World Journal of Emergency Surgery

Acute phlegmonous appendicitis is considered an intermediate inflammatory subtype between uncomplicated and complicated appendicitis. Although nonoperative management is increasingly accepted for uncomplicated appendicitis, evidence for phlegmonous appendicitis remains limited. This study aimed to evaluate the 1-year success rate of antibiotic treatment and identify early factors associated with treatment outcomes. This retrospective study included 476 patients with CT-defined acute phlegmonous appendicitis treated at Zhongshan Hospital between January 2021 and June 2025. Patients with incomplete follow-up were excluded from the primary analysis. Of these patients, 374 initially received antibiotic therapy, and the primary endpoint was the 1-year success rate of antibiotic treatment. Clinical characteristics, appendicolith status, and changes in inflammatory markers during the first 24 h were analyzed. Multivariable logistic regression was performed to identify factors associated with successful antibiotic treatment, and a nomogram was developed and internally validated. The model was considered exploratory and requires external validation before clinical application. The complete-case 1-year treatment success rate among the 374 patients receiving antibiotic therapy was 50.3

In 2021, the World Journal of Emergency Surgery published consensus guidelines classifying immunocompromised patients with acute abdomen into “mild-moderate” and “severe” immune deficiency categories to standardize perioperative risk assessment and guide surgical decision-making. We assessed whether published mortality and complication data are consistent with this classification. We conducted a structured literature review of PubMed and MEDLINE (2000–2025) for studies reporting mortality and complications in adult immunocompromised patients undergoing emergency colectomy, cholecystectomy, appendectomy, or small bowel resection, with a non-immunocompromised control group. Of the fifteen immunocompromising conditions in the classification, three were excluded for confounding or insufficient data (burns, trauma, post-splenectomy) and two pairs combined (symptomatic HIV/AIDS with CD4 < 200 cells/mm3; malignancy with and without chemotherapy), yielding ten categories. For each, we calculated procedure-specific relative mortality and complication rates. We defined a severe-risk threshold of greater than 3 × mortality and tested concordance at alternative thresholds (2–4 ×) in a sensitivity analysis. The guidelines classified five conditions as severe (neutropenia, steroid use, HIV < 200 cells/mm3, malignancy, transplant) and five as mild-moderate (uremia, advanced age, malnutrition, diabetes, HIV > 200 cells/mm3). Among the severe conditions, three (neutropenia, steroid use, HIV < 200 cells/mm3) showed greater than 3 × mortality risk, with neutropenia highest ( 12 ×); the other two (malignancy 2–3 × , transplant 1–2 ×) showed only mild-moderate excess risk. Among the mild-moderate conditions, two (uremia 6–7 × , advanced age 2–9 ×) showed excess mortality and complication risk more consistent with severe immunocompromise. Observed procedure-specific mortality and complication data do not consistently support the 2021 consensus severity ranking: four of the ten conditions were discordant with their assigned classification. This analysis suggests reconsidering uremia and advanced age as severe, and malignancy and transplant as mild-moderate. Because immunocompromise severity may influence whether and when patients undergo surgery, these findings highlight a priority for evidence-based refinement of severity ranking in emergency general surgery.

Patients undergoing emergency abdominal surgery often have limited time to prepare. This may lead to anxiety, which can adversely affect postoperative recovery. A structured intervention, Calming Anxiety and Relaxation for Emergency (Abdominal) Surgery (CARES) program, was developed to address this concern. In this prospective quasi-experimental study, the effects of the CARES program on pre- and postoperative anxiety were evaluated among adult patients undergoing emergency abdominal surgery at a regional hospital in Hong Kong. Participants were allocated to either the intervention group (IG) or the control group (CG) based on bed availability. The IG received the CARES program (pre- and postoperative counseling sessions plus daily self-practiced body–mind exercises for five consecutive days) in addition to usual care, while the CG received usual care alone. Pre- and postoperative anxiety and postoperative pain were measured using a visual analog scale and analyzed over time using a generalized estimating equation model. Postoperative analgesic consumption, time to first flatus, and length of hospital stay were compared between the groups using independent t-tests or Mann–Whitney U tests. All analyses adhered to the intention-to-treat principle. A total of 120 participants were enrolled and allocated equally to the IG and CG (n = 60 per group). The overall discontinuation rate was 3.33

