7922-9-35
PMCID: PMC4008416  PMID: 24795777
Aneurysm; Thrombosis; Portal vein
7.  Repair of diaphragmatic hernia following spinal surgery by laparoscopic mesh application: a case report and review of the literature 
We describe the laparoscopic management of diaphragmatic hernia (DH) caused by vertebral pedicle screw displacement.
A 58-year-old woman underwent surgery for scoliosis and underwent posterior pedicle screw fixation. In the first postoperative (PO)day, she developed mild dyspnea. An anteroposterior chest radiograph revealed bilateral pleural effusion, which was more pronounced on the left side.
A thoracoabdominal computed tomography (CT) scan, performed in the second PO day, revealed a solid mass in the pleural cavity that was associated with screw displacement, which had also entered into the peritoneal cavity without apparent other lesion of hollow and solid viscous. In the third PO day, after the screw was removed, explorative laparoscopy was carried out. We observed herniation of the omentum through a small diaphragmatic tear. Once the absence of visceral injury was confirmed, we reduced the omentum into the abdomen. Then, we repaired the hernia by applying a dual layer polypropylene mesh over the defect with a 3-cm overlap. The remainder of the postoperative period was uneventful.
Iatrogenic DH due to a pedicle screw displacement has never been described before. In cases of pleural effusion following spinal surgery, rapid assessment and treatment are crucial. We conclude that a laparoscopic approach to iatrogenic DH could be feasible and effective in a hemodynamically stable patient with negative CT findings because it enables the completion of the diagnostic cascade and the repair of the tear, providing excellent visualization of the abdominal viscera and diaphragmatic tears.
doi:10.1186/1749-7922-9-34
PMCID: PMC4012096  PMID: 24808922
Diaphragmatic hernia; Surgical complication; Mesh repair; Laparoscopic repair
8.  Right diaphragmatic injury and lacerated liver during a penetrating abdominal trauma: case report and brief literature review 
Introduction
Diaphragmatic injuries are rare consequences of thoracoabdominal trauma and they often occur in association with multiorgan injuries. The diaphragm is a difficult anatomical structure to study with common imaging instruments due to its physiological movement. Thus, diaphragmatic injuries can often be misunderstood and diagnosed only during surgical procedures. Diagnostic delay results in a high rate of mortality.
Methods
We report the management of a clinical case of a 45-old man who came to our observation with a stab wound in the right upper abdomen. The type or length of the knife used as it was extracted from the victim after the fight. CT imaging demonstrated a right hemothorax without pulmonary lesions and parenchymal laceration of the liver with active bleeding. It is observed hemoperitoneum and subdiaphragmatic air in the abdomen, as a bowel perforation. A complete blood count check revealed a decrease in hemoglobin (7 mg/dl), and therefore it was decided to perform surgery in midline laparotomy.
Conclusion
In countries with a low incidence of inter-personal violence, stab wound diaphragmatic injury is particularly rare, in particular involving the right hemidiaphragm. Diaphragmatic injury may be underestimated due to the presence of concomitant lesions of other organs, to a state of shock and respiratory failure, and to the difficulty of identifying diaphragmatic injuries in the absence of high sensitivity and specific diagnostic instruments. Diagnostic delay causes high mortality with these traumas with insidious symptoms. A diaphragmatic injury should be suspected in the presence of a clinical picture which includes hemothorax, hemoperitoneum, anemia and the presence of subdiaphragmatic air in the abdomen.
