IntroductionEmergent primary ventral or incisional hernias (PVIHs) are a common cause of surgical admission, leading to significantly higher rates of morbidity and mortality compared to elective hernia repairs. Despite this, management varies widely due to a lack of evidence-based consensus. This article presents the new European Hernia Society (EHS) guidelines for the emergency treatment of adult patients with PVIH.Material and MethodsThis project was developed by the EHS Science Committee following AGREE-S, GRADE, and GIN standards. A guideline panel, composed of general and emergency surgeons along with patient partners, formulated seven key health questions addressing the surgical approach, mesh type and placement, and the management of defects of varying sizes and contamination levels to support general surgeons in their decision-making process. A systematic review was conducted, and recommendations were developed using a formal evidence-to-decision framework, ensuring consensus was reached on all recommendations.ResultsThe guidelines expert panel provides recommendations for several clinical scenarios. For defects amenable to direct closure, mesh-based repair is suggested over primary suture repair, regardless of the contamination grade. Furthermore, a laparoscopic approach with intraperitoneal mesh, an open approach with onlay mesh placement, and the use of large-pore synthetic meshes are recommended. For large defects, not amenable to closure, a staged approach that avoids immediate mesh-based repair is suggested.ConclusionAdherence to these guidelines can help standardise the management of emergent PVIHs, potentially improving patient outcomes. The recommendations advocate for a “damage control” mindset, prioritising physiological stability over immediate definitive reconstruction. Further research is needed to address gaps in the current literature, particularly with regard to long-term recurrence rates and the specific protocols for managing these complex cases.

Injury is a major cause of death and disability globally, with the highest burden in low- and middle-income countries (LMICs). Strengthening the organization and planning for trauma care (care of the injured) can improve care and lower mortality. In 2004, the International Association for Trauma Surgery and Intensive Care (IATSIC) and the World Health Organization (WHO) co-published the Guidelines for Essential Trauma Care (EsTC). The goals of the Guidelines for EsTC were to promote affordable and achievable standards for trauma care resources that could realistically be achievable at health care facilities anywhere in the world, even in the lowest-income settings. By so doing, IATSIC and WHO hoped to strengthen trauma care services globally, especially in LMICs. Since its publication in 2004, the Guidelines for EsTC have been extensively cited. More importantly, there have been documented, published examples of implementation of the Guidelines in 48 countries worldwide, spanning all economic levels from low-income to high-income countries. The current publication represents the first update and revision of the Guidelines for EsTC. As with the first edition, the current edition contains resource tables listing human resources (skills, training, staffing) and physical resources (equipment and supplies) that should be available at varying health care facilities in all countries, ranging from clinics to first-level hospitals to second-level hospitals to tertiary hospitals. These resource tables cover the breadth of trauma care, including initial management and resuscitation to definitive care of most major injuries. As with the original version, these resource tables are meant to be flexible to allow adjustments as needed to tailor them based on local health care system resources and capabilities. The Guidelines focus on fixed facilities, as other publications address prehospital care.

Many European surgeons lack access to high-volume trauma training. A Trauma Traveling Fellowship, supported by the European Society of Trauma and Emergency Surgery (ESTES), could broaden educational and clinical exposure to trauma care, but feasibility and implementation factors are unclear. The aims of this survey are to assess the aspirations, expectations, and perceived challenges of prospective fellows and host centres for an ESTES Trauma Traveling Fellowship. A cross-sectional, web-based survey was distributed to all ESTES members, capturing demographics, fellowship aspirations, perceived barriers, and host centre capacities. The survey incorporated Likert scales, free-text responses, and was guided by the Consolidated Framework for Implementation Research (CFIR) and the Reach, Effectiveness, Adoption, Implementation, and Maintenance / Practical Robust Implementation and Sustainability Model (RE-AIM/PRISM). Of 903 invited, 210 responses (23.3