The open abdomen (OA) has become an integral component of modern acute care, trauma, and vascular surgery. Since 2009, the Björck classification, amended in 2016, has provided a common language for describing the status and progression of the OA and remains the most widely used system worldwide. More than fifteen years of international experience, together with advances in temporary abdominal closure, negative pressure wound therapy, mesh-mediated fascial traction, critical care, more timely effective septic source control and abdominal wall reconstruction, have broadened the spectrum of patients encountered and altered the natural history of the OA. In this setting, certain concepts within the classification—particularly developing fixation and the frozen abdomen—are interpreted inconsistently among surgeons and institutions. In this narrative review, we revisit the contemporary application of the Björck classification and argue that its principal current challenge is one of interpretive consistency rather than validity. We distinguish OA from complex abdomen, clarify the practical meaning of each grade, and emphasise that anatomical grade describes a current state rather than an inevitable trajectory. The aim is to preserve the simplicity and structure of the original framework while improving communication, research comparability, and clinical decision-making in the management of patients with complex OA conditions. To this end we propose that interpretation is enhanced by considering two complementary domains: a contamination domain, already embedded in the amended system, and a surgical accessibility domain that describes the progressive loss of operative access from free access through developing fixation to loss of lateral access (the frozen abdomen).

Despite its routine use in elective procedures, the role of laparoscopy in emergency colorectal surgery remains debated due to limited evidence. This study compared laparoscopic and open surgery regarding complications, mortality, and hospital stay following emergency colon operations. This retrospective study included adult patients treated at Päijät–Häme Central Hospital between 2010 and 2020 who underwent emergency colon resection. Propensity score matching was used to adjust for comorbidities, prior ICU admission, surgical indication, and contamination between laparoscopic and open surgery groups. All together 484 patients had an emergency colorectal resection of which 85 (17.6

Kultanaruangnonth et al. recently reported a well-conducted double-blind randomized trial comparing intraoperative irrigation with 0.05

To assess real-world adherence to evidence-based international guidelines in the early management of acute pancreatitis (AP), and to identify how variability in clinical decision-making is distributed during the first 72 h of care. This multicentre, cross-sectional survey was conducted among consultant physicians and trainees in General Surgery, Gastroenterology, and Emergency Medicine actively practising in Catalonia, Spain. An expert-reviewed 21-item questionnaire assessed self-reported practices across eight key domains of early AP management relative to international consensus recommendations (IAP/APA and WSES). Factors associated with guideline adherence were analysed using chi-square tests and multivariable logistic regression. A total of 165 clinicians clinicians completed the survey. Self-reported adherence to key recommendations was low, particularly for target-directed fluid resuscitation and early oral feeding, while more than half of respondents reported antibiotic use in the absence of confirmed infection. Crucially, clinical practice variability was not uniformly distributed. The greatest differences were observed in time-sensitive, treatment-related decisions, particularly fluid resuscitation and nutritional strategies, where adherence varied significantly according to clinician experience and hospital size. In contrast, antibiotic use showed no significant variation across subgroups, indicating a consistent and widespread deviation from guideline recommendations. On multivariable analysis, overall adherence was independently associated with clinician experience (p = 0.035) and hospital size (p = 0.009), but not with medical speciality or clinician age. Early AP management showed substantial variation in self-reported practice across clinical domains. Variability was greatest for time-sensitive therapeutic decisions, whereas antibiotic overuse appeared to represent a widespread pattern of non-concordant practice across subgroups. Structured local pathways and decision-support tools may help reduce these implementation gaps.

