Patients' survival and quality of life are key factors in assessing value of treatments. However, limited evidence exists about the trajectory and key determinants of patients' health-related quality of life (QoL) following emergency abdominal surgery. Using the Enhanced Peri-Operative Care for High-risk patients study with measured QoL during eight months follow-up using the EQ-5D-3L questionnaire, we summarise the trajectory of patients' QoL after emergency abdominal surgery and use multivariable regression models to relate patients' demographic and clinical characteristics, pre-surgery characteristics, and time elapsed since surgery with their QoL. In further analysis we assess the contribution of post-surgery patient characteristics. Data from 686 patients undergoing emergency abdominal surgery (50.4% female; mean age 66.6 (standard deviation (SD) 12.8) years; 50.1% with intestinal obstruction as indication for surgery), with QoL measurements were analysed. Shortly after surgery (mean days 7.59 (SD 7.48)), the mean EQ-5D-3L QoL utility score was 0.21 (SD 0.46), which improved among survivors to 0.74 (SD 0.31) in the medium- to long-term (i.e., three to eight months) following surgery. Patient's sex and preoperative risk of mortality were key determinants of QoL shortly after surgery. In addition to time since surgery, patient's sex, Charlson Comorbidity index, ASA physical status and indication for surgery were key pre-surgery predictors of QoL in the medium- to long-term post-surgery. From post-surgery characteristics, duration of hospital admission for index surgery and further days in hospital within 30 days prior to QoL measurement were key further determinants of QoL in the medium- to long-term. Individual patient, surgery, and recovery characteristics determine QoL post-emergency abdominal surgery and can help inform clinician-patient discussions and assessments of value of abdominal surgery interventions.
The growth of the geriatric population, resulting in an exponential increase in the number of injured older people, determines the necessity of ensuring adequate access to specialized units such as trauma centers (TCs). The specificity of pathophysiological processes that progress with age, worsening the body's response to trauma, makes it difficult to develop an optimal triage protocol for geriatric patients, reducing high undertriage, i.e., underestimation of injuries and referral to lower-reference units. To verify the TC qualification criteria for 65+ patients and analyze the weights of individual triage factors for these patients. This was a retrospective analysis of the medical records of ED patients from the Clinical Hospital with TC in Poland admitted from 1.01.2017 to 31.12.2020. Among 155,320 ED patients, 6541 who formed Trauma group 65+ were selected, in which the TRISS score was estimated. The TC 65+ group meeting the currently applicable TC qualification criteria was selected. The TRISS cutoff value, TRISS 65+ group and TC-omitted 65+ group were determined. The significance of TC qualification factors was estimated. Receiver operating characteristic (ROC curve) analysis and multiple linear regression analysis were used for statistical classification. The value of ≤ 88.84% determined the threshold for TC qualification, and the leakage of criteria was 58.51%. Six significant factors with different typing weights were identified: GCS ≤ 8 (- 42.90%), extensive crush injury of the extremities (- 33.74%), and RR < 10/min (- 16.16%), blunt injury to thoracic internal organs (- 13.75%), pelvic fracture (- 11.35%) and SBP ≤ 80 mmHg (- 10.41%) were performed. The weight + SD of each factor reduced the potential TRISSe value to ≤ 88.84% (threshold). Modifications of the cutoff values of significant physiological parameters were determined, i.e., GCS ≤ 14 (sensitivity = 79.79%, specificity = 98.25%, AUC = 0.896, Youden index = 0.780) and SBP ≤ 129 mmHg with questionable efficacy of the result. The current TC qualification criteria require modification for geriatric patients, which would complete the leakage estimated at 58.51% according to the TRISS scale. The leakage results from underestimation of the weight of the 6 triage factors to the TC, and the modification of the criteria should include a reduction in the current requirement of 4 factors to 1 and allow admission to the TC of a 65+ trauma patient with one of the following anatomical injuries: extensive crush injury of extremities, blunt injuries with symptoms of damage to internal thoracic organs, pelvic fracture, or one of the disorders of physiological parameters: GCS ≤ 8, RR < 10/min, or SBP ≤ 80 mmHg. In the other cases, the modification should also take into account the change in the GCS limit value to ≤ 14 (instead of ≤ 8) and the change in the SBP cutoff value from ≤ 80 mmHg to a higher one (but ≤ 129 mmHg) or the use of another factor. To complete the formula (undertriage according to ISS = 73.47%), additional factors, such as the mechanism of injury, must be included. It is necessary to develop research on the criteria for the qualification of geriatric patients to the TC, and the use of weight analysis of individual factors may contribute to the identification of properly balanced triage criteria.