doi:10.1186/1749-7922-9-33
PMCID: PMC4016783  PMID: 24817907
Diaphragmatic injury; Penetrating abdominal trauma; Diaphragmatic repair; Liver laceration; Stab wound
9.  Robotic right colectomy for hemorrhagic right colon cancer: a case report and review of the literature of minimally invasive urgent colectomy 
Right colon cancer rarely presents as an emergency, in which bowel occlusion and massive bleeding are the most common clinical presentations. Although there are no definite guidelines, the first line treatment for massive right colon cancer bleeding should ideally stop the bleeding using endoscopy or interventional radiology, subsequently allowing proper tumor staging and planning of a definite treatment strategy. Minimally invasive approaches for right and left colectomy have progressively increased and are widely performed in elective settings, with laparoscopy chosen in the majority of cases. Conversely, in emergent and urgent surgeries, minimally invasive techniques are rarely performed. We report a case of an 86-year-old woman who was successfully treated for massive rectal bleeding in an urgent setting by robotic surgery (da Vinci Intuitive Surgical System®). At admission, the patient had severe anemia (Hb 6 g/dL) and hemodynamic stability. A computer tomography scanner with contrast enhancement showed a right colon cancer with active bleeding; no distant metastases were found. A colonoscopy did not show any other bowel lesion, while a constant bleeding from the right pre-stenotic colon mass was temporarily arrested by endoscopic argon coagulation. A robotic right colectomy in urgent setting (within 24 hours from admission) was indicated. A three-armed robot was used with docking in the right side of the patient and a fourth trocar for the assistant surgeon. Because of the patient’s poor nutritional status, a double-barreled ileocolostomy was performed. The post-operative period was uneventful. As the neoplasia was a pT3N0 adenocarcinoma, surveillance was decided after a multidisciplinary meeting, and restoration of the intestinal continuity was performed 3 months later, once good nutritional status was achieved. In addition, we reviewed the current literature on minimally invasive colectomy performed for colon carcinoma in emergent or urgent setting. No study on robotic approach was found. Seven studies evaluating the role of laparoscopic colectomy concluded that this technique is a safe and feasible option associated with lower blood loss and shorter hospital stay. It may require longer operative time, but morbidity and mortality rates appeared comparable to open colectomy. However, the surgeon’s experience and the right selection of candidate patients cannot be understated.
doi:10.1186/1749-7922-9-32
PMCID: PMC4005854  PMID: 24791165
Hemorrhagic colon cancer; Robotic surgery; Laparoscopic surgery; Emergency surgery; Minimally invasive surgery; Review
10.  Comparison of the Canadian CT head rule and the new orleans criteria in patients with minor head injury 
Aim
The aim of the study was to compare the New Orleans Criteria and the New Orleans Criteria according to their diagnostic performance in patients with mild head injury.
Methods
The study was designed and conducted prospectively after obtaining ethics committee approval. Data was collected prospectively for patients presenting to the ED with Minor Head Injury. After clinical assessment, a standard CT scan of the head was performed in patients having at least one of the risk factors stated in one of the two clinical decision rules.
Patients with positive traumatic head injury according to BT results defined as Group 1 and those who had no intracranial injury defined as Group 2. Statistical analysis was performed with SPSS 11.00 for Windows. ROC analyze was performed to determine the effectiveness of detecting intracranial injury with both decision rules. p < 0.05 was considered statistically significant.
Results
175 patients enrolled the study. Male to female ratio was 1.5. The mean age of the patients was 45 ± 21,3 in group 1 and 49 ± 20,6 in group 2. The most common mechanism of trauma was falling. The sensitivity and specificity of CCHR were respectively 76.4% and 41.7%, whereas sensitivity and specificity of NOC were 88.2% and 6.9%.
Conclusion
The CCHR has higher specificity, PPV and NPV for important clinical outcomes than does the NOC.
doi:10.1186/1749-7922-9-31
PMCID: PMC3997198  PMID: 24742359
Emergency; Head injury; CT rules
12.  Extended negative pressure wound therapy-assisted dermatotraction for the closure of large open fasciotomy wounds in necrotizing fasciitis patients 
Background
Necrotizing fasciitis (NF) is a rapid progressive infection of the subcutaneous tissue or fascia and may result in large open wounds. The surgical options to cover these wounds are often limited by the patient condition and result in suboptimal functional and cosmetic wound coverage. Dermatotraction can restore the function and appearance of the fasciotomy wound and is less invasive in patients with comorbidities. However, dermatotraction for scarred, stiff NF fasciotomy wounds is often ineffective, resulting in skin necrosis. The authors use extended negative pressure wound therapy (NPWT) as an assist in dermatotraction to close open NF fasciotomy wounds. The authors present the clinical results, followed by a discussion of the clinical basis of extended NPWT-assisted dermatotraction.