Abstract Background Patients with severe liver injury may carry a high risk of complications with significant mortality. Non-operative management (NOM) is increasingly common for severe injuries and may be associated with lower morbidity when compared with surgery. Objective To evaluate the incidence of NOM for severe liver trauma (American Association for the Surgery of Trauma (AAST) Grade IV and V) and compare outcomes for NOM vs operative management. Methods All patients admitted between 2012–2022 with severe liver trauma to Birmingham and Nottingham Major Trauma Centres (MTCs) were identified from a validated dataset. Outcomes were compared between those managed by surgery vs treated by NOM. Adjusted multivariable logistic regression models were used to determine the odds ratio (OR) and 95% confidence interval (95% CI) for surgical management, survival rates, and development of liver-specific complications (adjusting for age, sex, ISS, AAST grade, polytrauma). Results There were 190 patients; median age 28 years (IQR 20–41); 134 (71%) were male. Median ISS was 27 (IQR 17–41). Overall mortality was 7% (14/190). 122/190 (64%) patients were managed initially by NOM, with only 8/122 (7%) requiring subsequent surgery. Multivariable logistic regression models showed higher ISS, lower SBP on admission, Grade V injuries and penetrating trauma to be independent predictors for surgical treatment. 34/190(18%) patients had liver-specific complications. There was no difference between NOM and operative management groups for 30-day mortality (p = 0.145), but patients in the NOM group had shorter ICU (p < 0.001) and total lengths of stay (p < 0.001) compared to the operative group. Conclusion In this modern MTC setting, a high proportion of patients with severe liver trauma were managed by NOM with a low failure rate. Overall mortality rate was low, but liver-specific complications were common. These data support the evolution of traumatic liver injury management in the UK and favour NOM even in severe liver injuries where patient physiology allows. Trial registration This study was approved by Nottingham University Hospital Clinical Audit Team (ID Reference 22-709C) and University Hospitals Birmingham NHS Foundation Trust Clinical Audit Registration and Management System (ID Reference CARMS 19146). Consent for participation in the study was not obtained as this was a large retrospective audit with anonymised data. Level of evidence Level III.

BACKGROUND:Enhanced recovery after surgery (ERAS) protocols reduce length of stay, complications, and costs for elective surgical procedures. It remains challenging to implement ERAS concepts in the acute trauma patient due to deranged physiological reserve from the penetrating or blunt trauma producing altered physiology. However, systems of care improve access to early intervention and potentially reduce mortality. These consensus guidelines examine optimal pre-hospital, resuscitation-room, intra-, and post-operative treatment, systems of ethical management, and overall care for trauma patients in the post-resuscitation phase of care. The guideline is presented in three parts, this being part 1. METHODS:Experts in aspects of management of trauma surgical patients and intensive care were invited to contribute by the International ERAS Society and IATSIC. PubMed, Cochrane, Embase, and MEDLINE database searches on English language publications were performed for ERAS elements using the patient intervention comparator outcome (PICO) consensus questions created by the expert group. Studies were selected with particular attention to randomized clinical trials, systematic reviews, meta-analyses, and large cohort studies, reviewed, and summarized recommendations were graded using the grading of recommendations, assessment, development and evaluation (GRADE) system. These recommendations based on current best evidence, with extrapolation from elective patient studies, where appropriate, were followed by a modified two-round Delphi method to validate final recommendations. Several ERAS components are already standard of care within national and society guidelines and are endorsed. The bulk of the text focuses on key areas pertaining specifically to trauma care of major trauma and polytrauma in the ICU-requiring group. RESULTS:Overall 37 aspects of trauma care were considered with multiple PICO questions and sub-points. Consensus was reached after two rounds of a modified Delphi process involving all authors, with minor adjustments to some phrasing required, but with 87% overall agreement on all statements (100% agreement on 31 of the main statement sets, prior to minor edits to address the points of difference for the rest with 100% total agreement thereafter). None were rejected outright. The recommendations and level of evidence for each aspect of trauma care that may impact on improved recovery and reduced length of hospital stay are presented with grade of recommendation. CONCLUSIONS:The guidelines relating to initial care and decision-making are presented in part 1 of the Guidelines. These guidelines are based on current best evidence for an ERAS approach to patients who have had major injuries and polytrauma. The guidelines are not exhaustive but collate the best available evidence on important components of care for this patient population. As some of the evidence is extrapolated from elective surgery and non-trauma emergency surgery, some of the components need further evaluation in future studies.