Laparoscopic surgery (LS) is well established in the United Kingdom (UK), while robotic surgery (RS) is increasingly adopted in elective practice. However, its role in emergency general surgery (EGS) remains undefined. This study provides the first national estimates of RS use in UK EGS, evaluating trends in utilisation, outcomes, and workforce capacity. Two rounds of Freedom of Information (FOI) requests were submitted to all NHS acute trusts and boards providing EGS services across Great Britain, covering 1 January 2019-1 January 2023 and 1 January 2023-1 January 2025. Data collected included robotic system ownership, numbers and types of robotic procedures, length of stay (LOS), complication rates, and staffing. LOS data were reported as mean ± standard deviation, with differences between approaches assessed using Welch's t-tests. Response rates were 83% (113/136 trusts, 2019-2023) and 65% (91/140 trusts, 2023-2025). Robotic availability increased from 36 to 91 systems nationally (147% rise), with the number of trusts performing emergency RS doubling (13 to 26). A total of 1816 emergency robotic procedures were performed in 2023-2025, alongside 9232 elective cases. Cholecystectomy was the most frequent emergency procedure, increasing almost sixfold (200 → 1396). Complications were infrequent, with device-related issues (n = 18) and tissue injury (n = 27) most common. LOS was consistently shorter for RS compared with open surgery across all procedures (all p < 0.01), with particularly marked reductions in cholecystectomy, Hartmann's procedures, and small bowel resections. Comparisons with LS were procedure-specific: RS was shorter in cholecystectomy and hernia repair, equivalent in small bowel resection, and longer in appendectomy. Workforce capacity remained a limiting factor, with median in-hours trained staff unchanged (11 vs 10), but out-of-hours staff rising from 3 to 24 across all trusts. Robotic surgery in UK emergency general surgery is feasible, safe, and expanding, though utilisation continues to lag behind elective practice. RS offers clear LOS advantages over open surgery, with variable benefits compared to laparoscopy. Scaling adoption will require addressing cost, system heterogeneity, and the shortage of trained out-of-hours staff. National policy must prioritise training, standardised data collection, and equitable access to ensure safe integration of RS into routine emergency care.
Traumatic diaphragmatic injuries are a significant cause of morbidity and mortality. Particular attention to isolated diaphragmatic injuries and not overlooking them is critical to preventing damage from hernias that may occur immediately or later. The use of a thoracic tube during repair of a diagnosed diaphragmatic injury should be considered a necessary routine procedure. Clearly, the current guidelines resulting from the WSES-AAST collaboration reiterate this traditional recommendation. However, selective tube use should be considered, and the "one-size-fits-all" approach should be discussed. This detail deserves reconsideration to minimize patient morbidity and discomfort.
The first World Congress of Trauma and Emergency Leagues (WCTEL) was held at the University of Campinas (Unicamp), Brazil, on July 3rd to 6th, 2025. The meeting was organized by undergraduate medical and nurse students, guided by their professors, and with a support of Brazilian and international societies. Pre-congress activities included a Students World Championship in Emergency and Trauma Simulation. More than 1000 participants from 19 countries attended the WCTEL, enabling exchanges of experiences and the possibility of cooperation between students. This new kind of congress could be a good way to attract young people to work with trauma and emergency surgery in the future.