Methods
A retrospective case series of eight patients with NF who underwent open fasciotomy was approved for the study. After serial wound preparation, dermatotraction was applied in a shoelace manner using elastic vessel loops. Next, the extended NPWT was applied over the wound. The sponge was three times wider than the wound width, and the transparent covering drape almost encircled the anatomical wound area. The negative pressure of the NPWT was set at a continuous 100 mmHg by suction barometer. The clinical outcome was assessed based on wound area reduction after treatment and by the achievement of direct wound closure.
Results
After the first set of extended NPWT-assisted dermatotraction procedures, the mean wound area was significantly decreased (658.12 cm2 to 29.37 cm2; p = 0.002), as five out of eight patients achieved direct wound closure. One patient with a chest wall defect underwent latissimus dorsi musculocutaneous flap coverage, with primary closure of the donor site. Two Fournier’s gangrene patients underwent multiple sets of treatment and finally achieved secondary wound closure with skin grafts. The patients were followed up for 18.3 months on average and showed satisfactory results without wound recurrence.
Conclusions
Extended NPWT-assisted dermatotraction advances scarred, stiff fasciotomy wound margins synergistically in NF and allows direct closure of the wound without complications. This method can be another good treatment option for the NF patient with large open wounds whose general condition is unsuitable for extensive reconstructive surgery.
doi:10.1186/1749-7922-9-29
PMCID: PMC3996171  PMID: 24731449
Necrotizing fasciitis; Negative pressure wound therapy; Dermatotraction; Fournier’s gangrene; Fasciotomy
13.  Comparison of 3-Factor Prothrombin Complex Concentrate and Low-Dose Recombinant Factor VIIa for Warfarin Reversal 
Introduction
Prothrombin complex concentrate (PCC) and recombinant Factor VIIa (rFVIIa) have been used for emergent reversal of warfarin anticoagulation. Few clinical studies have compared these agents in warfarin reversal. We compared warfarin reversal in patients who received either 3 factor PCC (PCC3) or low-dose rFVIIa (LDrFVIIa) for reversal of warfarin anticoagulation.
Methods
Data were collected from medical charts of patients who received at least one dose of PCC3 (20 units/kg) or LDrFVIIa (1000 or 1200 mcg) for emergent warfarin reversal from August 2007 to October 2011. The primary end-points were achievement of an INR 1.5 or less for efficacy and thromboembolic events for safety.
Results
Seventy-four PCC3 and 32 LDrFVIIa patients were analyzed. Baseline demographics, reason for warfarin reversal, and initial INR were equivalent. There was no difference in the use of vitamin K or fresh frozen plasma. More LDrFVIIa patients achieved an INR of 1.5 or less (71.9% vs. 33.8%, p =0.001). The follow-up INR was lower after LDrFVIIa (1.25 vs. 1.75, p < 0.05) and the percent change in INR was larger after LDrFVIIa (54.1% vs. 38.8%, p = 0.002). There was no difference in the number of thromboembolic events (2 LDrFVIIa vs. 5 PCC3, p = 1.00), mortality, length of hospital stay, or cost.
Conclusions
Based on achieving a goal INR of 1.5 or less, LDrFVIIa was more likely than PCC3 to reverse warfarin anticoagulation. Thromboembolic events were equivalent in patients receiving PCC3 and LDrFVIIa.
doi:10.1186/1749-7922-9-27
PMCID: PMC3996494  PMID: 24731393
Anticoagulation; Hemorrhage; Trauma; Prothrombin complex concentrate; Recombinant factor VIIa; Warfarin
14.  Goal-directed transfusion protocol via thrombelastography in patients with abdominal trauma: a retrospective study 
Introduction
The optimal transfusion protocol remains unknown in the trauma setting. This retrospective cohort study aimed to determine if goal-directed transfusion protocol based on standard thrombelastography (TEG) is feasible and beneficial in patients with abdominal trauma.
Methods
Sixty adult patients with abdominal trauma who received 2 or more units of red blood cell transfusion within 24 hours of admission were studied. Patients managed with goal-directed transfusion protocol via TEG (goal-directed group) were compared to patients admitted before utilization of the protocol (control group).
