Acute appendicitis is the most common abdominal surgical emergency worldwide and a leading cause of emergency hospital admissions and operations. Despite its frequency, substantial variability persists in diagnosis and management across patient populations and health care settings. To provide updated, evidence-based recommendations for the diagnosis and treatment of acute appendicitis in adults, children, pregnant women, older patients (aged ≥65 years), immunocompromised individuals, and patients with obesity (body mass index ≥30), developed by the World Society of Emergency Surgery (WSES) using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. A systematic literature search was performed in MEDLINE, Embase, Scopus, Web of Science, and the Cochrane Library to identify relevant studies published until May 2025. Eligible designs included randomized clinical trials, observational studies, systematic reviews, and meta-analyses. Risk of bias was assessed with design-appropriate tools (RoB-2, ROBINS-I, QUADAS-2). Evidence profiles and evidence-to-decision frameworks were generated for each of 19 key clinical questions. The certainty of evidence was rated as high, moderate, low, or very low. Recommendations were classified as strong or conditional (weak) according to GRADE. Six key clinical domains were addressed across 19 questions. Thirty-five recommendations were formulated. Key findings include: (1) clinical risk scores and imaging improve diagnostic accuracy and reduce negative appendectomy rates; (2) nonoperative management with antibiotics is safe and effective in selected patients with uncomplicated appendicitis, with recommendations tailored for specific populations; (3) appendectomy for uncomplicated appendicitis may be safely delayed within 24 hours without increased risk of adverse outcomes; (4) laparoscopic appendectomy remains the standard surgical approach; (5) postoperative antibiotic therapy should be limited to short courses (2-3 days) in complicated disease; and (6) follow-up strategies are essential after nonoperative management of complicated appendicitis with abscess to detect neoplasms. The 2025 WSES Jerusalem Guidelines provide updated, evidence-based recommendations for the diagnosis and treatment of acute appendicitis with the aim to standardize practice, reduce unwarranted variability, and support safe, effective, and patient-centered care across diverse populations and health care systems. Their implementation should be adapted to local resources.

Importance:Acute appendicitis is the most common abdominal surgical emergency worldwide and a leading cause of emergency hospital admissions and operations. Despite its frequency, substantial variability persists in diagnosis and management across patient populations and health care settings. Objective:To provide updated, evidence-based recommendations for the diagnosis and treatment of acute appendicitis in adults, children, pregnant women, older patients (aged ≥65 years), immunocompromised individuals, and patients with obesity (body mass index ≥30), developed by the World Society of Emergency Surgery (WSES) using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. Evidence Review:A systematic literature search was performed in MEDLINE, Embase, Scopus, Web of Science, and the Cochrane Library to identify relevant studies published until May 2025. Eligible designs included randomized clinical trials, observational studies, systematic reviews, and meta-analyses. Risk of bias was assessed with design-appropriate tools (RoB-2, ROBINS-I, QUADAS-2). Evidence profiles and evidence-to-decision frameworks were generated for each of 19 key clinical questions. The certainty of evidence was rated as high, moderate, low, or very low. Recommendations were classified as strong or conditional (weak) according to GRADE. Findings:Six key clinical domains were addressed across 19 questions. Thirty-five recommendations were formulated. Key findings include: (1) clinical risk scores and imaging improve diagnostic accuracy and reduce negative appendectomy rates; (2) nonoperative management with antibiotics is safe and effective in selected patients with uncomplicated appendicitis, with recommendations tailored for specific populations; (3) appendectomy for uncomplicated appendicitis may be safely delayed within 24 hours without increased risk of adverse outcomes; (4) laparoscopic appendectomy remains the standard surgical approach; (5) postoperative antibiotic therapy should be limited to short courses (2-3 days) in complicated disease; and (6) follow-up strategies are essential after nonoperative management of complicated appendicitis with abscess to detect neoplasms. Conclusions and Relevance:The 2025 WSES Jerusalem Guidelines provide updated, evidence-based recommendations for the diagnosis and treatment of acute appendicitis with the aim to standardize practice, reduce unwarranted variability, and support safe, effective, and patient-centered care across diverse populations and health care systems. Their implementation should be adapted to local resources.