Bowel obstruction is a critical emergency. Although imaging like X-ray and computed tomography (CT) aids diagnosis, cost-effective hematological biomarkers are still needed. This study evaluates the diagnostic values of hematological biomarkers for detecting complications, determining the need for surgery, and predicting prognosis in patients with bowel obstruction. A systematic review and meta-analysis was conducted following PRISMA guidelines. We systematically searched Web of Science, PubMed, Scopus, Embase and Cochrane Library for studies published up to June 2025. Inclusion criteria encompassed observational or case-control studies reporting sensitivity/specificity of neutrophil-lymphocyte ratio (NLR), C-reactive protein (CRP), procalcitonin (PCT), D-dimer, or lactate in bowel obstruction outcomes. Data extraction included true/false, positives/negatives, cutoff values, and receiver operating characteristic (ROC) parameters. Bivariate models pooled sensitivity/specificity, while summary ROC curves and Youden index determined optimal thresholds. This study included 34 articles comprising a total of 5871 patients. CRP at a cutoff of 26.91 mg/L (Youden index: 0.97) for diagnosing bowel ischemia showed pooled sensitivity and specificity of 0.80 and 0.92, respectively, with a summary receiver operating characteristic (SROC) curve and an area under the curve (AUC) of 0.91. PCT in determining the need for surgery achieved a cutoff of 0.12 ng/mL (Youden index: 0.8), with sensitivity and specificity of 0.75 and 0.74 (AUC: 0.79). NLR showed a cutoff of 7.2 (Youden index: 0.68), yielding sensitivity and specificity of 0.74 and 0.83 (AUC: 0.84) in the diagnosis of bowel ischemia. D-dimer (cutoff: 1.72 mg/L, Youden index: 0.91) and lactate (cutoff: 2.98 mmol/L, Youden index: 0.8) exhibited sensitivities of 0.83 and 0.77, specificities of 0.70 and 0.79, and AUCs of 0.85 for both, in the diagnosis of bowel ischemia. NLR, CRP, PCT, D-dimer, and lactate may provide supplementary diagnostic value for bowel ischemia in patients with bowel obstruction. A PCT threshold > 0.12 ng/mL may assist in evaluating the need for surgery.
Recent studies confirm that intra-abdominal hypertension (IAH) frequently develops in critically ill patients, posing a significant risk of organ failure and increased mortality. Accurate intra-abdominal pressure (IAP) measurement is essential for effective diagnosis, prevention, and treatment. Previous studies indicate that accurate IAP measurement using traditional Foley catheters requires the bladder to be filled with a maximum of 25 mL of sterile saline solution after clamping the catheter, restricting the ability to monitor IAP continuously due to variations in the bladder fill volume. The TraumaGuard catheter enables continuous IAP measurement irrespective of bladder fill volume. The primary objective was the validation of the TraumaGuard catheter (Sentinel Medical Technologies, Jacksonville, Florida, USA), a new continuous bladder pressure monitoring device. ICU patients were studied across different body positions to assess measurement accuracy by comparing the correlation, bias, precision, and agreement between IAP readings obtained using the TraumaGuard catheter and the FoleyManometer measurement method (SecurMeter, Deltamed, Viadana, Italy), which serves as the gold standard. The secondary endpoint of this study was to investigate the impact of different body positions on IAP. Adult ICU patients (≥ 18 years) requiring bladder catheterisation were enrolled. IAP was measured using a TraumaGuard catheter (IAPTG) and FoleyManometer method (IAPFM) across multiple positions to have a broad range of IAP values and to study the impact of body position on IAP measurement. Pairwise analysis of IAPTG and IAPFM in the supine, reverse Trendelenburg (15°, 30°, and 45°), and head-of-bed (HOB) elevation positions (15°, 30°, and 45°) was performed using correlation, concordance, and Bland-Altman analyses. The error-grid analysis assessed the risk associated with inaccurate measurements at each body position. The robustness of the TraumaGuard catheter as a detection system for IAH detection system was evaluated by receiver operating characteristic (ROC) curve. The IAP variation as a function of body position was investigated and compared with the reviewed literature. Gender, age, body mass index (BMI), and sequential organ failure assessment (SOFA) score were also recorded for each participant. Twenty-five adult ICU patients with a mean age of 63.6 ± 11.6 years and BMI of 28.3 ± 3.7 kg/m2 were included. The mean IAP increased from 9.8 ± 1.7 mmHg in supine to 10.4 ± 1.5 mmHg in reverse Trendelenburg and 14.9 ± 1.6 mmHg in HOB elevation positions. The correlation coefficients were 0.9, 0.9, and 0.8 for supine, reverse Trendelenburg, and HOB elevation positions. The supine positions showed a bias and precision of 0.8 and 1.7 mmHg according to Bland-Altman analysis. Reverse Trendelenburg and HOB elevation positions showed a bias of − 0.3 and 1.5 mmHg with a precision of 1.5 and 1.6 mmHg, respectively. The lower and upper limits of agreement were − 2.5–4.2 mmHg, − 3.2–2.6 mmHg, and − 1.6–4.6 mmHg for supine, reverse Trendelenburg, and HOB elevation positions with a percentage error of 35%, 28%, and 21%, respectively. Concordance coefficients were highest in reverse Trendelenburg positions (100.0%) compared to supine (95.3%) and HOB elevation (92.1%) positions. The error-grid analysis indicated no medium/high-risk errors for supine and reverse Trendelenburg and a 2.7% medium-risk error at HOB elevation positions. The results of this validation of a new continuous IAP monitoring device in ICU patients showed excellent results when compared to the gold standard. Changing the body position from supine to reverse Trendelenburg or HOB elevation increases the IAP. The online version contains supplementary material available at 10.1186/s13017-025-00644-0.