Results
There were 29 patients in the goal-directed group and 31 in the control group. Baseline parameters were similar except for higher admission systolic blood pressure in the goal-directed group than the control group (121.8 ± 23.1 mmHg vs 102.7 ± 26.5 mmHg, p < 0.01). At 24 h, patients in the goal-directed group had shorter aPTT compared to patients in the control group (39.2 ± 16.3 s vs 58.6 ± 36.6 s, p = 0.044). Administration of total blood products at 24 h appeared to be fewer in the goal-directed group than the control group (10.2 [7.0-43.1]U vs 14.8 [8.3-37.6]U, p = 0.28), but this was not statistically significant. Subgroup analysis including patients with ISS ≥16 showed that patients in the goal-directed group had significantly fewer consumption of total blood products than patients in the control group (7[6.1, 47.0]U vs 37.6[14.5, 89.9]U, p = 0.015). No differences were found in mortality at 28d, length of stay in intensive care unit and hospital between the two groups.
Conclusions
Goal-directed transfusion protocol via standard TEG was achievable in patients with abdominal trauma. The novel protocol, compared to conventional transfusion management, has the potential to decrease blood product utilization and prevent exacerbation of coagulation function.
doi:10.1186/1749-7922-9-28
PMCID: PMC3999505  PMID: 24731406
Transfusion; Thrombelastography; Trauma-induced coagulopathy; Abdominal trauma
15.  Acute appendicitis: position paper, WSES, 2013 
Appendectomy is one of the most frequently performed operative procedures in general surgery departments of every size and category. Laparoscopic Appendectomy – LA - as compared to Open Appendectomy – OA - was very controversial at first but has found increasing acceptance all over the World, although the percentage of its acceptance is different in the various single National setting. Various meta-analyses and Cochrane reviews have compared LA with OA and different technical details. Furthermore, new surgical methods have recently emerged, namely, the single-port/incision laparoscopic appendectomy and NOTES technique. Their distribution among the hospitals, however, is unclear. Using laparoscopic mini-instruments with trocars of 2–3.5 mm diameter is proposed as a reliable alternative due to less postoperative pain and improved aesthetics. How to proceed in case of an inconspicuous appendix during a procedure planned as an appendectomy remains controversial despite existing study results. But the main question still is: operate or not operate an acute appendicitis, in the meaning of an attempt of a conservative antibiotic therapy. Therefore, we have done a literature survey on the performance of appendectomies and their technical details as well as the management of the intraoperative finding of an inconspicuous appendix in order to write down – under the light of the latest evidence – a position paper.
doi:10.1186/1749-7922-9-26
PMCID: PMC3984433  PMID: 24708651
17.  Gastrostomy tube dislodgment acute pancreatitis 
Percutaneous gastrostomy is well established root for long term feeding of patients who cannot be fed orally. The risks of percutanous gastrostomy insertion are low. Tube related complications often resolved by placing a Foley catheter or other balloon gastrostomy tube as a temporary solution. Gastrostomy tube related gastric, duodenal and billiary obstruction were reported. Gastrostomy tube related pancreatitis is scarcely described. We described a patient who suffered a pancreatitis related to Foley catheter gastrostomy dislodgment. Reviewing all reported cases of gastrostomy related pancreatitis revealed higher incidence in patient with Foley catheter used as gastrostomy and revealed questionable trends in conducting tube replacement. We suggest a proper manner for tube replacement and concluded that should a Foley catheter used as a temporary solution a replacement should be schedule in a timely manner to avoid life threatening complications.
doi:10.1186/1749-7922-9-23
PMCID: PMC3974449  PMID: 24674106
Pancreatitis; Gastrostomy; Percutaneous endoscopic gastrostomy (PEG); Foley catheter
18.  Current concept of abdominal sepsis: WSES position paper 
Although sepsis is a systemic process, the pathophysiological cascade of events may vary from region to region.
Abdominal sepsis represents the host’s systemic inflammatory response to bacterial peritonitis.
It is associated with significant morbidity and mortality rates, and is the second most common cause of sepsis-related mortality in the intensive care unit.