OBJECTIVE:To evaluate the use and impact of current surgical guidelines for chronic pancreatitis (CP) across Europe. SUMMARY BACKGROUND DATA:Current guidelines recommend morphology-based surgery for CP, but international studies evaluating their use and impact are lacking. METHODS:Post hoc analysis of the prospective multicenter ESCOPA study, including patients undergoing surgery for symptomatic CP at 22 centers in 13 countries (June 2021-November 2022), with 6-month follow-up. Patients were stratified by morphologic subtype: "isolated dilated main pancreatic duct (MPD)," "isolated enlarged pancreatic head (PH)," "combined dilated MPD and enlarged PH," and "small duct disease." Treatment was based on the European HaPanEU and International IAP-APA-JPS-EPC guidelines. Primary outcomes were 90-day major morbidity, mortality, and pain relief at 6 months. Practice variation was assessed, including a case-based survey. RESULTS:Overall, 207 patients were included following surgery for CP, with 1.4% 90-day mortality and 72.6% pain relief. The surgical approach varied widely by morphologic subtype: duodenum-preserving pancreatic head resections (DPPHR) were most common for "combined dilated MPD and enlarged PH" (46.8%, P=0.016); whereas formal pancreatectomy predominated for "isolated dilated MPD" (63.3%, P=0.040) and "small duct disease" (66.0%, P=0.004). Guideline-concordant surgery (66%) was not associated with improved rates of major morbidity (12.9% vs. 18.8%, P=0.387), mortality (1.6% vs. 1.6%, P>0.999), or pain relief (75.3% vs. 66.7%, P=0.468). Outcomes were also comparable between drainage/parenchyma-preserving surgery and formal pancreatectomy. Survey findings confirmed practice variation, including the use of formal and V-shaped pancreatectomy for small duct disease. CONCLUSION:The substantial variation in surgical practice for CP across Europe highlights the need for unified guidelines with clear recommendations, particularly regarding formal and V-shaped pancreatectomy.

Acute appendicitis has traditionally been seen as a progressive disease that necessitates surgery to prevent complications like perforation. However, recent studies emphasize the importance of distinguishing between complicated and uncomplicated appendicitis, rather than treating all cases the same. This evolving understanding has led to a paradigm shift in how uncomplicated appendicitis is diagnosed and treated, with options like antibiotic therapy being considered alternatives to immediate surgery. This shift challenges the long-held belief that surgery is always required, and instead encourages more personalized treatment approaches and shared decision-making between clinicians and patients.

IMPORTANCE Patients with painful chronic pancreatitis and a dilated pancreatic duct can be treated by early surgery or an endoscopy-first approach. OBJECTIVE To compare long-term clinical outcomes of early surgery vs an endoscopy-first approach using follow-up data from the ESCAPE randomized clinical trial. DESIGN, SETTING, AND PARTICIPANTS Between April 2011 and September 2018, 88 patients with painful chronic pancreatitis were randomly assigned to early surgery or an endoscopy-first approach in 30 hospitals in the Netherlands collaborating in the Dutch Pancreatitis Study Group as part of the ESCAPE randomized clinical trial. For the present cohort study, long-term clinical data were collected after the initial 18-month follow-up. Follow-up was completed in June 2022, and data analysis was performed in June 2023. EXPOSURE Patients with chronic pancreatitis were randomly assigned to early surgery or an endoscopy-first approach. MAIN OUTCOMES AND MEASURES The primary end point was pain, assessed by the Izbicki pain score; secondary end points included patient-reported complete pain relief and satisfaction. Predefined subgroups included patients who progressed from endoscopy to surgery and those with ductal clearance obtained by endoscopy. Analysis was performed according to the intention-to-treat principle. RESULTS In this cohort study, 86 of 88 overall patients could be evaluated, with a mean (SD) follow-up period of 98 (16) months. Of 88 initial patients, 21 patients (24%) were female, and mean (SD) patient age was 61(10) years. At the end of long-term follow-up, the mean (SD) Izbicki pain score was significant lower (33 [31] vs 51 [31]) in the early surgery group, as was the rate of patient-reported complete pain relief (14 of 31 patients [45%] vs 6 of 30 patients [20%]), compared to the endoscopy-first group. After the initial 18-month follow-up, 11 of 43 patients in the early surgery group (26%) underwent reinterventions vs 19 of 43 patients in the endoscopy-first group (44%). At the end of follow-up, more patients in the early surgery group were "very satisfied" with their treatment (22 of 31 patients [71%] vs 10 of 30 patients [33%]). Patients who progressed from endoscopy to surgery (22 of 43 patients [51%]) had significantly worse mean (SD) Izbicki pain scores (33 [31] vs 52 [24]) compared to the early surgery group and had a lower rate of complete pain relief (55% for early surgery vs 12% for endoscopy first). In the endoscopy-first group, patients with endoscopic ductal clearance had similar mean (SD) Izbicki pain scores as the remaining patients (49 [34] vs 53 [28]). CONCLUSIONS AND RELEVANCE In this cohort study evaluating long-term outcomes of the ESCAPE randomized clinical trial, after approximately 8 years of follow-up, early surgery was superior to an endoscopy-first approach in patients with painful chronic pancreatitis and a dilated main pancreatic duct in pain scores and patient satisfaction. Notably, patients who progressed from endoscopy to surgery had worse outcomes compared to patients undergoing early surgery, and obtaining endoscopic ductal clearance did not improve outcomes.