Surgical stabilisation of rib fractures (SSRF) is a procedure that has been shown to reduce mortality and complications in patients with thoracic trauma. However, correct patient selection is required, since the immunological hit of a thoracic surgery in the context of trauma is not without risk. In this study we aimed to analyse real-world data on the effect of SSRF mortality and hospital length of stay. A retrospective propensity matched analysis of real-world health claims data of a German statutory health insurance company of Management of serial rib fractures and unstable thorax via SSRF compared to conservative treatment was performed. The primary endpoints were in-hospital mortality, 1 year post hospital mortality and intensive-care unit length of stay. Subgroup analyses with respect to age-group, overall injury severity and time-point of surgery were performed. Multivariate regression was used to confirm these results and analyse interaction between different variables. Overall, 62,011 patients with serial rib fractures were identified, of which 532 patients receiving SSRF and 532 receiving conservative management could be matched. The data showed a significant reduction in in-hospital mortality in the SSRF cohort (4.7% for SSRF versus 9.21% for conservative treatment, p = 0.005). Subgroup analysis showed this effect to be most pronounced in patients with high, but not extremely high injury severity (injury severity score (ISS) 16-24). The survival benefit could be demonstrated across age groups, although the extent of the benefit decreased with increasing age. Hospital length of stay was increased in the SSRF cohort, although this effect was driven through an increase in the low injury severity (ISS < 16 subgroup). Overall, the data shows that SSRF can lead to reduced mortality in appropriately selected patients. Based on this real-world data, patients across all age-groups with high but not extreme injury severity (ISS 16-24), in other words patients in whom the thoracic injury is a major component of overall injury severity, appear to benefit most.
Although laparoscopy continues to be the predominant minimally invasive approach in most emergency settings, the advantages of robotics, well established in elective surgery, are currently being explored in selected scenarios and specialized centres. A systematic review was conducted using PubMed, Cochrane Library and Scopus databases until January 2025. Primary outcome was safety and feasibility of robotics in emergency colorectal surgery. Secondary endpoints included perioperative and postoperative outcomes. Fifteen articles were included with a total of 46 robotic emergency colorectal surgical procedures. Most were performed in a tertiary centre with a da Vinci system. Most common procedures were robotic right hemicolectomy for colon cancer and sigmoid colectomy for acute diverticulitis. Mean operating time for robotic right hemicolectomy was 134 min for benign cases and 241 ± 7 min for malignant cases; robotic sigmoid colectomy showed a mean operating time of 171 ± 3 min. No intraoperative complications were recorded. One case required conversion. Intracorporeal anastomosis was performed in most cases (n = 13). Mean length of stay was 5 days. No Clavien-Dindo grade ≥ 3 complications, reoperation or readmission were reported. Five complete mesocolic excisions (CMEs) were performed. Pathology outcomes were available for four CMEs: showing R0 resection with a mean lymph node harvest of 54 ± 13. In four CMEs, the involved team included an on-call robotic colorectal surgeon and an experience theatre team including experienced anaesthetist in robotic procedures. Robotics in emergency settings is feasible and safe but requires additional training and dedicated teams for optimal outcomes.
The role of prophylactic mesh reinforcement in emergency laparotomy closure remains controversial. While prophylactic mesh may reduce incisional hernia, its use in unstable and contaminated settings raises concerns regarding operative time, seroma development, and wound complications. This meta-analysis of randomized controlled trials (RCTs) evaluated the safety and efficacy of prophylactic mesh versus primary suture closure in emergency midline laparotomy. A systematic search was performed for RCTs comparing prophylactic mesh with suture closure in adult patients undergoing emergency midline laparotomy. Primary outcomes were overall wound complications (OWC) and incisional hernia (IH). Secondary outcomes included superficial and deep surgical site infection, wound dehiscence (WD), seroma, hematoma, operative time, postoperative pain, quality of life, hospital and ICU stay, transfusion, and mortality. Seven RCTs comprising 643 patients were included. Mesh reinforcement reduced incisional hernia incidence, with significant reductions at 1 month (RR 0.29, 95% CI 0.12-0.68), 6 months (RR 0.11, 95% CI 0.01-0.86), 12 months (RR 0.21, 95% CI 0.09-0.49), and 24 months (RR 0.27, 95% CI 0.15-0.49). Mesh increased seroma risk (RR 2.45, 95% CI 1.38-4.35) and, was associated with higher overall wound complications (RR 1.50, 95% CI 1.04-2.18). No significant differences were found in SSI, wound dehiscence, hematoma, transfusion, ICU or hospital stay, pain, quality of life, or mortality. Operative time was longer with mesh (MD 26 min, 95% CI 15.9-36.9). Prophylactic mesh in emergency laparotomy closure poses a clinical dilemma: it lowers the risk of incisional hernia but prolongs surgery and increases seroma and wound complications. Current evidence underscores the trade-off between long-term prevention and short-term morbidity. Larger, protocol-driven trials with long-term follow-up are needed to determine in which patients and wound classes mesh reinforcement is justified.