The review focuses on sepsis in the specific setting of severe peritonitis.
doi:10.1186/1749-7922-9-22
PMCID: PMC3986828  PMID: 24674057
19.  Allocating operating room resources to an acute care surgery service does not affect wait-times for elective cancer surgeries: a retrospective cohort study 
Introduction
Acute care surgical services provide timely comprehensive emergency general surgical care while optimizing the use of limited resources. At our institution, 50% of the daily dedicated operating room (OR) time allocated to the Acute Care Emergency Surgery Service (ACCESS) came from previous elective general surgery OR time. We assessed the impact of this change in resource allocation on wait-times for elective general surgery cancer cases.
Methods
We retrospectively reviewed adult patients who underwent elective cancer surgeries in the pre-ACCESS (September 2009 to June 2010) and post-ACCESS (September 2010 to June 2011) eras. Wait-times, calculated as the time between booking and actual dates of surgery, were compared within assigned priority classifications. Categorical and continuous variables were compared using chi-square and Mann–Whitney U tests respectively.
Results
A total of 732 cases (367 pre-ACCESS and 365 post-ACCESS) were identified, with no difference in median wait-times (25 versus 23 days) between the eras. However, significantly fewer cases exceeded wait-time targets in the post-ACCESS era (p <0.0001). There was a significant change (p = 0.027) in the composition of cancer cases, with fewer breast cancer operations (22% versus 28%), and more colorectal (41% versus 32%) and hepatobiliary cancer cases (5% versus 2%) in the post-ACCESS era.
Conclusion
These results suggest that shifting OR resources towards emergency surgery does not affect the timeliness of surgical cancer care. This study may encourage more centres to adopt acute care surgical services alongside their elective or subspecialty practices.
doi:10.1186/1749-7922-9-21
PMCID: PMC3986936  PMID: 24669771
Acute care surgery; Cancer wait-times; Resource allocation; Health outcomes research
20.  Successful interventional management of abdominal compartment syndrome caused by blunt liver injury with hemorrhagic diathesis 
We report that a case of primary abdominal compartment syndrome (ACS), caused by blunt liver injury under the oral anticoagulation therapy, was successfully treated. Transcatheter arterial embolization (TAE) was initially selected, and the bleeding point of hepatic artery was embolized with N-Butyl Cyanoacylate (NBCA). Secondary, percutaneous catheter drainage (PCD) was performed for massive hemoperitoneum. There are some reports of ACS treated with TAE. However, combination treatment of TAE with NBCA and PCD for ACS has not been reported. Even low invasive interventional procedures may improve primary ACS if the patient has hemorrhagic diathesis or coagulopathy discouraging surgeon from laparotomy.
doi:10.1186/1749-7922-9-20
PMCID: PMC3994338  PMID: 24656215
Abdominal compartment syndrome; Transcatheter arterial embolization; N-butyl cyanoacylate
21.  An acute care surgery service expedites the treatment of emergency colorectal cancer: a retrospective case–control study 
Introduction
Emergency colorectal cancer (CRC) is a complex disease that requires multidisciplinary approaches for management. However, it is unclear whether acute care surgery (ACS) services can expedite the workup and treatment of complex surgical diseases such as emergency CRC. We sought to assess the impact of an Acute Care and Emergency Surgery Service (ACCESS) on wait-times for inpatient colonoscopy and surgical resection among emergency CRC patients.
Methods
This retrospective case–control study was conducted at a tertiary-care, university-affiliated, cancer centre in London, Ontario, Canada. All patients aged 18 or older who presented to the emergency department with a recent (within 48 hours) diagnosis of CRC, or were diagnosed with CRC after admission, were included in the study. Patients were either in the pre-ACCESS (July 1, 2007-June 31, 2010) or post-ACCESS (July 1, 2010-June 30, 2012) groups. A third group of emergency CRC patients treated at an adjacent cancer centre that lacked ACCESS (non-ACCESS) was evaluated separately. The primary outcome was time from admission to colonoscopy and surgery.