OBJECTIVE:Patients with acute pancreatitis show reduced gut microbiome diversity and high abundance of pathogenic bacteria compared with healthy subjects. Admission microbiome profiles are increasingly linked to severity, but methodology and study quality hamper interpretation. Our aim was to investigate whether admission microbiome analysis provides robust and reproducible associations with severity and complications of acute pancreatitis. METHODS:Patients with acute pancreatitis were prospectively enrolled from 20 Dutch hospitals (2019-2022). Admission saliva and rectal samples from 276 patients underwent 16S rDNA sequencing for microbiome profiling. Subgroups were defined based on a literature search. The microbiota endpoints (alpha- and beta-diversity, and genus abundance) were compared across subgroups and with previous studies. Robustness of the significant associations was classified as 'moderate' or 'high' in case of statistical significance in, respectively, 2 or ≥3 differential abundance models. RESULTS:Rectal alpha diversity (Shannon Index 3.55 vs 3.63, p=0.026) was decreased in necrotising (n=49) versus oedematous pancreatitis (n=218). Microbiota communities of either saliva or rectal samples differed in all the subgroups. In total, 270 (rectal) and 138 (saliva) genera were associated with severity or complications, of which 35 and 3 (Anaeroglobus and Finegoldia in saliva; Lachnospiraceae_FE2018_group in rectal) were classified as, respectively, moderately and highly robust. Fourteen associations were previously reported, of which 10 were in the opposite direction compared with this study. CONCLUSION:Three admission microbiome taxa associated with severity and complications were highly robust, although their biological relevance remains unclear. This study also shows the lack of replicable findings of admission microbiome associations, highlighting the need for longitudinal studies to establish temporal relationships between microbiome changes and disease progression.

Background:Surgical site infections (SSI) are common. We selected five interventions from recent SSI prevention guidelines, to form the Enhanced PeriOperative Care and Health program (EPO2CH), a perioperative care bundle. We aimed to investigate the effect of the EPO2CH bundle on the incidence of SSI. Methods:The EPO2CH trial concerns an open label, pragmatic, randomised controlled parallel-group multicentre trial, in which we assigned patients, scheduled for elective abdominal surgery with incisions larger than five centimetres, to either standard care or standard care plus the EPO2CH bundle consisting of intraoperative high fraction of inspired oxygen; Goal-Directed Fluid Therapy; normothermia; perioperative glucose control; and incisional wound irrigation. The study was conducted in seven hospitals in the Netherlands. Patients were randomised per hospital per day in a 1:1 ratio with variable block sizes using an internet-based automated assignment system. The primary outcome was the incidence of SSI within 30 days in the intention-to-treat population. This study is registered at CCMO register (NL-OMON50566). Findings:Between March 1st, 2016, and March 26th, 2020, 1777 patients were included. The intervention group included 869 patients (mean age 63.1, 467 female and 402 male) versus 908 in the control group (mean age 64.0, 530 female and 378 male). The incidence of SSI was 18.4% (160/869) in the intervention and 18.9% (172/908) in the control group; relative risk 0.98 (95% CI: 0.81-1.18) in the intention-to-treat analysis and 0.91 (95% CI: 0.60-1.37) in the per-protocol analysis. The percentage of patients with a serious adverse event was 33.3% (289/869) versus 33.5% (304/908), RR 0.99, 95% CI 0.87-1.23. Interpretation:In a high-income health care setting, a care bundle did not lead to a lower incidence of surgical site infections when added to standard care including preoperative systemic antibiotic prophylaxis and alcohol-based surgical skin preparation. Considering the persistent high risk of SSI, research into interventions that may help to reduce this risk remains urgently needed. Funding:The Netherlands Organisation for Health Research and Development (ZonMW), and co-financed by Innovatiefonds Zorgverzekeraars, and Ethicon.

