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Ten hot topics in general surgery.

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Session Description

This rapid-fire/quick-shot session will cover ten currently popular issues in general surgery.

Moderator: Kenneth W. Sharp, MD, FACS, Nashville, TN

Co-Moderator: E. Christopher Ellison, MD, FACS, Powell, OH

Presentations

Bullet Removal: Pros and Cons John A. Weigelt, MD, DVM, FACS, Lead, SD

Nipple-Sparing Mastectomy: Use and Indications Raeshell S. Sweeting, MD, Nashville, TN

Troubleshooting Surgical Staple Failure and Malfunction Jon C. Gould, MD, FACS, Milwaukee, WI

Laparoscopic Common Duct Exploration Dana A. Telem, MD, MPH, FACS, Ann Arbor, MI

Extremity Lumps and Bumps Valerie P. Grignol, MD, FACS, Columbus, OH

Update on Tranverse Abdominus Release for Ventral Hernia Bruce Ramshaw, MD, FACS, Knoxville, TN

Recurrent Rectal Prolapse: What to Do? Alexander T. Hawkins, MD, MPH, Nashville, TN

The Case for Robotics in Rural Surgery Jared M. Slater, MD, FACS, Victoria, MN

Optimal Surgical Treatment or Type II Diabetes: Gastric Sleeve or Bypass? Jonathan Carter, MD, San Francisco, CA

Transoral Thyroidectomy: Ready for Prime Time Gustavo G. Fernandez Ranvier, MD, PhD, FACS, Long Island City, NY

Sponsored by the Advisory Council for General Surgery

Learning Objectives

• Apply new knowledge and ideas to improve their surgical practice
• Adapt concepts and quality measures in support of research advancements
• Enhance the quality of patient care

For questions about the course, please contact [email protected] .

• 1.50 AMA PRA Category 1 Credit™
• 1.50 Certificate of Completion
• 1.50 Self Assessment Credit

Disclosure Information

In accordance with the ACCME Accreditation Criteria, the American College of Surgeons must ensure that anyone in a position to control the content of the educational activity (planners and speakers/authors/discussants/moderators) has disclosed all relevant financial relationships with any commercial interest. For additional information, please visit the ACCME website .

The ACCME also requires that ACS manage any reported conflict and eliminate the potential for bias during the educational activity. Any conflicts noted below have been managed to our satisfaction. The disclosure information is intended to identify any commercial relationships and allow learners to form their own judgments. However, if you perceive a bias during a activity, please report it on the evaluation.

(Download the full list of disclosures ).

Faculty and Disclosures

Alexander T. Hawkins MD, MPH - Nothing to Disclose Bruce Ramshaw, MD, FACS - Atrium: Consulting Fee: Consultant; Ethicon (J & J): Honoraria: Consultant; ConMed: Honoraria: Consultant; Medtronic: Honoraria: Speaker; Pacira Pharmaceutical: Honoraria: Consultant, Speaker; WL Gore: Honoraria: Consultant, Speaker E. Christopher Ellison, MD, FACS - McGraw Hill Medical: Royalty: Author; Wolters Kluwer: Royalty: Associate Editor Eric M. Pauli MD, FACS, FASGE - Nothing to Disclose Gustavo G. Fernandez-Ranvier MD, PhD, FACS - Nothing to Disclose Jared M. Slater MD, FACS - Nothing to Disclose John A. Weigelt MD, DVM, FACS - Nothing to Disclose Jon C. Gould, MD, FACS - Gore: Honorarium: Speaker; Torax/Ethicon: Consulting Fee: Consultant and preceptor for LINX Jonathan Carter, MD - VERB Surgical: Consulting Fee: Consultant Kenneth W. Sharp MD, FACS - Nothing to Disclose Raeshell S. Sweeting MD - Nothing to Disclose Valerie P. Grignol MD, FACS - Nothing to Disclose

Program Committee and Disclosures

CHAIR: Henri R. Ford, MD, MHA, FACS, FAAP, FRCSEng(Hon), Miami, FL - Nothing to Disclosure VICE-CHAIR: David T. Cooke, MD, FACS, Sacramento, CA - Nothing to Disclosure

David C. Borgstrom, MD, FACS, Morgantown, WV - Nothing to Disclosure Daniel L. Dent, MD, FACS, San Antonio, TX - Nothing to Disclosure Roger R. Dmochowski, MD, FACS, Nashville, TN - Allergen: Honoraria: Consultant Cynthia D. Downard, MD, FACS, Louisville, KY - Nothing to Disclosure Audra A. Duncan, MD, FACS, London, ON - Nothing to Disclosure Mariam F. Eskander, MD, Boston, MA - Nothing to Disclosure Paula Ferrada, MD, FACS, Richmond, VA - Nothing to Disclosure Neil H. Hyman, MD, FACS, Chicago, IL - Nothing to Disclosure Martin S. Karpeh, Jr., MD, FACS, New York, NY - Nothing to Disclosure Dennis H. Kraus, MD, FACS, New York, NY - Nothing to Disclosure Kenneth W. Sharp, MD, FACS, Nashville, TN - Nothing to Disclosure

Ex-Officios

Daniel M. Herron, MD, FACS, FASBMS, New York, NY - Nothing to Disclosure Edith Tzeng, MD, FACS, Pittsburgh, PA - Nothing to Disclosure

Consultants

Barbara Lee Bass, MD, FACS, FRCSEng(Hon), FRCSI(Hon), FCOSECSA(Hon), Houston, TX - Nothing to Disclosure Quan-Yang Duh, MD, FACS, San Francisco, CA - Nothing to Disclosure B. J. Hancock, MD, FACS, FRCSC, Winnipeg, MB - Nothing to Disclosure Ronald V. Maier, MD, FACS, FRCSEd(Hon), Seattle, WA - Nothing to Disclosure

Continuing Medical Education Credit Information

The American College of Surgeons is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

AMA PRA Category 1 Credits™

The American College of Surgeons designates this enduring activity for a maximum of 1.5 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Of the AMA PRA Category 1 Credits™ listed above, a maximum of 1.5 credits meets the requirements for Self-Assessment.

Note: Residents will receive a Certificate of Completion.

Available Credit

This course is available as part of the Clinical Congress 2019 Webcast Packages

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The following represent additions to UpToDate from the past six months that were considered by the editors and authors to be of particular interest. The most recent What's New entries are at the top of each subsection.