Results
A total of 149 patients (47 pre-ACCESS, 37 post-ACCESS, and 65 non-ACCESS) were identified. Only 19% (n = 9) of pre-ACCESS patients underwent inpatient colonoscopy, compared to 38% (n = 14) in the post-ACCESS group (p = 0.023). Additionally, 100% of patients in the post-ACCESS era underwent inpatient colonoscopy and surgery during the same admission, compared to only 44% of pre-ACCESS patients (p = 0.006). Median wait-times for inpatient colonoscopy (2.0 and 1.8 days for pre- and post-ACCESS groups respectively, p = 0.08) and surgical resection (1.6 and 2.3 days for pre- and post-ACCESS groups respectively, p = 0.40) were similar.
Conclusions
Patients admitted to ACCESS underwent more inpatient colonoscopies and were more likely to have definitive surgery on that admission. ACS services can facilitate the workup and management of complex surgical diseases such as emergency CRC without delaying treatment.
doi:10.1186/1749-7922-9-19
PMCID: PMC3994420  PMID: 24656174
Colorectal/anal neoplasia; Colonoscopy; Acute care surgery; Health outcomes
22.  Management of hemodynamically unstable pelvic trauma: results of the first Italian consensus conference (cooperative guidelines of the Italian Society of Surgery, the Italian Association of Hospital Surgeons, the Multi-specialist Italian Society of Young Surgeons, the Italian Society of Emergency Surgery and Trauma, the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care, the Italian Society of Orthopaedics and Traumatology, the Italian Society of Emergency Medicine, the Italian Society of Medical Radiology -Section of Vascular and Interventional Radiology- and the World Society of Emergency Surgery) 
Hemodynamically Unstable Pelvic Trauma is a major problem in blunt traumatic injury. No cosensus has been reached in literature on the optimal treatment of this condition. We present the results of the First Italian Consensus Conference on Pelvic Trauma which took place in Bergamo on April 13 2013. An extensive review of the literature has been undertaken by the Organizing Committee (OC) and forwarded to the Scientific Committee (SC) and the Panel (JP). Members of them were appointed by surgery, critical care, radiology, emergency medicine and orthopedics Italian and International societies: the Italian Society of Surgery, the Italian Association of Hospital Surgeons, the Multi-specialist Italian Society of Young Surgeons, the Italian Society of Emergency Surgery and Trauma, the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care, the Italian Society of Orthopaedics and Traumatology, the Italian Society of Emergency Medicine, the Italian Society of Medical Radiology, Section of Vascular and Interventional Radiology and the World Society of Emergency Surgery. From November 2012 to January 2013 the SC undertook the critical revision and prepared the presentation to the audience and the Panel on the day of the Conference. Then 3 recommendations were presented according to the 3 submitted questions. The Panel voted the recommendations after discussion and amendments with the audience. Later on a email debate took place until December 2013 to reach a unanimous consent. We present results on the 3 following questions: which hemodynamically unstable patient needs an extraperitoneal pelvic packing? Which hemodynamically unstable patient needs an external fixation? Which hemodynamically unstable patient needs emergent angiography? No longer angiography is considered the first therapeutic maneuver in such a patient. Preperitoneal pelvic packing and external fixation, preceded by pelvic binder have a pivotal role in the management of these patients.
Hemodynamically Unstable Pelvic Trauma is a frequent death cause among people who sustain blunt trauma. We present the results of the First Italian Consensus Conference.
doi:10.1186/1749-7922-9-18
PMCID: PMC3975341  PMID: 24606950
Pelvic trauma; Angiography; Preperitoneal pelvic packing; External fixation; Pelvic binder
23.  Methylene Blue injection via superior mesenteric artery microcatheter for focused enterectomy in the treatment of a bleeding small intestinal arteriovenous malformation 
Introduction
Obscure gastrointestinal bleeding from the small intestine may present the Acute Care Surgeon with a formidable diagnostic and therapeutic challenge. Despite the current array of diagnostic studies, localization of the causative pathology may be elusive, especially when the bleeding is intermittent. When a small intestinal arteriovenous malformation is the responsible lesion, a technique combining super-selective angiography with intra-operative methylene blue injection and focused enterectomy has been described in a number of case series. The current case report utilizes this same approach with emphasis on computed tomography angiography representing a key first step in the diagnostic algorithm.