Wound dehiscence after emergency midline laparotomy is a severe complication linked to high morbidity and mortality. While continuous closure is standard in elective surgery, its superiority is not established in high-risk emergency settings, where patient factors like infection and malnutrition can compromise healing. This systematic review and meta-analysis of randomized controlled trials (RCTs) aimed to compare the efficacy and safety of interrupted versus continuous fascial closure techniques after emergency midline laparotomy. A comprehensive search of PubMed, Scopus, CENTRAL, Google Scholar, and Web of Science was conducted for RCTs up to October 2025. The primary outcome was wound dehiscence. Secondary outcomes included wound infection, incisional hernia, and length of hospital stay (LoS). Risk ratios (RR) and mean differences (MD) were pooled using STATA 19.5, with 95% confidence intervals (CI). Twenty-five RCTs involving 3,548 patients were included. Interrupted closure significantly reduced the risk of wound dehiscence compared to continuous closure (RR: 0.47, 95% CI [0.38, 0.87]; p < 0.001). There was no significant difference in wound infection (RR: 0.91, 95% CI [0.76, 1.09]; p = 0.31) or incisional hernia (RR: 0.83, 95% CI [0.57, 1.22]; p = 0.34). However, interrupted closure was also associated with a significantly shorter LoS (MD: - 3.52 days, 95% CI [- 4.75, - 2.29]; p < 0.001). In the high-risk emergency midline laparotomy setting, current evidence suggests that interrupted fascial closure may be associated with a reduction in wound dehiscence and a shorter LoS compared to continuous closure. However, given the risk of bias and clinical heterogeneity among the included studies, these findings should be interpreted with caution, and further high-quality, standardized trials are warranted.
Injury is one of the leading causes of death globally, with the largest burden in low- and middle-income countries. Injuries resulting in both hemorrhage and traumatic brain injury (TBI) are associated with high mortality. We seek to quantify the contribution of each injury process, hemorrhage and TBI, and their severity on mortality among patients with concurrent hemorrhage + TBI. This is a secondary analysis from the Epidemiology and Outcomes of Prolonged Trauma Care (EpiC) study conducted in the Western Cape, South Africa. Adult patients experiencing both hemorrhage + TBI were included. Hemorrhage and TBI severity (mild, moderate, or severe) were assigned according to physiology, injury severity, laboratory and imaging data, and clinical interventions. The independent association of hemorrhage and TBI severity on 7-day mortality was assessed by an adjusted Cox proportional hazards model. Adjustment covariates included age, sex, primary EMS transport, TEWS, and NISS. Secondary endpoints included 48-h and 30-day mortality. A total of 877 patients were included in the final analysis. Patients were 86% (n = 758) male with a median age of 32 years. 66% (n = 581) of patients were injured by a non-penetrating force. The adjusted rate of death was significantly higher with increasing severity of both hemorrhage and TBI. For the primary outcome of 7-day mortality, severe TBI compared to mild had a 5.11 times higher rate of mortality (aHR 5.11, 95% CI 3.29-7.93) and severe versus moderate TBI had a 5.02 times higher rate (aHR 5.02, 95% CI 4.22-5.96). When assessing across hemorrhage severity, the rate of 7-day mortality was 4.5 times higher (aHR 4.5, 95% CI 3.70-5.47) comparing severe to mild and 3.2 times higher (aHR 3.2, 95% CI 2.53-4.12) comparing severe to moderate. The largest increased rate of death was found in the 48-h mortality analysis comparing severe to mild hemorrhage, with an 18.4 times higher mortality rate (aHR 18.4, 95% CI 12.02-28.21). Increasing severity of hemorrhage and TBI are both independently associated with a three to five times higher rate of 7-day mortality. These findings highlight the importance of timely hemorrhage control and resuscitation to reduce mortality and the risk of progression to severe disease.