ABDOMINAL WALL AND HERNIA SURGERY

Updated analysis on the risks and benefits of paraesophageal hernia repair (March 2024)

Paraesophageal hernia repair has not been advised for asymptomatic patients due to a high perioperative mortality relative to the risk of developing symptoms. However, in an updated Markov analysis of surgery versus expectant management for such patients, the mortality of elective laparoscopic repair was reduced to <0.5 percent, while the mortality of emergency repair remained high at 10 percent on average [ 1 ]. The annual probabilities of developing symptoms that would necessitate elective and emergency surgery were estimated to be 5.8 and 1.7 percent, respectively. Based on this new analysis, patients with a paraesophageal hernia should be referred for surgical consultation regardless of symptoms to determine if they are an appropriate candidate for hernia repair. In particular, older patients have a higher incidence of paraesophageal hernia and should not be denied surgical consultation. (See "Surgical management of paraesophageal hernia", section on 'Indications for surgical repair' .)

COLORECTAL SURGERY

Duration of antibiotic therapy following appendectomy for perforated appendicitis (February 2024)

The duration of antibiotic therapy following appendectomy for perforated appendicitis is debated. In a trial of 104 patients with complicated appendicitis (defined as gangrenous or perforated) who received 24 hours of intravenous or oral amoxicillin-clavulanate , the 30-day complication rate was not different (15 percent in both groups) [ 2 ]. Because the study population was dominated by patients with gangrenous appendicitis (75 percent) and 67 percent of organ/space infections occurred in patients with perforated appendicitis, these findings may not be generalizable to the latter group. Thus, until further data are available, we continue to suggest two to four days of intravenous antibiotics after appendectomy for those with perforated appendicitis, based on data from previous trials. (See "Management of acute appendicitis in adults", section on 'Antibiotics for perforated appendicitis' .)

Timing of appendectomy for uncomplicated appendicitis (November 2023)

Appendectomy is traditionally performed urgently to reduce the risk of perforation. However, a large randomized trial showed that patients with uncomplicated appendicitis (including those with appendicolith on computed tomography) who had an in-hospital delay of up to 24 hours before surgery had no increased risk of perforation or other complications compared with those who underwent surgery within 8 hours [ 3 ]. Given these data and general acceptance of antibiotic management of these patients, we suggest performing appendectomy within 24 hours of presentation in patients with uncomplicated appendicitis who elect to undergo surgery. (See "Management of acute appendicitis in adults", section on 'Timing of appendectomy' .)

BREAST SURGERY

Regional nodal radiation in early breast cancer (November 2023)

Studies are evaluating the impact of adjuvant regional nodal radiotherapy (RT) in patients with early breast cancer. In a meta-analysis including over 12,000 patients, absolute improvements in breast cancer recurrence and mortality from regional nodal RT in trials from the 1990s through 2000s were greatest for patients at highest risk for recurrence; absolute reductions in 15-year breast cancer mortality were 1 to 2 percent among those with no positive axillary lymph nodes, 2 to 3 percent among those with one to three positive nodes, and 4 to 5 percent for those with four or more positive nodes [ 4 ]. However, no benefits were observed in earlier trials of nodal RT. The discrepancy is likely due to refinements in radiation techniques. For patients with node-positive or high-risk node-negative breast cancer, we offer adjuvant regional nodal RT. (See "Adjuvant radiation therapy for women with newly diagnosed, non-metastatic breast cancer", section on 'Approach' .)

Peritumoral lidocaine injection before incision for breast cancer surgery (September 2023)

In a multicenter, randomized trial of over 1000 patients with early breast cancer undergoing mastectomy or breast-conserving surgery, peritumoral injection of 0.5% lidocaine prior to incision improved five-year disease-free survival (87 versus 83 percent) and five-year overall survival (90 versus 86 percent) [ 5 ]. The mechanism is unknown but thought to involve blocking voltage-gated sodium channels and thereby preventing activation of prometastatic pathways. The trial protocol for surgical management of breast cancer deviated from what may be considered standard treatment in many clinical practices, so further validation is necessary; however, peritumoral injection of lidocaine may be a reasonable intervention given its simplicity and minimal cost. (See "Breast-conserving therapy", section on 'Incision' .)

ENDOCRINE SURGERY

Risk of autoimmune disease after surgical cure of Cushing disease (February 2024)

In patients with a corticotropin (ACTH)-secreting pituitary tumor (Cushing disease), transsphenoidal surgery with adenomectomy provides a high rate of initial cure. Surgical cure of Cushing disease improves skeletal and cardiometabolic health, but it also may contribute to increased risk of autoimmune disorders. In a retrospective study in predominantly female adults (mean age approximately 44 years) with pituitary adenoma who underwent successful surgical management, patients with Cushing disease (n = 194) had a higher rate of new-onset autoimmune disease following surgery compared with patients with a nonfunctioning adenoma (n = 92; cumulative three-year incidence 10.4 versus 1.6 percent, respectively) [ 6 ]. Autoimmune thyroid disease was most common, and family history of autoimmune disease was associated with higher risk of developing an autoimmune disorder. These findings support the need for long-term monitoring of patients with Cushing disease, even after curative surgical treatment. (See "Primary therapy of Cushing disease: Transsphenoidal surgery and pituitary irradiation", section on 'Long-term health risks' .)

Cardiometabolic features of adrenal incidentaloma with mild autonomous cortisol secretion (December 2023)

In some individuals with adrenal incidentaloma, mild autonomous cortisol secretion (MACS) is evident in the absence of clinical features of Cushing syndrome. The long-term risks of MACS and optimal management strategies are not well defined. In a meta-analysis of 47 observational studies in 17,156 patients with adrenal incidentaloma, individuals with MACS (defined as serum cortisol >1.8 mcg/dL after a 1 mg overnight dexamethasone suppression test) exhibited a higher prevalence of diabetes, hypertension, and dyslipidemia compared with individuals with nonfunctioning adrenal adenomas [ 7 ]. Further, patients with MACS who underwent adrenalectomy showed greater improvement in cardiometabolic parameters than those who did not undergo surgery. These findings demonstrate the potential cardiometabolic risks of MACS and support our preference for adrenalectomy in patients with MACS and younger age or evidence of cardiometabolic dysregulation. (See "Evaluation and management of the adrenal incidentaloma", section on 'Clinical manifestations' .)