Surgical site infections (SSIs) are common after emergency laparotomy and are associated with substantial morbidity, prolonged recovery, and increased health care costs. Negative pressure wound therapy (NPWT) has been increasingly used prophylactically on closed incisions in high-risk surgical patients; however, evidence supporting its effectiveness after emergency laparotomy remains heterogeneous. This updated systematic review and meta-analysis aimed to reassess the effectiveness of NPWT compared with standard postoperative dressings for the prevention of SSI and other wound-related complications following emergency laparotomy. A systematic review and meta-analysis was conducted in accordance with the Cochrane Handbook and PRISMA 2020 guidelines. PubMed, Embase, Web of Science, Cochrane CENTRAL, and ClinicalTrials.gov were searched for studies published from April 2, 2022, to December 10, 2025, updating a prior review. Randomized clinical trials and comparative observational studies evaluating NPWT versus standard dressings in adult patients undergoing emergency laparotomy were included. The primary outcome was SSI. Secondary outcomes included superficial and deep SSI, wound dehiscence, seroma, hematoma, and length of hospital stay. Random-effects meta-analyses were performed. Risk of bias was assessed using RoB 2 and ROBINS-I, and certainty of evidence was evaluated with GRADE. Twenty-three studies involving 5371 patients were included, of whom 2528 received NPWT. NPWT was associated with a significantly lower risk of SSI compared with standard dressings (risk ratio, 0.53; 95

Peritoneal surface malignancies (PSM) are primary or secondary neoplastic deposits involving the peritoneum and are commonly associated with colorectal, gastric, appendiceal, gynecological, pancreaticobiliary, and other intra-abdominal or extra-abdominal cancers. Malignant bowel obstruction (MBO) is one of the most frequent and clinically consequential emergency presentations in this population, yet diagnostic and therapeutic pathways remain heterogeneous. We aimed to develop evidence-informed recommendations for emergency management of MBO in patients with PSM by integrating a systematic review, meta-analysis and a structured international expert consensus process. This systematic review, meta-analysis, and Delphi consensus followed PRISMA, Cochrane, and relevant MOOSE reporting principles. PubMed/MEDLINE and the Cochrane Library were searched from inception to June 2025 (English language). Five predefined PICO/PIRT questions addressed: (1) the diagnostic role of CT, plain abdominal X-ray, or Gastrografin-enhanced X-ray in PSM-related MBO; (2) nonoperative medical management versus surgical or endoscopic therapy; (3) surgical versus endoscopic treatment after failure of nonoperative management; (4) bowel resection versus stoma or bypass in surgical candidates; and (5) endoscopic stenting versus endoscopic ultrasound-guided bypass with lumen-apposing metal stents in endoscopic candidates. Study selection and data extraction were performed independently and in duplicate. Risk of bias was assessed with ROBINS-I for comparative non-randomized studies and MINORS for non-comparative studies; certainty of evidence was rated with GRADE. Random-effects meta-analyses (REML) produced odds ratios (OR), mean differences (MD), pooled means, or pooled proportions with 95

Evidence on the management of bezoar ileus in patients who have already undergone abdominal surgery is limited. We reviewed conservative and surgical pathways in clinically selected patients, with particular attention to patient selection criteria and how each pathway was defined. We reviewed 80 patients with CT-confirmed bezoar ileus and previous abdominal surgery who were treated between January 2010 and December 2021. Twenty-six completed conservative treatment, and 54 underwent surgery. In practice, conservative treatment was used for clinically stable patients without peritonitis or CT signs suggesting ischaemia, perforation or closed-loop obstruction, provided that close clinical monitoring was possible. Conservative treatment included bowel rest, intravenous fluids, electrolyte correction, symptom-directed medication and nasogastric decompression when needed. Failure was defined by clinical deterioration, persistent or worsening obstruction, inability to tolerate oral intake, or new radiological concern. The primary outcome was clinical resolution during the index admission. Secondary outcomes were hospitalisation, in-hospital mortality, postoperative complications and readmission after discharge. The treatment groups were not equivalent at baseline. Patients treated surgically more often had gastric bezoars (18/54, 33.3