Acute Care Surgery (ACS) has emerged as a structured solution to challenges in emergency general surgery (EGS), including subspecialisation, fragmented coverage, and delays in operative care. This narrative review outlines the global ACS evolution and examines Singapore's experience over the past decade, focusing on implementation models, outcomes, and ongoing challenges. Since 2014, Singapore's public hospitals have adopted variations of the ACS framework, ranging from consultant of the week rosters to dedicated full time ACS teams. These models have improved timeliness of care, efficiency, and surgical training. Innovations such as Emergency Laparotomy Pathways and abscess protocols reduced delays and improved perioperative coordination. Local outcomes demonstrate reduced time to intervention by 30-40%, shorter hospital stays by 1-2d and sustained improvements in morbidity and mortality. However, challenges persist in trauma workforce sustainability, registrar training variability, theatre access, and the absence of national credentialing. ACS has improved the delivery of emergency and trauma surgery in Singapore. To sustain these gains, national credentialing, workforce planning, and structured training frameworks are required to secure ACS as a core part of the surgical system.
Existing predictive models in critical care, specifically for postoperative critically ill patients, often struggle to accurately predict prolonged intensive care unit (ICU) stays, a key aspect of patient care. The integration of artificial intelligence (AI) offers a promising approach for bridging this gap. We aimed to develop an AI-based model to predict mortality and prolonged ICU stay in postoperative critically ill patients, enhance prognostic accuracy, and address the shortcomings of current models. This retrospective study included data from 6,029 postoperative critically ill patients from two medical centers, including a wide range of clinical, surgical, and laboratory variables. Multiple machine-learning models, including extreme gradient boosting, light gradient boosting, category boosting, random forest, and multilayer perceptron, were employed. A soft-voting ensemble model was developed to aggregate the strengths of individual models. The models underwent external validation, and the SHapley Additive exPlanations (SHAP) method was utilized to assess the impact of various features on predictions. In internal validation, the ensemble model demonstrated superior performance with an area under the receiver operating characteristic curve (AUROC) of 0.8812 for mortality and 0.7944 for prolonged ICU stay. It achieved 0.9095 accuracy and an F1 score of 0.7014 for mortality predictions. For prolonged ICU stay, it attained an accuracy of 0.9368 and an F1 score of 0.5762. During external validation, the model maintained high performance, with an AUROC of 0.8330 for mortality and 0.7376 for prolonged ICU stay. It showed 0.9200 accuracy and an F1 score of 0.6768 for mortality and 0.9028 accuracy with an F1 score of 0.5689 for prolonged ICU stay. SHAP analysis confirmed that key predictors, including emergency surgery, serum osmolality, lactate levels, and diastolic blood pressure, remained significant. This study represents a significant advancement in the application of AI in critical care, especially for postoperative critically ill patients. The developed AI model outperformed existing models in predicting mortality and prolonged ICU stay, demonstrating notable accuracy and reliability. Its ability to identify critical, under-emphasized clinical factors could enhance decision-making in critical care settings. Although promising, further validation in diverse clinical settings is essential to confirm the model's efficacy and broader applicability.
To map and critically appraise the current literature on Artificial Intelligence (AI) applications in emergency general surgery, with a focus on clinical decision-support tools for preoperative risk stratification and intraoperative assistance, and to identify ethical, structural, and regulatory barriers to implementation. A scoping review was conducted within the ARIES project, following established methodological frameworks. Relevant studies evaluating AI-based tools in emergency surgical settings were systematically identified and analyzed. The literature describes AI applications mainly in two domains: preoperative decision support, including risk prediction and diagnostic or triage models for acute abdominal and traumatic conditions, and intraoperative assistance, largely focused on computer vision-based systems for anatomical recognition, safety guidance, and navigation in minimally invasive emergency procedures. Additional contributions address training and telementoring platforms, as well as cross-cutting ethical, legal, and regulatory considerations relevant to AI adoption in emergency surgical care. AI has the potential to complement emergency surgeons' clinical judgment, but its routine adoption in emergency surgical practice remains limited. Addressing methodological, ethical, and regulatory challenges, together with the development of robust data infrastructures and targeted training pathways, is essential to support safe, effective, and equitable implementation in acute care settings. In addition, the lack of dedicated investment and sustainable funding models for large-scale clinical implementation and prospective evaluation represents a critical barrier to the translation of AI from research into routine emergency surgical practice.