PERIOPERATIVE CARE

Postoperative noninvasive ventilation or high-flow nasal oxygen for patients with obesity (November 2023)

The optimal postoperative ventilatory strategy for patients with severe obesity has been unclear. In a 2023 network meta-analysis of randomized trials that compared various postoperative noninvasive ventilatory strategies in these patients, high-flow nasal oxygen (HFNO) or bilevel positive airway pressure (BiPAP) reduced atelectasis; HFNO, BiPAP, or continuous positive airway pressure (CPAP) reduced postoperative pneumonia; and HFNO reduced length of stay compared with conventional oxygen therapy [ 8 ]. For patients with obesity who are hypoxic in the post-anesthesia care unit despite oxygen supplementation and incentive spirometry, we suggest a trial of HFNO, BiPAP, or CPAP prior to considering intubation. (See "Anesthesia for the patient with obesity", section on 'Post-anesthesia care unit management' .)

Negative pressure wound therapy for contaminated surgical wounds (November 2023)

Prophylactic negative pressure wound therapy (NPWT) is used on clean surgical wounds, but it may also be useful for contaminated surgical wounds. In a randomized trial that compared NPWT with standard wound care in 69 patients who underwent surgery for gastrointestinal perforation and had fascial closure, NPWT reduced rates of surgical site infection (18 versus 61 percent) and fascial dehiscence (9 versus 48 percent), increased the rate of delayed primary skin closure (91 versus 48 percent), and decreased median time to wound healing (19 versus 26 days) [ 9 ]. The results of this small trial are encouraging, and, in the absence of contraindications, we use NPWT over intact fascia to expedite closure of contaminated surgical wounds. (See "Negative pressure wound therapy", section on 'Prophylactic use' .)

SKIN AND SOFT TISSUE SURGERY

Lymphatic venous bypass reduces cellulitis frequency in patients with lower extremity lymphedema (March 2024)

Observational studies suggest lymphatic venous bypass procedures provide benefits beyond limb volume reduction. In a trial comparing lymphatic venous anastomosis (LVA) plus complex decongestive therapy (CDT) versus CDT alone in patients with lower extremity lymphedema, LVA resulted in a greater reduction in cellulitis frequency from baseline (0.57 versus 0.21 fewer episodes over six months) [ 10 ]. LVA also reduced thigh area hardness; however, limb circumference and pain were similar. All patients had undergone at least three months of CDT before randomization. The outcomes of this trial support our practice of offering LVA for patients with lymphedema and recurrent cellulitis. (See "Surgical treatment of primary and secondary lymphedema", section on 'Lymphatic bypass outcomes' .)

TRANSPLANTATION

Lung transplant outcomes for COVID-19 end-stage lung disease (September 2023)

COVID-19 end-stage lung disease is a new indication for lung transplantation with limited outcome data. Two groups have recently analyzed overlapping cohorts of approximately 400 patients who underwent lung transplantation in the United States for COVID-19-associated end-stage lung disease between March 2020 and August 2022 and who comprised almost 9 percent of all lung transplants performed during this time period [ 11,12 ]. Compared with other lung transplant recipients, these patients were generally younger and more likely to need mechanical ventilation or extracorporeal membrane oxygenation support before transplantation. Despite longer hospital stays, overall survival over the first 12 months was similar to that seen in patients who received lung transplantation for other causes (86 to 87 percent). Lung transplantation provides effective treatment for carefully selected patients with irreversible end-stage lung disease caused by COVID-19. (See "Lung transplantation: General guidelines for recipient selection", section on 'Lung disease due to COVID-19' .)

TRAUMA AND BURN SURGERY

Skin preparation prior to fracture repair (March 2024)

The optimal preparation of contaminated or dirty wounds and whether any skin preparation can influence surgical site infection (SSI) independent of other factors (eg, prophylactic systemic antibiotics) are unknown. In a multiple-period, cluster-randomized, crossover trial comparing skin preparation with iodine povacrylex in alcohol versus chlorhexidine gluconate in alcohol in 1700 open fracture repairs, the incidence of superficial or deep SSI was similar for both approaches [ 13 ]. Based on these findings, which are consistent with those from a previous trial, either chlorhexidine- or iodine-based skin preparations can be used prior to surgery for open, traumatic lower extremity wounds. (See "Surgical management of severe lower extremity injury", section on 'Limb preparation and skin antisepsis' .

Whole blood transfusion for severe traumatic hemorrhage (January 2024)

For severe traumatic hemorrhage, whole blood transfusion is an alternative to balanced component transfusion (1:1:1 ratio of packed red blood cells/plasma/platelets). In an observational study comparing these two approaches, low titer group O whole blood transfusion was associated with lower 24-hour mortality (8 versus 19 percent) and lower volume of blood products received at 72 hours (48 versus 82 mL/kg) [ 14 ]. The survival benefit was greatest in patients with shock or coagulopathy. While this study suggests improved outcomes for whole blood transfusion, randomized trials are needed to determine which transfusion strategy might be superior and which patients would benefit the most. (See "Ongoing assessment, monitoring, and resuscitation of the severely injured patient", section on 'Whole blood transfusion' .)

Tranexamic acid for burn wound excision (November 2023)

Randomized trials have established that tranexamic acid (TXA) reduces blood loss and transfusion requirements in various surgical settings, but data in burn surgery are limited. In a meta-analysis of observational studies evaluating intravenous and topical TXA in burn surgery, use of TXA was associated with reductions in blood loss, use of intraoperative transfusion, and number of units transfused but no change in venous thromboembolism or mortality rates [ 15 ]. Based on this review and data from other surgical settings, we routinely administer intravenous TXA for burn wound excisions over 20 percent of total body surface area. (See "Overview of the management of the severely burned patient", section on 'Coagulopathy' .)

No benefit of Cryoprecipitate in massive transfusion protocol for trauma (October 2023)

Cryoprecipitate is a source of fibrinogen; some institutions may include it in their massive transfusion protocols for trauma patients. In a new trial, 1604 trauma patients were randomly assigned to receive or not receive Cryoprecipitate in addition to a standard massive transfusion protocol [ 16 ]. Mortality at 28 days was comparable between the no Cryoprecipitate controls and the Cryoprecipitate group (26 versus 25 percent). This finding supports the practice of reserving Cryoprecipitate for patients with low fibrinogen levels. Transfusion medicine personnel and/or individuals with hemostasis expertise can help to determine the value for specific patients. (See "Cryoprecipitate and fibrinogen concentrate", section on 'Trauma' .)