Traditionally, rib fracture severity has been quantified by fracture count and radiographic displacement. However, emerging evidence indicates that the outcomes following rib fractures widely vary and are not fully explained by injury burden alone. Whether anterior and posterior fracture locations lead to distinct recovery patterns remains unclear. A prospective longitudinal cohort study involving patients with traumatic rib fractures was conducted. Fractures were classified as anterior or posterior based on radiographic location. Pain intensity and functional status were serially evaluated for up to 3 months. Multivariable analyses were conducted with adjustment for age, body mass index, injury severity score, fracture number, displacement severity, associated injuries, and surgical stabilization of rib fractures (SSRF). Fracture displacement severity and the number of fracture ribs independently predicted higher pain intensity. After adjustment, anterior and posterior fractures exhibited comparable pain trajectories over time. However, posterior fractures were linked to greater functional status improvement from 1 to 3 months. Surgical stabilization might be associated with greater early pain reduction and higher early functional scores but did not alter the long-term recovery slope. Early health status on day 14 strongly predicted 3-month outcomes, independent of baseline injury severity. The number of fracture ribs and displacement severity appear to reflect injury intensity, whereas fracture location may influence physiologic consequences. Posterior fractures show similar pain levels to anterior fractures but somewhat greater functional recovery.

During the multidisciplinary Definitive Surgical and Anesthetic Trauma Care (DSATC) course, trauma specialists are trained to apply damage control principles to polytrauma patients. The course was redesigned in 2020 from a three-day, traditional format to a restructured two-day format combining online and traditional learning methods to enhance course quality and learning outcomes. Considering that learning opportunities on the work floor are scarce, continuous course evaluation is crucial to ensure benefits for medical professionals and their patients. This retrospective non-inferiority study compared self-assessed confidence in technical and non-technical skills between a cohort in the traditional DSATC course and a cohort in the redesigned DSATC course. Self-assessed confidence ratings were collected through quantitative pre-course and post-course questionnaires. Mean changes in confidence ratings were calculated and compared using independent samples t-tests with a non-inferiority margin of -0.5. Sub-analyses investigated differences between participants of the same profession, between physicians with different levels of experience, and the influence of individual preparation on self-assessed confidence in skills before on-site training. A total of 180 (21

Adhesions are a common complication following surgery, and they can cause significant morbidity. However, adhesions are not easily diagnosed with imaging, and often only become apparent when they cause intestinal obstruction symptoms. The pathophysiology of adhesion formation is complex, thus despite advances in surgical techniques and postoperative care, adhesions remain a persistent problem in clinical practice. Despite evidence for efficacy of some strategies in reducing adhesion formation question remain regarding the indications and impact on clinically relevant outcomes. The paper, supported by the World Society of Emergency Surgery (WSES), aims to provide a thorough examination of the pathophysiological mechanisms underlying adhesion formation and assess the efficacy of existing preventive strategies to guide future research and clinical practice in the management of adhesions. Study design and Framework This position paper was developed in accordance with the World Society of Emergency Surgery (WSES) methodology for consensus-based guidelines. The objective was to synthesize current evidence on adhesion pathophysiology and translate it into a clinically applicable "Narrative". Expert Panel Selection and Composition: The expert panel was composed of international specialists in general, trauma, and emergency surgery. Experts were selected based on their clinical leadership and academic contributions to the fields of peritoneal surgery and postoperative complication management. The panel included senior representatives from major surgical departments in Singapore (Sengkang and Singapore General Hospital), The Netherlands (Radboud University), and Italy (University of Bologna and Bufalini Hospital). Literature Search and Evidence Synthesis: A comprehensive search was conducted across major medical databases (e.g., PubMed, Scopus, Cochrane Library) to identify literature concerning the pathophysiology and prevention of adhesions. The search strategy employed Medical Subject Headings (MeSH) descriptors and keywords including: "peritoneal adhesions," "postoperative adhesions," "adhesion prevention," "adhesion barriers," "carboxymethylcellulose," "hyaluronic acid," "icodextrin," "oxidized regenerated cellulose," "polyethylene glycol," "adhesive small bowel obstruction," "adhesiolysis". No language restrictions were applied to the search strategy. A total of 56 studies were selected, including systematic reviews, meta-analyses, randomized clinical trials (RCTs), and retrospective cohort studies. The panel focused on clinically relevant outcomes, specifically looking for evidence that connected interventions to reduced rates of adhesive small bowel obstruction (ASBO) and reoperation. Studies were screened based on their ability to address three specific pillars: surgical approach (MIS vs. Open), technical manoeuvres (haemostasis and tissue handling), and the use of mechanical or chemical adjuncts. Consensus Achievement and Formulation: The recommendations were developed through a structured, iterative revision process: Literature Synthesis: Lead authors performed the primary review and drafted the pathophysiological and preventative sections. Internal Peer Review: The manuscript underwent rigorous revision by the international expert panel to reach a consensus on the position statements. Final Validation: All authors reviewed and approved the final manuscript and the resulting "Bundle" recommendations to ensure they were supported by the cited data. A total of 56 studies (systematic review and meta-analysis, randomized clinical trial, retrospective comparative cohort studies, case series) have been included in this paper to be discussed. Surgical techniques, as well as chemical and mechanical barriers were discussed in depth in this paper to come up with the recommendation. The WSES expert panel suggests the following bundle to reduce postoperative peritoneal adhesions: Bundle 1: Whenever possible, opt for minimally invasive surgery (MIS) or laparoscopic procedures. Bundle 2: Good surgical techniques. Bundle 3: Utilise barriers.