Background The effect of the number of door openings in the operating room (OR) on surgical site infections (SSI) risk remains a controversial topic. Many SSI prevention bundles include a restriction on the maximum number of door openings as intervention, often to ten per hour. However, existing evidence is limited and heterogeneous. This individual participant data (IPD) meta-analysis aims to evaluate the effect of the number of door openings in the OR on SSI occurrence. Methods We searched MEDLINE (Pubmed) and Embase (Ovid) up to 15 January 2024, for studies investigating the effect of the number of door openings on SSI incidence. Authors of eligible studies were invited to collaborate. IPD were merged and analysed with a logistic regression model with mixed-effects. This study is registered with PROSPERO, CRD42022309958. Findings IPD from eight observational studies, encompassing 4412 patients, revealed a 6.0% overall SSI incidence. The logistic regression model with mixed-effects indicated a difference in SSI risk for each extra door opening per hour (OR 1.01 [95% c.i. 1.004–1.02]; very low certainty of evidence). To enhance the practical applicability, door openings were categorised. Inconclusive evidence was found regarding SSI risk difference for 10 to 31.7 door openings per hour (OR 1.11 [95% c.i. 0.77–1.59]) compared to 10 or fewer. While for more than 31.7 door openings per hour (OR 1.52 [95% c.i. 1.02–2.26]) a conclusive difference in SSI risk was found compared to 10 or fewer. Interpretation Very low certainty of evidence indicated a marginal increase in SSI risk for each extra door opening per hour. However, a restriction on the number of door openings in the OR to a maximum of 10 per hour has little to no effect on SSI risk. Funding This systematic review is funded by the Dutch Stichting Kwaliteitsgelden Medisch Specialisten (SKMS, Foundation Quality Funds Medical Specialists).

BACKGROUND:Randomized trials have demonstrated the superiority of surgery over endoscopy in patients with symptomatic chronic pancreatitis. However, large international studies quantifying the impact of surgery on chronic pancreatitis are lacking. The aim of this study was to evaluate current practice across Europe regarding indications, surgical techniques, and outcomes of surgery for chronic pancreatitis. METHODS:A prospective multicentre study of consecutive patients undergoing surgery for symptomatic chronic pancreatitis from 22 centres in 13 countries from 1 June 2021 to 30 November 2022 was conducted. The outcome of interest in patients with pain as an indication was the Izbicki pain score at 6-month follow-up, with complete pain relief defined as an Izbicki pain score ≤10 and partial pain relief defined as an Izbicki pain score >10, but with a >50% decrease compared with the baseline score. Quality of life was assessed using Pancreatitis Quality of Life Instrument (PANQOLI) and 12-Item Short-Form (SF-12) surveys. Predictors of pain relief were analysed using multivariable analysis. RESULTS:Overall, 207 patients underwent surgery (24.6% underwent surgical drainage procedures, 29.5% underwent duodenum-preserving head resections, and 45.9% underwent formal pancreatic resections). Before surgery, 48.8% used opioids and 51.2% had undergone prior endoscopic treatment. Major morbidity occurred in 14.0% and the 90-day mortality rate was 1.4%. Among 113 patients operated on for pain, the median Izbicki pain score decreased from 61.3 to 19.0 at 6 months (P < 0.001). Pain relief was achieved in 72.6% (43 patients reported complete pain relief and 39 patients reported partial pain relief). PANQOLI and SF-12 Physical Component Summary scores improved significantly (P < 0.001). Longer symptom duration (OR 0.95 (95% c.i. 0.90 to 1.00), P = 0.045) and use of opioids before surgery (OR 3.16 (95% c.i. 1.04 to 9.64), P = 0.043) predicted less pain relief. CONCLUSION:Surgery for chronic pancreatitis across Europe was performed with low morbidity. Patients reported good pain relief and improvements in quality-of-life scores. Multidisciplinary consultation is recommended for all patients with chronic pancreatitis before undergoing any intervention.