VASCULAR AND ENDOVASCULAR SURGERY

Phosphodiesterase type 5 inhibition for Raynaud phenomenon (January 2024)

Phosphodiesterase type 5 (PDE5) inhibitors such as sildenafil and tadalafil are widely used to treat digital ischemia from Raynaud phenomenon. In an updated meta-analysis of nine randomized trials comprising 411 patients with Raynaud phenomenon (most of whom had scleroderma), treatment with PDE5 inhibition resulted in three fewer attacks weekly and a reduction in the average duration of the attacks by five minutes [ 17 ]. However, PDE5 inhibition led to minimal to no reduction in the pain associated with Raynaud phenomenon. This study implies that while PDE5 inhibition has a modest impact on the duration and frequency of Raynaud attacks, it might not be adequate to address all symptoms experienced by patients with severe disease. (See "Treatment of Raynaud phenomenon: Initial management", section on 'Phosphodiesterase type 5 inhibitor' .)

Genes associated with an increased risk for Raynaud phenomenon (October 2023)

A genetic basis for Raynaud phenomenon (RP) is supported by family and twin studies, but robust evidence for specific causal genes has been lacking. A genome-wide association study has identified two candidate genes associated with an increased risk for RP: ADRA2A and IRX1 [ 18 ]. The potential role of these genes in the pathogenesis of RP requires further study. (See "Pathogenesis and pathophysiology of Raynaud phenomenon", section on 'Genetic factors' .)

OTHER SURGICAL SPECIALTIES

Moderate hypothermia during aortic arch surgery with antegrade cerebral perfusion (March 2024)

Observational data have supported a shift from deep to moderate hypothermia during circulatory arrest for aortic arch surgery, particularly with adjunctive antegrade cerebral perfusion (ACP). A recent trial has now compared outcomes for 251 patients undergoing aortic arch surgery with ACP and randomly assigned to deep (≤20.0°C), low-moderate (20.1 to 24.0°C), or high-moderate (24.1 to 28.0°C) circulatory arrest temperature [ 19 ]. At one-month follow-up, the three groups had similar neurocognitive and neuroimaging outcomes and similar mortality, major morbidity, and quality of life. The volume of transfused blood products was higher in the deep group, but transfusion-related complications were not different. Based on this trial, moderate (20.1 to 28.0°C) rather than deep hypothermia is reasonable during aortic arch surgery when ACP is also used. Whether a low-moderate or high-moderate temperature is selected depends on the anticipated duration of hypothermia. (See "Overview of open surgical repair of the thoracic aorta", section on 'Basic principles' .)

Complications of transrectal versus transperineal prostate biopsy (February 2024)

The merit of transrectal versus transperineal prostate biopsy has been vigoroulsy debated. In the first randomized trial comparing these procedures in over 760 patients undergoing biopsies in the office setting, the two approaches had similar rates of both infectious (2.6 versus 2.7 percent) and non-infectious (1.7 versus 2.2 percent) complications [ 20 ]. This suggests that both approaches can be performed with a low risk of complications. Antibiotic prophylaxis was given to all patients prior to transrectal biopsy but omitted in most patients undergoing transperineal biopsy. (See "Prostate biopsy", section on 'Transrectal versus transperineal biopsy' .)

Pregnancy and childbirth after urinary incontinence surgery (January 2024)

Patients with stress urinary incontinence (SUI) have historically been advised to delay midurethral sling (MUS) surgery until after childbearing because of concerns for worsening SUI symptoms following delivery. In a meta-analysis of patients with MUS surgery who were followed for a mean of nearly 10 years, similar low SUI recurrence and reoperation rates were reported for the 381 patients with and the 860 patients without subsequent childbirth [ 21 ]. Birth route did not affect the findings. Although the total number of recurrences and reoperations was small, this study adds to the body of evidence suggesting that subsequent childbirth does not worsen SUI outcomes for patients who have undergone MUS. (See "Surgical management of stress urinary incontinence in females: Retropubic midurethral slings", section on 'Subsequent pregnancy' .)

Tranexamic acid to reduce bleeding after percutaneous nephrolithotomy (December 2023)

Postoperative bleeding can occur after percutaneous nephrolithotomy (PNL) for kidney stone removal; most bleeding is venous in origin and can be managed with conservative measures. A recent meta-analysis of 10 randomized trials found that use of tranexamic acid (TXA), an antifibrinolytic agent used to reduce bleeding in other clinical settings, may reduce the risk of blood transfusion after PNL [ 22 ]. Most trials were conducted in low- to middle-income settings in populations that were younger than those in higher-income settings; whether these findings are generalizable to practice in higher-income settings is uncertain. Pending additional data, we do not routinely use TXA after PNL. (See "Kidney stones in adults: Surgical management of kidney and ureteral stones", section on 'Bleeding' .)

Choice of intervention for aortic stenosis with low surgical risk (November 2023)

The choice of intervention for severe aortic stenosis (AS) is based upon an individualized assessment by a multidisciplinary heart valve team. Two randomized trials reported outcomes for transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR) in selected low surgical risk patients with severe AS [ 23,24 ]:

● In one trial in which nearly 1500 patients were randomly assigned to TAVI with a self-expanding valve or SAVR, rates of mortality, disabling stroke, and aortic valve rehospitalization at four years were similar in the two groups.

● In another trial in which 1000 patients were randomly assigned to TAVI with a balloon-expanding valve or SAVR, rates of mortality, stroke, and rehospitalization at five years were similar in the two groups.

These trials indicate generally favorable results for TAVI up to four and five years for selected low surgical risk patients with severe AS and anatomical suitability for TAVI; additional data, including longer-term outcomes, will further inform the choice of intervention in this clinical setting. (See "Choice of intervention for severe calcific aortic stenosis", section on 'In low-risk symptomatic patients' .)