A recent meta-analysis by Fanchulli et al. concluded that cholecystectomy (CC) is associated with lower mortality and readmission than percutaneous cholecystostomy (PC) for acute cholecystitis, but this interpretation is limited by confounding by indication to management. The pooled evidence in this article consists predominantly of observational cohorts where crude or minimally adjusted comparisons are vulnerable to case-mix imbalance; even the CHOCOLATE randomised trial, which supports laparoscopic cholecystectomy in selected high-risk but eligible patients (ASA III–IV, age ≥ 70 or comorbidity, excluding peritonitis/septic shock), does not validate interchangeability across the broader PC and CC populations synthesised in unadjusted meta-analyses. Future evidence synthesis should prioritise adjusted estimates, stratification by Tokyo severity/ASA class, and, where feasible, individual participant data meta-analysis; clinically, CC remains preferred for appropriate surgical candidates, whereas PC should be reserved as a bridge or salvage strategy in selected high-risk patients.

Abstract Introduction Malignant gastric outlet obstruction is the consequence of advanced cancer resulting in mechanical obstruction to gastric emptying. Traditionally, surgical bypass (GJ) is performed and is known for its durability but also for its high morbidity. In contrast, endoscopic stenting (ES) is less invasive option but carries a notable risk of stent dysfunction and the need for subsequent reinterventions. These patients usually have limited life expectancy with reduced quality of life. The aim of this study is to review the different treatment options and compare their safety and efficacy. Method We performed a systematic review and meta-analysis comparing GJ to ES for malignant gastric outlet obstruction (mGOO). Comprehensive search of electronic databases between January 2001 and December 2022 was performed to identify relevant studies. The primary outcomes assessed were length of stay, reintervention rate, procedure-related complications and secondary outcome was mortality. Results 32 articles were abstracted in this meta-analysis with a total of 3296 patients. The re-intervention pooled risk ratio was 0.34 (95% CI 0.22, 0.52), indicating the risk of reintervention was lower among patients who underwent GJ. However, the results were comparable between ES and GJ for procedure-related complications and mortality. The length of stay was higher among those who underwent GJ, with a weighted mean difference of 11.2 days (95% CI 4.4, 18.1). Conclusion GJ bypass was associated with lower risk of re-intervention and comparable mortality and procedure-related complications compared to ES in patients with malignant gastric outlet obstruction, despite also being associated with longer length of stay.

Small bowel obstruction (SBO) is a common surgical emergency, most often caused by adhesions, whereas congenital peritoneal bands (CPBs) represent a rare etiology in adults. Limited contemporary data exist, with most adult series reporting fewer than ten cases. This study describes seven adult patients treated for CPB-related SBO and compares their characteristics and outcomes with those in the literature. A retrospective review was conducted of adult patients presenting with SBO due to congenital bands at a single tertiary center between 2010 and 2022. Inclusion criteria were age ≥ 18 years, imaging-confirmed SBO, intraoperative confirmation of a congenital band, and a virgin abdomen. Clinical, radiologic, and operative data were collected. A narrative review of the literature was performed for comparison. Seven of 269 SBO admissions (2.6