Emergency laparotomy is associated with high rates of postoperative wound complications, contributing substantially to patient morbidity and healthcare burden. Closed incision negative pressure wound therapy (ciNPWT) has been proposed as a prophylactic strategy to reduce wound-related complications; however, its effectiveness in the emergency laparotomy setting remains uncertain. We evaluated whether ciNPWT reduces wound complications after emergency laparotomy compared with standard dressings. This study is a systematic review and meta-analysis of randomized controlled trials (RCTs). Six databases and trial registries were systematically searched for RCTs from inception to October 10, 2025, with the search subsequently updated using automated database alerts (RSS) up to the time of manuscript submission. Six randomized controlled trials (1208 patients) were included. Compared with standard dressings, ciNPWT reduced overall wound morbidity (RR 0.49, 95% CI 0.38-0.62; I2 = 0%) and overall SSI (RR 0.40, 95% CI 0.26-0.61; I2 = 0%). ciNPWT also reduced superficial SSI (RR 0.46, 95% CI 0.24-0.85) and wound dehiscence (RR 0.40, 95% CI 0.20-0.80). No significant differences were observed for seroma (RR 0.59, 95% CI 0.34-1.01), length of hospital stay (MD - 0.43 days, 95% CI- 1.14 to 0.29), mortality (RR 1.18, 95% CI 0.64-2.15), or 30-day complications (RR 0.98, 95% CI 0.85-1.15). In adult patients undergoing emergency laparotomy with primary abdominal closure, ciNPWT significantly reduces key incision-related complications, particularly superficial SSI and wound dehiscence. Its clinical benefit appears confined to incision-level outcomes, with no effect on systemic or multifactorial postoperative endpoints. These findings support the selective use of ciNPWT in high-risk emergency laparotomy patients and highlight the need for standardized application protocols and longer-term outcome assessment.
Hemodynamically unstable patients with pelvic fractures have a high mortality rate. Most bleeding from pelvic fractures originates from venous and bony sources; therefore, direct compression of the pelvic wall can be effective, and preperitoneal pelvic packing (PPP) should be considered as a first-line intervention. PPP can be performed in both the emergency department (ED) and the operating room (OR). However, outcomes according to the location of PPP have not been clearly established. This study evaluated the outcomes of ED-PPP and OR-PPP based on the location where the surgery was performed. This single-center, retrospective, observational study included patients who underwent PPP for pelvic fractures with an Abbreviated Injury Scale score of ≥ 4 from July 2015 to June 2025. Data were collected from a prospectively maintained trauma registry. Patients were categorized into ED-PPP and OR-PPP groups according to the site of PPP. Baseline characteristics, injury severity (Injury Severity Score, Revised Trauma Score, and Trauma and Injury Severity Score), and interventions, including ED thoracotomy, resuscitative endovascular balloon occlusion of the aorta, tranexamic acid administration, and time to PPP and transfusion, were compared. Mortality outcome measures were evaluated at 24 h, 7 days, and as overall in-hospital mortality and were risk-adjusted using W- and Z-statistic. Fifty patients were included, with 17 and 33 in the ED-PPP and OR-PPP groups, respectively. Patients in the ED-PPP group were more critically ill at presentation, with lower systolic blood pressure, lower Glasgow Coma Scale scores, and a higher incidence of cardiac arrest before PPP. Time from scene to PPP (114.4 ± 68.6 vs. 284.3 ± 186.9 min) and to transfusion (84.5 ± 53.3 vs. 126.3 ± 72.5 min) was shorter in the ED-PPP group. The W-statistic demonstrated a greater number of actual survivors than expected in the ED-PPP and OR-PPP groups at 24 h (38.31 vs. 29.69) and 7 days (26.55 vs. 17.57), despite the high crude mortality rates (76.5% vs. 27.3%). Risk-adjusted in-hospital mortality showed no significant difference (W-statistic 3.02 vs. 5.45). PPP is associated with improved early and intermediate survival. ED-PPP significantly reduces the time to hemorrhagic control and should be strongly considered as an important rescue damage control intervention for patients with life-threatening pelvic bleeding.