No benefit to routinely adding vancomycin for prophylaxis before joint replacement (November 2023)

For preoperative antibiotic prophylaxis in patients undergoing joint replacement, vancomycin is sometimes added to cefazolin to empirically cover methicillin-resistant staphylococci. In a randomized trial of over 4000 patients undergoing joint replacement, the rate of surgical site infection was similar following prophylaxis with cefazolin plus vancomycin compared with cefazolin plus placebo (4.5 versus 3.5 percent) [ 25 ]. There were no differences in rates of infection due to methicillin-resistant Staphylococcus aureus (MRSA) or Staphylococcus epidermidis. We use cefazolin alone for prophylaxis in patients undergoing joint replacement who are not known to have MRSA colonization or infection. (See "Prevention of prosthetic joint and other types of orthopedic hardware infection", section on 'Antimicrobial prophylaxis' .)

Timing of prophylactic aortic surgery for patients with bicuspid aortic valve (October 2023)

The optimal timing for prophylactic aortic surgery for patients with a bicuspid valve (BAV) and ascending aorta diameters of 5.0 to 5.4 cm is uncertain. In a retrospective multicenter study including nearly 500 patients with BAV and aortic diameters in this range who were followed for a median of seven years, over one-half of the patients underwent elective aortic surgery, with an operative mortality rate of 1.9 percent [ 26 ]. Aortic dissection occurred during surveillance in 1.8 percent of the nearly 500 patients. These findings illustrate the risk trade-offs for early surgery versus surveillance for patients with BAV; a randomized trial is underway to compare these approaches in patients with ascending aorta diameters of 5.0 to 5.4 cm, including patients with BAV. (See "Bicuspid aortic valve: Intervention for valve disease or aortopathy in adults", section on 'Without high-risk features' .)

High-dose dual-antibiotic loaded cement does not reduce infection compared with low-dose single-antibiotic loaded cement in hip arthroplasty (September 2023)

The optimal dosing and effectiveness of antibiotic-loaded cement for hip arthroplasty is uncertain. In a randomized trial, high-dose dual-antibiotic-loaded cement did not reduce the incidence of deep surgical site infection after hip arthroplasty compared with low-dose single-antibiotic-loaded cement [ 27 ]. Based on this trial, when antibiotic cement fixation is selected for hip arthroplasty, available cement preparations that use a low-dose single antibiotic are adequate for reducing the risk of surgical site infection and also minimize the risk of fixation weakening associated with high-dose dual-antibiotic-loaded cement. (See "Total hip arthroplasty", section on 'Total hip arthroplasty implant design' .)

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• Lipping E, Saar S, Reinsoo A, et al. Short Postoperative Intravenous Versus Oral Antibacterial Therapy in Complicated Acute Appendicitis: A Pilot Noninferiority Randomized Trial. Ann Surg 2024; 279:191.
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• Nyanyo DD, Mikamoto M, Galbiati F, et al. Autoimmune Disorders Associated With Surgical Remission of Cushing's Disease : A Cohort Study. Ann Intern Med 2024.
• Pelsma ICM, Fassnacht M, Tsagarakis S, et al. Comorbidities in mild autonomous cortisol secretion and the effect of treatment: systematic review and meta-analysis. Eur J Endocrinol 2023; 189:S88.
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• Okumura K, Jyothula S, Kaleekal T, Dhand A. 1-Year Outcomes of Lung Transplantation for Coronavirus Disease 2019-Associated End-Stage Lung Disease in the United States. Clin Infect Dis 2023; 76:2140.
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• PREP-IT Investigators, Sprague S, Slobogean G, et al. Skin Antisepsis before Surgical Fixation of Extremity Fractures. N Engl J Med 2024; 390:409.
• Shea SM, Mihalko EP, Lu L, et al. Doing more with less: low-titer group O whole blood resulted in less total transfusions and an independent association with survival in adults with severe traumatic hemorrhage. J Thromb Haemost 2024; 22:140.
• Fijany AJ, Givechian KB, Zago I, et al. Tranexamic acid in burn surgery: A systematic review and meta-analysis. Burns 2023; 49:1249.
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• Hughes GC, Chen EP, Browndyke JN, et al. Cognitive Effects of Body Temperature During Hypothermic Circulatory Arrest Trial (GOT ICE): A Randomized Clinical Trial Comparing Outcomes After Aortic Arch Surgery. Circulation 2024; 149:658.
• Mian BM, Feustel PJ, Aziz A, et al. Complications Following Transrectal and Transperineal Prostate Biopsy: Results of the ProBE-PC Randomized Clinical Trial. J Urol 2024; 211:205.
• Nahshon C, Abramov Y, Kugelman N, et al. The effect of subsequent pregnancy and childbirth on stress urinary incontinence recurrence following midurethral sling procedure: a meta-analysis. Am J Obstet Gynecol 2024; 230:308.
• Cleveland B, Norling B, Wang H, et al. Tranexamic acid for percutaneous nephrolithotomy. Cochrane Database Syst Rev 2023; 10:CD015122.
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• Agni NR, Costa ML, Achten J, et al. High-dose dual-antibiotic loaded cement for hip hemiarthroplasty in the UK (WHiTE 8): a randomised controlled trial. Lancet 2023; 402:196.

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• Quick-Fire Session Spotlig...

Quick-Fire Session Spotlights 10 Hot Topics in General Surgery

September 20, 2023

In this popular 90-minute session, distinguished panelists will explore compelling topics that are fueling discussions throughout general surgery, selected from the ACS Communities, scientific conferences, and current research literature.

For the 12th time at Clinical Congress, ACS President E. Christopher Ellison, MD, FACS, and ACS Regent Kenneth W. Sharp, MD, FACS, have paired up to co-moderate Ten Hot Topics in General Surgery, which takes place on Wednesday, October 25, from 12:45 pm to 2:15 pm in Ballroom East.

“We’re going prime time this year,” said Dr. Christopher Ellison.

“We’re going prime time this year,” said Dr. Ellison, referring to the new day and afternoon time slot for this year’s session. (Clinical Congress 2023 ends on Wednesday instead of Thursday as it has in previous years.)

In this rapid-fire style session, a panel featuring experts in general surgery will present a series of 6-minute presentations on topics that are cutting edge and controversial.

“Honestly, with these fast-paced presentations, we have to depend a little bit on the skill of the speaker,” explained Dr. Sharp. “Between Dr. Ellison and me, we know 95% of these speakers personally, and we know that they can give a very focused talk in just a few minutes.”