Traumatic axillosubclavian arterial injuries are rare but associated with high morbidity and mortality. Endovascular repair (ER) has emerged as an alternative to open surgery (OS), yet comparative outcome data remain inconsistent. This systematic review and meta-analysis compared short-term outcomes of ER versus OS for these injuries. This study followed PRISMA guidelines and was registered in PROSPERO (CRD420251018150). PubMed, Embase, Cochrane Library, and Scopus were searched for studies. Eligible studies included adult patients with blunt or penetrating traumatic axillosubclavian arterial injuries treated with ER or OS. The primary outcome was short-term all-cause mortality (in-hospital or 30-day). Secondary outcomes included upper-extremity amputation, thrombosis of repair, and stroke. Pooled odds ratios with 95

Trauma is a leading cause of morbidity and mortality worldwide, particularly in younger populations. Early identification of high-risk trauma patients is critical for timely interventions and improved outcomes. Although artificial intelligence and machine learning have demonstrated promise in healthcare, their application in trauma mortality prediction has been limited. This study developed and validated machine learning models to predict mortality in trauma patients using a large public dataset from the National Community-Based Critical Injury Survey (South Korea, 2016–2020). Overall, 207,012 cases were analyzed. Six machine learning algorithms, including logistic regression, k-nearest neighbor, decision tree, random forest (RF), extreme gradient boosting (XGB), and multi-layer perceptron, were trained and evaluated. Their performance was assessed using the areas under the receiver operating characteristic curve (AUROC) and precision-recall curve (AUPRC), and other metrics. Shapley additive explanations (SHAP) scores were used to interpret feature importance. The XGB model demonstrated the highest performance (AUROC 0.985; AUPRC 0.957), followed closely by the RF model (AUROC 0.984; AUPRC 0.956). Performance remained stable during the COVID-19 period, supporting the model’s temporal robustness under systemic disruption. SHAP analysis identified clinically actionable features such as out-of-hospital cardiac arrest, injury severity score, age, and time to transfusion. Unlike many prior studies based on small or single-center datasets, our model was developed using a nationally representative cohort and prioritized interpretability, scalability, and generalizability. This study presents a high-performing, interpretable machine learning framework for early mortality risk stratification in trauma patients using nationwide registry data. The strong discrimination and temporal robustness of the model support its value as a system-level prediction tool; however, further calibration analyses, external validation, and prospective implementation studies are required before integration into clinical workflows.

Injury is a global health problem, especially in low- and middle-income countries (LMICs). Sustainable trauma registries in these settings require concise, locally relevant, and low-cost solutions. This methodology paper shares a minimal trauma registry dataset developed and tested over 7 years, together with its accompanying MS Access database, which is made freely available to help LMIC institutions establish locally owned trauma registries. Two prospectively tested registries were sequentially designed, implemented, analyzed, and refined in Al-Ain City, United Arab Emirates: a 200-variable single-center hospital registry and a 50-variable multicenter road traffic collision registry. Finally, an 80-variable Trauma and Emergency Research Group registry was developed. Variables were retained or removed according to feasibility, data completeness, clinical usefulness, prevention value, and demonstrated research utility. The first registry enrolled 2573 patients over 3 years and the second enrolled 1008 patients over 18 months. Experience from these registries generated 21 publications from the first registry, 13 from the second, 3 combined analyses, and 5 follow-up studies, which informed the final open-access registry. The resulting tool is a five-page, 80-variable minimal dataset organized into seven sections: personal details, trauma details, road trauma details, emergency department assessment, discharge summary, death details, and injuries and scores. It balances prevention variables such as crash mechanics, safety equipment, education level, and injury location with core outcome variables needed for benchmarking and system evaluation. A carefully selected minimal dataset can support clinically useful, prevention-oriented, and affordable trauma surveillance in resource-limited settings. Making the form and accompanying MS Access database freely available may help LMIC institutions establish locally owned trauma registries that are scalable, sustainable, and adaptable to national systems, provided that minimum resources for implementation, maintenance, governance, data quality, and reporting are planned.

The 2025 WSES Guidelines endorse nonoperative management (NOM) for uncomplicated acute appendicitis. However, the oncologic risks and methodological limitations of this approach require strict scrutiny. Applying the GRADE framework, admission computed tomography presents severe clinical indirectness, underestimating microperforations and failing to exclude occult appendiceal neoplasms in up to 3.2