Considerable heterogeneity exists in the configuration and implementation maturity of trauma systems across European healthcare settings, and the opportunities for guideline-informed high-quality care varies considerably. Therefore, the European Society of Trauma and Emergency Surgery (ESTES), with its constituent national societies, has developed comprehensive consensus recommendations for care-context appropriate treatment of polytrauma patients in Europe, from the pre-hospital setting to the first surgical phase. Adhering to the RAND/UCLA Appropriateness Method (RAM), ESTES conducted a three-round modified Delphi consensus. National society expert delegates assessed Grade of Recommendation (GoR) A and Good Clinical Practice Points (GPP) elements of the German Society of Trauma Surgery (DGU) “S3 guidelines for polytrauma/severe injury management” for appropriateness and implementability within their respective healthcare systems. In the first consensus round, 82 GoR A and 57 GPP recommendations were analysed. Of these, seven GPP were rephrased for clarity and four were removed due to redundancy or conflicting content. Consequently, 135 recommendations (82 GoR A and 53 GPP) remained, with 128 (77 GoR A and 51 GPP) deemed appropriate and necessary, and seven as uncertain due to expert disagreement. These ESTES recommendations constitute the first cohesive Europe-wide framework for managing the polytrauma patient from the prehospital setting to the end of the first surgical phase. They serve as a foundational tool for the development of national guidelines, particularly in regions with evolving trauma systems, and promote alignment towards a uniform standard-of-care across Europe.

Incisional hernias (IH) represent common complications following abdominal surgeries, with emergency repair associated with increased morbidity and mortality. This scoping review aimed to map the existing literature on emergency incisional hernia repair, identify research gaps, and inform future guideline development. A comprehensive literature search was conducted in PubMed MEDLINE and SCOPUS for studies published between January 2000 and August 2024. Articles addressing any aspect of emergency incisional hernia repair in adults were included. Data extraction focused on study characteristics, patient demographics, surgical approaches, and outcomes. Of 801 unique articles identified, 73 met the inclusion criteria. Most were cohort studies (73.97

BackgroundEmergency presentations of ventral and incisional hernias are common and associated with significantly higher morbidity and mortality than elective procedures. Despite their frequency, clinical guidance on managing acutely complicated hernias in emergency settings remains limited and heterogeneous.ObjectiveThis protocol outlines the development of an evidence-based clinical guideline by the European Hernia Society (EHS) to support general and emergency surgeons in treating acutely complicated ventral and incisional hernias in adults.MethodsDeveloped according to AGREE-S and GRADE methodologies, this guideline will address seven key clinical questions concerning the use of mesh, surgical approach, and technique based on clinical contamination status and anatomical considerations. A steering group of hernia surgery experts and methodologists leads the project, supported by two independent evidence review teams. Patient input will be obtained via structured surveys to incorporate values and preferences. Systematic literature reviews, evidence-to-decision frameworks, and consensus meetings will guide the formulation of recommendations, with strength and direction defined according to GRADE standards.DiscussionThis is the first EHS guideline specifically targeting the emergency management of incisional and ventral hernias. By addressing urgent clinical decisions through a structured, transparent, and inclusive process, it aims to reduce variability in care, improve outcomes, and serve as a resource for clinical practice and future research. The guideline will be published open access and monitored for implementation and updates based on emerging evidence.

Trauma often causes long-lasting functional impairment, but the extent varies across populations. This study investigated disability six months after moderate to severe injury and identified sociodemographic and early injury-related predictors, including estimated rehabilitation complexity. Further, we assessed the implementation of direct transfer from acute care in the trauma centre to specialised inpatient rehabilitation, bypassing local hospitals. In this prospective study 398 adults, treated from January 2020 to January 2021 at two Norwegian trauma centres, were included. Self-reported disability was measured using the 12-item World Health Organization Disability Assessment Schedule 2.0. Ordinal logistic regression was applied to identify predictors of the 6-month disability outcome. At follow-up, 22% reported no disability, 49% mild/moderate and 29% severe. In multivariable analyses, low education, comorbidities, number of injuries and higher estimated rehabilitation complexity at discharge from acute care were significantly associated with greater disability. Only 20% were transferred directly to specialised inpatient rehabilitation, while 17% went via local hospitals. Participants with orthopaedic injuries and women were less likely to be transferred directly. In summary, most participants experienced some disability at 6 months. Indirect pathways to specialised rehabilitation via local hospitals remained common. Understanding predictors of disability and optimising rehabilitation pathways may improve trauma rehabilitation outcomes, highlighting the need for guidelines that identify patients with high rehabilitation needs.