"We really believe every attendee will come away with information that will be useful in their own practices," said Dr. Kenneth Sharp

Each presentation will be immediately followed by a 3-minute, unscripted discussion with the audience, representing a variety of thoughts and perspectives, and providing attendees with takeaway information for future reflection.

“We know that all ten topics will not suit every surgeon,” said Dr. Sharp. “But we really believe every attendee will come away with information that will be useful in their own practices—or that will stimulate them to look at two or three new areas that they don’t know much about.”

This year’s session will cover a wide scope of topics, each representing new and emerging areas of interest in general surgery, including a presentation by Patricia Sylla, MD, FACS, on transanal mesorectal excision for rectal cancer.

“This is a very advanced surgical technique that not everyone will adopt or use—but they should be aware of it because it enhances recovery and gives patients a better quality outcome than some of the standard techniques,” Dr. Ellison said.

Dr. Sharp added that while this cutting-edge technique likely will be limited to high-volume colorectal surgeons, “if you don't know about some of the new advances, you can't take advantage of them.”

The full agenda for this year’s session includes:

Repair of Paraesophesophageal Hiatal Hernias—Add a Fundoplication or Not? Kelly Haisley, MD, FACS, Columbus, OH

Peritoneal Dialysis Catheters—Tips and Tricks M. T. Nelson, MD, FACS, Tulsa, OK

Transanal Mesorectal Excision for Rectal Cancer Patricia Sylla, MD, FACS, New York, NY

Glucagon-like Peptide-1 (GLP-1) Agonists—The End of Bariatric Surgery? Matthew D. Spann, MD, FACS, Nashville, TN

Perforated Duodenal Ulcers: Close or Patch—And How? Jon C. Gould, MD, FACS, Milwaukee, WI

Biliary Dyskinesia—Why Are We Still Debating This? Bryan K. Richmond, MD, MBA, FACS, Charleston, WV

Appendiceal Carcinoma: Decision-Making for the General Surgeon Matthew F. Kalady, MD, FACS, Columbus, OH

Transoral Thyroidectomy William B. Inabnet III, MD, MHA, FACS, Lexington, KY

Surgical Rib Fixation in Trauma—Who and When? Brian J. Daley, MD, FACS, Knoxville, TN

Choosing Wisely—Management of the Axilla in Women over 70 with Breast Cancer Kelly C. Hewitt, MD, FACS, Nashville, TN

This session also will be available for on-demand viewing. 

About Clinical Congress

Access the virtual platform for on-demand content and credit claiming until May 1, 2024. Haven't registered yet? Register for virtual access.