Damage control surgery(DCS) is a well-established approach in emergency laparotomy when physiologic instability necessitates an abbreviated operation. In severe intraabdominal infections(IAI), open abdomen(OA) with Negative Pressure Wound Therapy(NPWT) has shown significant efficacy to help reducing morbidity and mortality. Early definitive abdominal closure is recommended to minimize complications, though not always achievable. From 108 cases of DCS and OA with NPWT performed between February 2015 and February 2024, 72 consecutive patients treated for severe IAI were retrospectively reviewed. We comparatively analyzed clinical and perioperative data of patients treated with OA for ≤ 7 days(short OA) or for > 7 days(long OA), focusing on late OA closure(> 7 days). Primary outcome was overall 30-day survival, secondary outcome the primary fascial closure rate. The main indication for OA was abdominal contamination. Fifty-six patients had short OA, 16 long OA. Overall mortality was 23.6%, with APACHE II score the only independent predictor (OR 1.9, 95% CI 1.25-2.92, p = 0.003). Fifty-two patients survived to achieve early closure and 12 late closure, respectively. Overall PFC rate was 92.2% (59 patients), 75% within late closure (p = 0.001). Compared to short OA, in long OA nine patients (56.3%, p < 0.001) experienced intraabdominal complications including enteroatmospheric fistula (EAF-3, 18.8%) and frozen abdomen (7, 43.8%); in 10 patients (87.5%, p < 0.001) NPWT regimen was modified to isolate and divert effluent or clean a contaminated field. Late closure of the OA for IAI may significantly associate with EAF and frozen abdomen. In these challenging scenarios NPWT specific properties may be leveraged to address complex anatomical situations, extensive contamination, or the need for targeted wound-healing responses.
Seo and colleagues compared early (≤ 48 h) versus delayed (> 48 h) planned reoperation following damage control surgery (DCS) in trauma patients and reported higher rates of re-bleeding in the early reoperation group. While this addresses an important clinical question, interpretation of these findings requires caution. First, all included studies were observational, and reoperation timing was determined by clinical judgment, introducing systematic confounding by indication. Physiologically unstable patients are more likely to undergo early re-exploration, while more stable patients are deferred, particularly in resource-constrained settings where system-level triage further shapes timing decisions. Second, the use of a 48-hour cut-off imposes a binary framework on what is inherently a continuous biological process, as physiological recovery varies substantially between patients, injury patterns, and operative burden. Third, pooling heterogeneous DCS indications, including haemorrhage- and contamination-driven strategies, limits the biological plausibility of a single time-based reoperation algorithm across diverse clinical contexts. Taken together, the available evidence suggests that timing is not the true causal exposure; rather, physiological readiness is the key determinant of outcomes after DCS. Future research should shift from clock-based thresholds to physiology-guided frameworks using objective markers of recovery to better inform reoperation strategies in trauma care.
Damage Control Surgery is a technique aimed at reducing mortality in trauma patients, but its use in pediatric patients lacks standardized indications. Proper patient selection is essential to mitigate morbidity associated with Damage Control Surgery. This review aims to clarify the reported indications for Damage Control Surgery in pediatric trauma patients. A systematic search of PubMed and Embase was conducted without publication year restrictions to identify studies reporting indications for performing Damage Control Surgery in pediatric trauma patients. Backward citation analysis was performed on identified review articles that were excluded. Indications or patient characteristics guiding surgical decision-making in the emergency department were extracted and categorized. Forty studies were included: 25 case reports, 13 case series, and 2 observational studies. The case reports and case series involved 98 patients with 368 reported indications, with severe trauma (26.1%), hemodynamic instability (18.2%), and radiological or clinical evidence of severe hemorrhage or contamination (28.2%) being the most observed. The observational studies found a higher Injury Severity Score, lower systolic blood pressure, decreased Glasgow Coma Scale, lower body temperature, and more frequent blood transfusions in the Damage Control Surgery groups compared to the control groups. Severe trauma, hemodynamic instability, and injuries related to severe hemorrhage or contamination emerged as key indications for Damage Control Surgery in pediatric trauma, consistent with findings in adult trauma populations. However, the lethal triad of acidosis, hypothermia and coagulopathy was infrequently reported as a primary indication for Damage Control Surgery in children. This may reflect the greater compensatory capacity of pediatric patients, potentially delaying the manifestation of these physiological derangements. Our findings suggest that early intervention with Damage Control Surgery in cases of severe trauma, exsanguination, gross contamination, and hemodynamic instability may help prevent the progression to critical physiological states such as the lethal triad. This underscores the importance of timely recognition and intervention in pediatric trauma management.