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

On January 30th, 2020, the World Health Organization declared the Severe Acute Respiratory Syndrome 2 (SARSCoV-2) outbreak an international public health emergency, and one day later, the first COVID-19 case was confirmed in Gomera Island, Spain. In the following weeks, the number of cases in several Spanish cities spiked alarmingly, with thousands reported. This new coronavirus outbreak generated unprecedented changes in the Surgery Departments around the world, first in Asia, followed weeks later in Europe and America. This novel scenario of health crisis demanded a change in logistics and organization to guarantee urgent operations onCOVID-19 cases without interrupting the capability to handle emergency and oncologic surgery in the virus-free population, minimizing the viral transmission to staff and other patients. This manuscript aims to summarize the changes adopted by the General and GI Surgery Departments to address this unprecedented clinical scenario, including the restructuring of surgical schedules, staff preparation, and the departments outbreak response protocols and recommendations for surgical techniques and risk management.

Purpose The COVID-19 pandemic has changed working conditions for emergency surgical teams around the world. International surgical societies have issued clinical recommendations to optimize surgical management. This international study aimed to assess the degree of emergency surgical teams' adoption of recommendations during the pandemic. Methods Emergency surgical team members from over 30 countries were invited to answer an anonymous, prospective, online survey to assess team organization, PPE-related aspects, OR preparations, anesthesiologic considerations, and surgical management for emergency surgery during the pandemic. Results One-hundred-and-thirty-four questionnaires were returned (N = 134) from 26 countries, of which 88% were surgeons, 7% surgical trainees, 4% anesthetists. 81% of the respondents got involved with COVID-19 crisis management. Social media were used by 91% of the respondents to access the recommendations, and 66% used videoconference tools for team communication. 51% had not received PPE training before the pandemic, 73% reported equipment shortage, and 55% informed about re-use of N95/FPP2/3 respirators. Dedicated COVID operating areas were cited by 77% of the respondents, 44% had performed emergency surgical procedures on COVID-19 patients, and over half (52%), favored performing laparoscopic over open surgical procedures. Conclusion Surgical team members have responded with leadership to the COVID-19 pandemic, with crisis management principles. Social media and videoconference have been used by the vast majority to access guidelines or to communicate during social distancing. The level of adoption of current recommendations is high for organizational aspects and surgical management, but not so for PPE training and availability, and anesthesiologic considerations.

Prognostic value of ADAMTS13 in patients with severe sepsis and septic shock Abstract Purpose: ADAMTS13 level was evaluated as a predictor of mortality in patients with severe sepsis and septic shock, and compared with Acute Physiology and Chronic Health Evaluation II (APACHE II) scores.Methods: This prospective observational study was conducted in the Medical and Surgical Intensive Care Units of King Khalid University Hospital. Detailed clinical evaluations were performed on 84 patients (56.08±18.18 years of age) with severe sepsis and septic shock. ADAMTS13 levels were determined (three blood samples at 24 hours intervals) and APACHE II scores, hematological profiles, indices of organ hypo-perfusion, renal functions and coagulation profiles were recorded. Primary outcome was 30 days ICU mortality and secondary outcomes were its comparison with APACHE II score, length of ICU stay and use of vasopressor agents.Results: Hypertension (53.6%) and diabetic mellitus (45.2%) were the commonest comorbidities. The median ADAMTS13 levels were 336.65, 339.35 and 313.9, respectively. ROC analysis showed maximum area under the curve for second ADAMTS13 (AUC=0.760) compared with first (AUC=0.660) and third samples (AUC=0.707) and APACHE II scores (AUC=0.662). Patients were divided into low and high ADAMTS13 groups according to the best cut-off point. Mortality was high in the low ADAMTS13 level group [OR=4.5]and was significantly associated with age, DBP, ADAMTS13, APACHE II score, DIC score and platelet count. ADAMTS13 (OR=5.3), APACHE II (OR=4.13) and DIC scores (OR=7.32) were significant risk factors for mortality.Conclusions: Low ADAMTS13 was associated with increased mortality in patients with severe sepsis and septic shock and was comparable to APACHE II scores for predicting mortality.

Background:Eye care is an essential component in the management of critically ill patients. Standardized eye care can prevent corneal complications in ventilated patients.Objective:This study was designed to compare old and new practices of corneal care for reduction in corneal complications in ventilated patients.Methods:This study was done in three phases each of six month duration. Phase 1 was the ongoing practice of eye care in the unit. Before the start of phase 2, a new protocol was made for eye care. Corneal complications were observed in terms of haziness, dryness, and ulceration. All nursing staffs were educated and made compliant with the new protocol. In phase 2, a follow-up audit was done to check the effectiveness and compliance to protocol. In phase 3, a follow-up audit was started 3 months after phase 2.Results:In phase 1, total ventilated patients were 40 with 240 ventilator days. The corneal dryness rate was 40 per 1000 ventilator days while the haziness and ulceration rate was 16 per 1000 ventilator days each. In the second phase 2, total ventilated patients were 53 making 561 ventilator days. The rate of corneal haziness and dryness was 3.52 and 1.78 per 1000 ventilator days, respectively, with no case of corneal ulceration. In phase 3, the number of ventilated patients was 91 with 1114 ventilator days. The corneal dryness rate was 2.69 while the haziness and ulceration rate was 1.79 each.Conclusion:Protocolized eye care can reduce the risk of corneal complications in ventilated patients.

Patients with traumatic brain injury complicated by acute respiratory distress syndrome (ARDS) are not uncommon in intensive care unit (ICU). The ventilatory management of patients combined with both of these catastrophic conditions is not straightforward. Evidence-based permissive hypercapnia strategy for ARDS could be fatal in patients with intracranial hypertension. Adjunctive use of inhaled nitric oxide (INO) is well-defined as a rescue therapy in severe ARDS, but its specific role in intracranial hypertension is somewhat uncertain. We report a case, which following traumatic brain injury developed both intracranial hypertension and ARDS. INO was given for ARDS, but coincidentally it also improved the raised intracranial pressure (ICP) and patient's neurological outcome. The case report will be followed by literature review on the role of INO in raised ICP.

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