INTRODUCTION:Abdominal wall surgery is emerging as a new subspecialty with reconstructive operations becoming increasingly complex. Central to any surgical subspecialty is comprehensive anatomical knowledge, which can be enhanced by cadaver dissection. An expert panel convened to develop a consensus framework highlighting key anatomical concepts and operative steps for teaching posterior component separation. METHODS:The panel consisted of opinion leading abdominal wall surgeons from the UK and Europe. Intellectual content derived from anatomy lectures, training videos, and cadaver dissection instructions formed the basis of the consensus framework. This framework was subsequently implemented during a pilot cadaveric workshop. Afterward, content from the workshop was further refined, resulting in this educational article, endorsed by all authors. This article comprises two sections, (1) theoretical aspects of abdominal wall anatomy; (2) stepwise technical guidance for cadaver dissection. RESULTS:In the first section, "Essential Anatomy," we discuss: Anterior abdominal wall musculature, posterior abdominal wall, the semilunar line, preperitoneal space, subxiphoid anatomy and pelvic anatomy. In the second section, "Practical Anatomy taught via Cadaver Dissection," we discuss: Rives-Stoppa dissection, caudal extension, cranial extension, classic top-down transversus abdominis release and posterior component separation with Madrid modification (bottom-up or "Madrid PCS"). CONCLUSIONS:Using content delivered by senior members of the abdominal wall reconstruction community, this article provides a structured educational framework for teaching posterior component separation. This is intended as a reference guide for surgical training and details the essential anatomical and operative concepts every abdominal wall surgeon should know.

Incisional hernias (IH) occur after 20–30

IMPORTANCE International guidelines recommend the use of triclosan-containing sutures for the prevention of surgical site infections. However, controversy still remains about triclosan-containing suture use in clinical practice since several new randomized clinical trials (RCTs) have shown contradicting results. OBJECTIVE To update a previous systematic review and meta-analysis of the association of triclosan-containing sutures with surgical site infections and explore the potential added value of new RCTs. DATA SOURCES PubMed, Embase, and Cochrane CENTRAL databases were searched from January 1, 2015, to March 14, 2023. The Preferred Reporting Items for Systematic Reviews and Meta- Analyses (PRISMA) guideline was followed. STUDY SELECTION Published RCTs comparing triclosan-containing sutures with similar sutures without triclosan for the prevention of surgical site infections in any type of surgery were included. DATA EXTRACTION AND SYNTHESIS Two authors (H.J. and A.S.T.) independently extracted and pooled data in a random-effects (Mantel-Haenszel) model. The certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation approach, and trial sequential analysis was used to estimate whether further studies would reveal different outcomes. MAIN OUTCOMES AND MEASURES The primary outcome was the incidence of surgical site infections, expressed as relative risk (RRs) and corresponding 95% CIs. Secondary outcomes were the incidence of surgical site infections according to depth (superficial incisional, deep incisional, and organ/space) and adverse events related to triclosan-containing sutures. RESULTS The systematic review yielded 15 additional RCTs compared with a previous published review in 2017. A meta-analysis of 31 studies including 17 968 participants (62% male) undergoing various types of surgery was performed. Use of triclosan-containing sutures was associated with fewer surgical site infections compared with sutures without triclosan (RR, 0.75; 95% CI, 0.65-0.86). The certainty of evidence was moderate after downgrading for heterogeneity (tau(2) = 0.04; I-2 = 43%). In the trial sequential analysis of all trials and a sensitivity analysis excluding studies with a high risk of bias, the cumulative z curve crossed the trial sequential monitoring boundary for benefit, confirming the robustness of the summary effect estimate. CONCLUSIONS AND RELEVANCE This updated meta-analysis found moderate-certainty evidence that wound closure with triclosan-containing sutures was associated with a lower risk of surgical site infections. The trial sequential analysis suggests that future trials that would change these findings are improbable.