Background: In bleeding patients with trauma-induced coagulopathy (TIC), factor (F)V becomes depleted, which may not be corrected with existing treatment strategies. It is currently unknown whether supplementing FV or FVa improves TIC. Objectives: To explore the relationship between FV activity and mortality in trauma patients, and to investigate the effect of FV(a) supplementation in addition to other treatment strategies in an in vitro model of TIC. Methods: The association between FV activity and mortality was studied using an international prospective cohort study of trauma patients. In an in vitro whole blood and plasma model of TIC, the effect of FV(a) on rotational thromboelastometry and fibrin formation was studied. Effects of FV(a) were evaluated either as a standalone therapy or as adjunctive therapy in combination with tranexamic acid, fibrinogen concentrate, and/or prothrombin complex concentrate. Results: A total of 1285 patients were included, with a median injury severity score of 16 (interquartile range: 8-26). Decreased FV activity was associated with increased mortality. In the whole blood TIC model, FVa increased maximum clot firmness and reduced fibrinolysis, both as a single and combination therapy. In the plasma TIC model, with lower tissue factor concentrations than in the whole blood model, FV(a) prolonged clotting times, both as a single treatment and in combination with other treatments. Conclusion: FV depletion after trauma is associated with increased mortality. In an in vitro model of TIC, FV(a) results in procoagulant, antifibrinolytic, and anticoagulant effects. Further research is highly warranted.

BACKGROUND:Enhanced recovery after surgery (ERAS) protocols reduce length of stay, complications, and costs for elective surgical procedures. It remains challenging to implement ERAS concepts in the acute trauma patient due to deranged physiological reserve from the penetrating or blunt trauma producing altered physiology. However, systems of care improve access to early intervention and potentially reduce mortality. These consensus guidelines examine optimal prehospital, resuscitation-room, intraoperative and postoperative treatment, systems of ethical management, and overall care for trauma patients in the postresuscitation phase of care. The guideline is presented in three parts, this being Part 2. METHODS:Experts in aspects of management of trauma surgical patients and intensive care were invited to contribute by the International ERAS Society and IATSIC. PubMed, Cochrane, Embase, and MEDLINE database searches on English language publications were performed for ERAS elements using the patient, intervention, comparator outcome (PICO) consensus questions created by the expert group. Studies were selected with particular attention to randomized clinical trials, systematic reviews, meta-analyses, and large cohort studies; reviewed and summarized recommendations were graded using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. These recommendations based on current best evidence, with extrapolation from elective patient studies, where appropriate, were followed by a modified two-round Delphi method to validate final recommendations. Several ERAS components are already standard of care within national and society guidelines and are endorsed. The bulk of the text focuses on key areas pertaining specifically to trauma care of major trauma and polytrauma in the ICU-requiring group. RESULTS:Overall, 37 aspects of trauma care were considered, with multiple PICO questions and subpoints. Consensus was reached after two rounds of a modified Delphi process involving all authors, with minor adjustments to some phrasing required, but with 87% overall agreement on all statements (100% agreement on 31 of the main statement sets, prior to minor edits to address the points of difference for the rest, with 100% total agreement thereafter). None were rejected outright. The recommendations and level of evidence for each aspect of trauma care that may impact on improved recovery and reduced length of hospital stay are presented with grade of recommendation. CONCLUSIONS:This paper presents the results of the postoperative care and ICU aspects. The guidelines are based on current best evidence for an ERAS approach to patients who have had major injuries and polytrauma. These guidelines are not exhaustive but collate the best available evidence on important components of care for this patient population. As some of the evidence is extrapolated from elective surgery and nontrauma emergency surgery, some of the components need further evaluation in future studies.

BACKGROUND:Trauma is the leading cause of death and disability in children globally. Studies indicate that severe traumatic brain injury (TBI) negatively affects quality of life (QoL) in children, but little is known about QoL after injury in children without TBI. This study aimed to investigate QoL in this group six months post-discharge. METHODS:Trauma patients aged 13-17 years admitted to a major Scandinavian trauma center were eligible if they met the following criteria: received by a trauma team, ISS > 9, required ICU monitoring, and hospital stay > 4 days. Patients with moderate to severe head injuries (AIS > 2) were excluded. Eighteen consenting adolescents were interviewed six to nine months after discharge. RESULTS:The main finding was that most participants were "coping well after experienced injuries." A minority reported challenges in daily life, including fatigue and difficulty in keeping up. Few used regular painkillers, and most were unconcerned about long-term consequences. However, many felt that more structured follow-up post-discharge would have been helpful. CONCLUSION:Among 18 moderate to severely injured adolescents, we found that the majority were coping well. Strong social relationships and involvement in school and social activities was important in all interviews. While several experienced fatigue and challenges in keeping up, the negative impact on daily life was manageable at the time of the interviews.