• Theatre Etiquette
• Hand Washing
• Scrubbing, Gowning, and Gloving
• Assisting in Theatre
• The Operation Note
• Surgical Safety
• Suture Materials
• Surgical Instruments
• Infiltration of Local Anaesthetic
• Drain Insertion
• Abscess Drainage
• Skin Lesion Excision
• Damage to Local Structures
• Acute Inflammation
• Chronic Inflammation
• Wound Healing
• Basic Wound Management
• Venepuncture
• Cannulation
• Blood Cultures
• Intravenous Infusions
• Female Catheterisation
• Male Catheterisation
• Pre-Op Assessment
• Pre-Op Management
• Fluid Management
• Blood Products
• Perioperative Nutrition
• Enhanced Recovery
• Day Case Surgery
• Haemorrhage
• Nausea & Vomiting
• Atelectasis
• Fat Embolism
• Anastomotic Leak
• Post-Op Ileus
• Bowel Adhesions
• Incisional Hernia
• Constipation
• Acute Kidney Injury
• Urinary Retention
• Urinary Tract Infection
• Hypoglycaemia
• Hyperkalaemia
• Hypokalaemia
• Hypernatremia
• Hyponatraemia
• Surgical Site Infection
• Wound Dehiscence
• Initial Assessment
• The General Approach
• A-E Assessment
• Referring a Patient
• IV Fluid Management
• Post-Op Fever
• Post-Op Pain
• Cardiovascular
• Respiratory
• Cardiothoracic Incisions
• Digital Rectal
• Abdominal Incisions
• Peripheral Vascular
• Peripheral Venous
• Cranial Nerves
• Peripheral Neurological
• Diabetic Foot
• Thyroid Gland
• Foot & Ankle
• Oral Cavity
• Certifying Death
• Acute Abdomen
• Haematemesis
• Gastric Outlet Obstruction
• Bowel Obstruction
• Bowel Perforation
• Rectal Bleeding
• Oesophageal Cancer
• Oesophageal Tears
• Motility Disorders
• Hiatus Hernia
• Peptic Ulcer Disease
• Gastric Cancer
• Inguinal Hernia
• Femoral Hernia
• Abdominal Wall Hernia
• Gastroenteritis
• Angiodysplasia
• Small Bowel Tumours
• Neuroendocrine Tumours
• Acute Appendicitis
• Colorectal Cancer
• Diverticular Disease
• Crohn’s Disease
• Ulcerative Colitis
• Pseudo-Obstruction
• Haemorrhoids
• Pilonidal Sinus
• Fistula-in-Ano
• Anorectal Abscess
• Anal Fissure
• Rectal Prolapse
• Anal Cancer
• Colic & Cholecystitis
• Cholangitis
• Cholangiocarcinoma
• Hepatocellular Carcinoma
• Liver Cysts
• Liver Abscess
• Acute Pancreatitis
• Chronic Pancreatitis
• Pancreatic Cancer
• Cystic Neoplasms of the Pancreas
• Splenic Infarct
• Splenic Rupture
• Acutely Painful Limb
• Lower Limb Ulcers
• Carotid Artery Disease
• Abdominal Aortic Aneurysm
• Aortic Dissection
• Thoracic Aortic Aneurysm
• Acute Limb Ischaemia
• Chronic Limb Ischaemia
• Acute Mesenteric Ischaemia
• Chronic Mesenteric Ischaemia
• Pseudoaneurysm
• Peripheral & Visceral Aneurysms
• Varicose Veins
• Venous Insufficiency
• Thoracic Outlet Syndrome
• Subclavian Steal Syndrome
• Hyperhidrosis
• Scrotal Pain
• Acute Urinary Retention
• Chronic Urinary Retention
• Lower Urinary Tract Symptoms
• Scrotal Lumps
• Renal Tract Calculi
• Pyelonephritis
• Renal Cancer
• Renal Cysts
• Urinary Incontinence
• Bladder Cancer
• Benign Prostatic Hyperplasia
• Prostate Cancer
• Prostatitis
• Epididymitis
• Testicular Torsion
• Testicular Cancer
• Fournier’s Gangrene
• Paraphimosis
• Penile Fracture
• Penile Cancer
• Peyronie’s Disease
• Hypospadias
• Cryptorchidism
• Balanitis Xerotica Obliterans
• Osteoarthritis
• Fracture Management
• Acutely Swollen Joint
• Open Fracture
• Compartment Syndrome
• Septic Arthritis
• Osteomyelitis
• Bone Tumours
• Clavicle Fracture
• Rotator Cuff Tear
• Shoulder Fracture
• Shoulder Dislocation
• Humeral Shaft Fracture
• Biceps Tendinopathy
• Adhesive Capsulitis
• Subacromial Impingement Syndrome
• Supracondylar Fracture
• Olecranon Fracture
• Radial Head Fracture
• Elbow Dislocation
• Olecranon Bursitis
• Epicondylitis
• Distal Radius Fracture
• Scaphoid Fracture
• Carpal Tunnel Syndrome
• Dupuytren’s Contracture
• De Quervain’s Tenosynovitis
• Ganglionic Cysts
• Trigger Finger
• Radiculopathy
• Degenerative Disc Disease
• Cervical Fracture
• Thoracolumbar Fracture
• Neck of Femur Fracture
• Hip Osteoarthritis
• Femoral Shaft Fracture
• Quadriceps Tendon Rupture
• Distal Femur Fracture
• Pelvic Fracture
• Acetabular Fracture
• Knee Osteoarthritis
• Meniscal Tear
• Patella Fracture
• Tibial Shaft Fracture
• Tibial Plateau Fracture
• Iliotibial Band Syndrome
• Ankle Fracture
• Calcaneal Fracture
• Achilles Tendonitis
• Talar Fracture
• Tibial Pilon Fracture
• Lisfranc injury
• Hallux Valgus
• Plantar Fasciitis
• The Limping Child
• Growth Plate Fracture
• Triple Assessment
• Galactorrhoea
• Inflammatory Disease
• Benign Tumours
• Gynaecomastia
• Carcinoma in Situ
• Invasive Cancer
• Surgical Treatments
• Non-Surgical Treatments
• Hoarse Voice
• Facial Palsy
• Hearing Loss
• Otitis Externa
• Acute Otitis Media
• Otitis Media with Effusion
• Chronic Mucosal Otitis Media
• Chronic Squamous Otitis Media
• Acute Rhinosinusitis
• Chronic Rhinosinusitis
• Periorbital Cellulitis
• Nasal Trauma
• Obstructive Sleep Apnoea
• Tonsillitis
• Deep Neck Space Infections
• Foreign Bodies
• Sialolithiasis
• Sialadenitis
• Salivary Gland Tumours
• Thyroid Cancer
• Head & Neck Cancer
• Assessment of Head Injury
• Extradural Haematoma
• Subdural Haematoma
• Diffuse Axonal Injury
• Traumatic Spinal Cord Injury
• Monro-Kellie Doctrine
• Intracranial Pressure Monitoring
• Hydrocephalus
• Subarachnoid Haemorrhage
• Intracranial Aneurysms
• Intracerebral Haemorrhage
• Arteriovenous Malformation
• Intracranial Infections
• Pituitary Tumours
• Spinal Tumours
• Deep Brain Stimulation
• Epilepsy Surgery
• Cauda Equina Syndrome
• Spinal Cord Compression
• Spinal Infections
• Principles of Wound Management
• Burns Assessment
• Burns Reconstruction
• Skin Grafts and Flaps
• Basal Cell Carcinoma
• Squamous Cell Carcinoma
• Flexor Tendon Injuries
• Extensor Tendon Injuries
• Metacarpal Fractures
• Phalangeal Fractures
• Nail Bed Injuries
• Finger Replantation
• Skin Abscess
• Necrotising Fasciitis
• Bite Injuries
• Hand Infections
• Cardiopulmonary Bypass
• Bridge to Transplantation
• Foetal & Adult Circulation
• Coronary Artery Disease
• Valvular Disease
• Cardiac Tumours
• Lung Cancer
• Airway Disorders
• Chest Wall Disorders
• Mediastinal Tumours
• Diaphragmatic Hernia
• Pneumothorax
• Haemothorax
• Principles of Transplantation
• Concepts of Brain Death
• Organ Retrieval
• Immunosuppression in Transplantation
• Renal Transplantation
• Liver Transplantation
• Pancreas Transplantation
• Heart Transplantation
• Lung Transplantation
• I&D Abscess
• Diagnostic Laparoscopy
• Appendicectomy
• Small Bowel Resection
• Hartmann’s Procedure
• Gastroscopy
• Colonoscopy
• Excision of a Lump
• Open Inguinal Hernia Repair
• Laparoscopic Inguinal Hernia Repair
• Open Umbilical Hernia Repair
• Laparoscopic Cholecystectomy
• Nissen Fundoplication
• Oesophagectomy
• Gastric Band
• Gastric Bypass
• Sleeve Gastrectomy
• Lay Open Fistula
• Haemorrhoidectomy
• Pilonidal Sinus Repair
• Reversal of a Stoma
• Right Hemicolectomy
• Left Hemicolectomy
• Anterior Resection
• Abdominoperineal Resection
• Carotid Endarterectomy
• Open AAA Repair
• Lower Limb Amputation
• Angioplasty and Stenting
• Embolectomy
• Femoral Endarterectomy
• Arterial Bypass
• Axillofemoral Bypass
• Lower Limb Bypass
• Fem-Fem Crossover
• Endovenous Ablation
• Varicose Veins Stripping
• Foam Sclerotherapy
• AV Fistula Formation
• Cervical Rib Excision
• Flexible Cystoscopy
• Rigid Cystoscopy
• Suprapubic Catheterisation
• Scrotal Exploration
• Inguinal Orchidectomy
• Hydrocoele Excision
• Epididymal Cyst Excision
• Circumcision
• Dorsal Slit Procedure
• Ureteric Stent Insertion
• Percutaneous Nephrolithotomy
• Nephrectomy
• Flexible Nasal Endoscopy
• Microlaryngoscopy
• Grommet Insertion
• Myringoplasty
• Adenoidectomy
• Septoplasty
• Functional Endoscopic Sinus Surgery
• Parotidectomy

Presentations

Within general surgery, there are a wide range of clinical presentations that patients can present with, and the underlying pathologies are even wider.