Case report
In this case report, we describe the diagnosis and treatment of obscure gastrointestinal bleeding emanating from an arteriovenous malformation in the small intestine of a 52 year old male. After an extensive work-up including upper and lower endoscopy, double balloon enteroscopy and capsule endoscopy, he was referred for computed tomography angiography. Though he was not actively bleeding, a jejunal arteriovenous malformation was localized on imaging. This prompted directed transfemoral angiography, placement of a super-selective microcatheter in the 4th jejunal arterial branch, intra-operative methylene blue injection and focused enterectomy with pathological confirmation. The patient was found to be free of gastrointestinal bleeding on 6 month follow-up.
Conclusions
A step-wise, rational diagnostic approach should be utilized in the evaluation of obscure gastrointestinal bleeding. In the non-actively bleeding patient, computed tomography angiogram may facilitate the diagnosis of a small intestinal arteriovenous malformation. Methylene blue injection via a super-selective angiographic microcatheter may then allow for focused enterectomy.
doi:10.1186/1749-7922-9-17
PMCID: PMC3931282  PMID: 24552355
Obscure gastrointestinal bleeding; Computed tomography angiography; Super-selective angiography; Intra-operative methylene blue injection
24.  The value of Serum BNP for diagnosis of intracranial injury in minor head trauma 
Objective
Head injury is the main cause of death among individuals younger than 45 years old. Cranial Computerized tomography (CT) is commonly used for diagnosis of head injury. Brain Natriuretic Peptide (BNP) is a peptide originally isolated from brain ventricles. The main aim of this study is to investigate BNP as an indicator of head injury among patients presenting to emergency department (ED) with minor head trauma.
Methods
This was a prospective study conducted at the emergency department of the Numune Training and Research Hospital. A total of 162 patients who presented to the ED with minor head injury were enrolled. The patients were categorized into 2 groups as the cranial CT-negative and positive groups. The normality of the data was tested using One Sample Kolmogorov Smirnov test. Mann–Whitney U test was used to compare 2 independent groups while the Kruskal-Wallis test was utilized for comparison of more than 2 groups. A p-value of <0.05 was considered to be significant.
Results
Ninety-six (59.3%) patients were male and 66 (40.7%) were female. The cranial CT-negative group had a median BNP level of 14.5 pg/ml while the cranial CT-positive group had a median BNP level of 13 pg/ml. There was no statistically significant difference between these two groups for serum BNP levels (p > 0.05).
Conclusion
This study suggested that serum BNP level wasn’t used in defined of intracranial injury.
doi:10.1186/1749-7922-9-16
PMCID: PMC3922242  PMID: 24512950
Emergency; Head trauma; Brain natriuretic peptide
25.  Position paper: timely interventions in severe acute pancreatitis are crucial for survival 
Severe acute pancreatitis has high mortality, but multiple and timely interventions can improve survival. Early in the course of the disease aggressive fluid resuscitation is needed for the prevention and treatment of shock. In conjunction with leaking capillaries this results in increased tissue edema, which may lead to intra-abdominal hypertension and abdominal compartment syndrome. Invasive hemodynamic monitoring is essential for optimizing fluid therapy while monitoring of intra-abdominal pressure is necessary for identification patients at risk of developing abdominal compartment syndrome. Abdominal compartment syndrome develops usually within the first days after hospitalization. Conservative treatment modalities are useful in prevention but also in the treatment of abdominal compartment syndrome. If conservative management fails surgical decompression of abdomen may be needed. Multiple organ dysfunction syndrome and increased intra-abdominal pressure predispose patients with severe pancreatitis to secondary infections. Extrapancreatic infections predominate during the first week of the disease, whereas infection of pancreatic necrosis usually develops later. Early enteral nutrition reduces the risk of infections whereas advantage of prophylactic antibiotics is lacking evidence. Surgery for infected pancreatic necrosis is associated with high mortality when performed within the first two weeks of the disease. Therefore surgery should be postponed as late as possible, preferably later than four weeks after disease onset.
doi:10.1186/1749-7922-9-15
PMCID: PMC3926684  PMID: 24512891

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