Journal of Wound CareVol. 34, No. 1 CommentarySurgical site infection prevention care bundles: evidence and guidelinesMarja Boermeester, Giles Bond-Smith, David LeaperMarja BoermeesterProfessor of Surgery; Clinical Epidemiologist, Department of Surgery, Amsterdam University Medical Center, the Netherlands, Giles Bond-SmithConsultant HPB and Emergency Surgeon, Oxford University Hospitals NHS Foundation Trust, UK, David LeaperConsultant HPB and Emergency Surgeon, Oxford University Hospitals NHS Foundation Trust, UKMarja Boermeester; Giles Bond-Smith; David LeaperPublished Online:11 Jan 2025https://doi.org/10.12968/jowc.2024.0415AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookXLinkedInEmail View article References 1 World Health Organization. Global guidelines for the prevention of surgical site infection. 2nd edition. 2018. https://tinyurl.com/27vzpdvx (accessed 3 December 2024) Google Scholar2 National Institute for Health and Care Excellence. Surgical site infections: prevention and treatment. NICE guideline NG125. 2020. https://www.nice.org.uk/guidance/ng125 (accessed 3 December 2024) Google Scholar3 Page MJ, McKenzie JE, Bossuyt PM et al.. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021; 29:372. https://doi.org/10.1136/bmj.n71 Google Scholar4 Ching PR. Care bundles in surgical site infection prevention: a narrative review. Curr Infect Dis Rep 2024; 1:1–0. https://doi.org/10.1007/s11908-024-00837-9 Google Scholar5 Wolfhagen N, Boldingh QJJ, Boermeester MA, de Jonge SW. Perioperative care bundles for the prevention of surgical-site infections: meta-analysis. Br J Surg 2022; 109(10):933–942. https://doi.org/10.1093/bjs/znac196 Crossref, Medline, Google Scholar6 Tanner J, Padley W, Assadian O et al.. Do surgical care bundles reduce the risk of surgical site infections in patients undergoing colorectal surgery? A systematic review and cohort meta-analysis of 8,515 patients. Surgery 2015; 158(1):66–77. https://doi.org/10.1016/j.surg.2015.03.009 Crossref, Medline, Google Scholar7 Zywot A, Lau CSM, Stephen Fletcher H, Paul S. Bundles prevent surgical site infections after colorectal surgery: meta-analysis and systematic review. J Gastrointest Surg 2017; 21(11):1915–1930. https://doi.org/10.1007/s11605-017-3465-3 Crossref, Medline, Google Scholar8 Bond-Smith G, Butcher L, Soonawalla Z, Leaper D. How to reduce SSI: a new infection reduction bundle for HPB surgery. J Wound Care 2021; 30(4):254–255. https://doi.org/10.12968/jowc.2021.30.4.254 Link, Google Scholar9 Gilhooly D, Green SA, McCann C et al.. Barriers and facilitators to the successful development, implementation and evaluation of care bundles in acute care in hospital: a scoping review. Implement Sci 2019; 14(1):47. https://doi.org/10.1186/s13012-019-0894-2 Crossref, Medline, Google Scholar10 Rochon M, Bond-Smith G, Leaper D. Preoperative surgical skin preparation. J Wound Care 2024; 33(9):676–677. https://doi.org/10.12968/jowc.2024.0237 Link, Google Scholar FiguresReferencesRelatedDetails 2 January 2025Volume 34Issue 1ISSN (print): 0969-0700ISSN (online): 2052-2916 Metrics History Published online 11 January 2025 Published in print 2 January 2025 Information© MA Healthcare LimitedPDF download