BACKGROUND:Enhanced recovery after surgery (ERAS) protocols reduce length of stay, complications, and costs for elective surgical procedures. It remains challenging to implement ERAS concepts in the acute trauma patient due to deranged physiological reserve from the penetrating or blunt trauma producing altered physiology. However, systems of care improve access to early intervention and potentially reduce mortality. These consensus guidelines examine optimal pre-hospital, resuscitation-room, intra- and post-operative treatment, systems of ethical management, and overall care for trauma patients in the post-resuscitation phase of care. The guideline is presented in three parts, this being part 3. METHODS:Experts in aspects of management of trauma surgical patients and intensive care were invited to contribute by the International ERAS Society and IATSIC. Pubmed, Cochrane, Embase, and MEDLINE database searches on English language publications were performed for ERAS elements using the patient intervention comparator outcome (PICO) consensus questions created by the expert group. Studies were selected with particular attention to randomized clinical trials, systematic reviews, meta-analyses, and large cohort studies; reviewed; and summarized recommendations were graded using the grading of recommendations, assessment, development and evaluation (GRADE) system. These recommendations based on current best evidence, with extrapolation from elective patient studies where appropriate, were followed by a modified two-round Delphi method to validate final recommendations. Several ERAS components are already standard of care within national and society guidelines and are endorsed. The bulk of the text focuses on key areas pertaining specifically to trauma care of major trauma and polytrauma in the ICU-requiring group. RESULTS:Overall 37 aspects of trauma care were considered with multiple PICO questions and sub-points. Consensus was reached after two rounds of a modified Delphi process involving all authors, with minor adjustments to some phrasing required but with 87% overall agreement on all statements (100% agreement on 31 of the main statement sets, prior to minor edits to address the points of difference for the rest with 100% total agreement thereafter). None were rejected outright. The recommendations and level of evidence for each aspect of trauma care that may impact on improved recovery and reduced length of hospital stay are presented with grade of recommendation. CONCLUSIONS:Four main areas of relevance to ethics and systems are presented as part 3. The guidelines are based on current best evidence for an ERAS approach to patients who have had major injuries and polytrauma. These guidelines are not exhaustive but collate the best available evidence on important components of care for this patient population. As some of the evidence is extrapolated from elective surgery and non-trauma emergency surgery, some of the components need further evaluation in future studies.

Objective The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with vascular trauma with the aim of assisting physicians in selecting the optimal management strategy. Methods The guidelines are based on scientific evidence completed with expert opinion. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to the ESVS evidence grading system, where the strength (class) of each recommendation is graded from I to III, and the letters A to C mark the level of evidence. Results A total of 105 recommendations have been issued on the following topics: general principles for vascular trauma care and resuscitation including technical skill sets, bleeding control and restoration of perfusion, graft materials, and imaging; management of vascular trauma in the neck, thoracic aorta and thoracic outlet, abdomen, and upper and lower extremities; post-operative considerations after vascular trauma; and paediatric vascular trauma. In addition, unresolved vascular trauma issues and the patients’ perspectives are discussed. Conclusion The ESVS clinical practice guidelines provide the most comprehensive, up to date, evidence based advice to clinicians on the management of vascular trauma.

PURPOSE OF REVIEW:Mass casualty incidents (MCIs) strain available healthcare resources requiring unusual actions. Within a trauma system, hospitals receiving patients from an MCI have a defined key role in the care of the casualties and their preparedness is critical for patient outcome. The aim of this review is to address recent relevant literature to highlight important elements necessary for an adequate hospital response to an MCI. RECENT FINDINGS:That disaster preparedness is a prerequisite for success during an MCI is undisputable. Key components in the hospital response to an MCI like triage, communication, leadership, security, and surge capacity are areas that still need attention. There has been an increased focus on optimal treatment of children and their families, and the psychosocial support for patients and staff involved. SUMMARY:The complexity and unpredictability of MCIs demands a predefined strategy within every hospital. This strategy should include increased attention to the specific needs for children, physical security and psychological support but not at the expense of frequent training of staff. Involvement of dedicated clinical leadership both during disaster preparedness planning, training and during actual MCIs is irreplaceable.