The most common of these is acute abdominal pain, often termed the “acute abdomen” and is essential to know how to approach this presentation and potential investigations required. Various abdominal incisions may be present as well for several patients you see, therefore knowing what the various scars mean is useful to know.

Bowel obstruction and bowel perforation are serious disease presentations and should be investigated and managed promptly. 

Haematemesis, melena, and haematochezia can also suggest slightly different pathologies present, yet all can lead to potential surgical intervention being required if severe or untreated, therefore are essential presentations to learn how to approach.

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Current Topics in Surgical Research

This article is only available in the PDF format. Download the PDF to view the article, as well as its associated figures and tables.

This is the third volume of papers from the Association for Academic Surgery. The presentations which are included in the current book were delivered at the fourth annual meeting of the Association which was held in Denver in November 1970. This surgical society is composed of young, fulltime academic surgeons, less than 40 years of age when elected. The editors selected for publication 46 of the 64 papers that were delivered at the 1970 meeting.

The papers are primarily reports of clinical and laboratory research studies. The contents have been divided into sections, so that papers are grouped, approximately equally, into the following categories: I: Cardiovascular; II: Wound Healing and Shock; III: Neurosurgery; IV: Genitourinary; V: Transplantation; VI: Oncology; VII: Gastrointestinal and Biliary. The authors of the papers represent 39 teaching institutions in the United States and Canada and include most of the surgical specialties.

The quality of the presentations

Beal JM. Current Topics in Surgical Research. Arch Surg. 1972;104(2):229. doi:10.1001/archsurg.1972.04180020107028

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General surgery resources for students

• Related content
• Peer review
• Matas Morkevicius , fifth year medical student 1
• 1 Vilnius University Medical School, Lithuania

Medical students spend lots of money on textbooks. But now the internet contains lots of resources including several surgical textbooks that are available free of charge.

Surgical Treatment: Evidence Based and Problem-Oriented ( www.ncbi.nlm.nih.gov/books/bv.fcgi?call=bv.View..ShowTOC&rid=surg.TOC ) is probably one of the best online texts which covers the various topics in general surgery. The contents follow the usual format of paper surgery textbooks and classify the chapters according to the diseased organ. At the end of each section, a reference section links to Pubmed.

An extensive list of relevant surgical topics is covered at Emedicine ( www.emedicine.com/med/GENERAL_SURGERY.htm ). You can find review and tutorial articles, written by experts in surgery. The text is aimed at students, so even the basic science part of each surgical condition is described in detail. At the bottom of each article are references which help you to find more detailed information.

The University of Chicago Medical School's website holds lecture notes for students on most common surgical topics ( http://surgery.uchicago.edu/ed/readings.cfm?section=General ). Visitors to this website are supposed to have some basic knowledge of normal anatomy since only information about clinically oriented anatomy is given. At the end of each lecture are self assessment questions. Although “acute appendicitis” is not covered, the site is still a good resource for most common surgical diseases.

The University of Iowa offers a few books in general surgery. The first one is the Emergency War Surgery Handbook ( www.vnh.org/EWSurg/EWSTOC.html ) which covers the pathologic basis and management of wounds. The second one, the General Surgery University of Iowa Family Practice Handbook ( www.vh.org/adult/provider/familymedicine/FPHandbook/15.html ), is a good resource for those who need just a brief guide. Here you can find really concise guidelines on urgent surgical conditions.

Few websites contain colour atlases, but one of them is Westcott Atlas of Surgery ( www.bgsm.edu/surg-sci/atlas/atlas.html ), which contains the schemes and pictures of different laparoscopic surgeries. Another site ( www.laparoscopy.com ) has a collection of pictures and videos of the most common laparoscopic procedures in the different branches of surgery. These websites are particularly useful for making presentations.

Advanced level medical students might refer to peer reviewed surgery journals with free access to full text articles. There are quite a few, including BMC Surgery ( www.biomedcentral.com/1471-2482 ), the Canadian Journal of Surgery ( www.cma.ca/cjs/index.htm ), and Contemporary Surgery ( www.contemporarysurgery.com ).

Originally published as: Student BMJ 2004;12:391

• Open access
• Published: 06 October 2023

Enhanced perioperative care in emergency general surgery: the WSES position paper

• Marco Ceresoli 1 , 2 ,
• Marco Braga 1 , 2 ,
• Nicola Zanini 3 ,
• Fikri M. Abu-Zidan 4 ,
• Dario Parini 5 ,
• Thomas Langer 1 , 6 ,
• Massimo Sartelli 7 ,
• Dimitrios Damaskos 8 ,
• Walter L. Biffl 9 ,
• Francesco Amico 10 ,
• Luca Ansaloni 11 ,
• Zsolt J. Balogh 12 ,
• Luigi Bonavina 13 ,
• Ian Civil 14 ,
• Enrico Cicuttin 11 ,
• Mircea Chirica 15 ,
• Yunfeng Cui 16 ,
• Belinda De Simone 17 ,
• Isidoro Di Carlo 18 ,
• Andreas Fette 19 ,
• Giuseppe Foti 1 , 20 ,
• Michele Fogliata 1 , 2 ,
• Gustavo P. Fraga 21 ,
• Paola Fugazzola 11 ,
• Joseph M. Galante 22 ,
• Solomon Gurmu Beka 23 ,
• Andreas Hecker 24 ,
• Johannes Jeekel 25 ,
• Andrew W. Kirkpatrick 26 ,
• Kaoru Koike 27 ,
• Ari Leppäniemi 28 , 29 ,
• Ingo Marzi 30 ,
• Ernest E. Moore 31 ,
• Edoardo Picetti 32 ,
• Emmanouil Pikoulis 33 ,
• Michele Pisano 34 ,
• Mauro Podda 35 ,
• Boris E. Sakakushev 36 ,
• Vishal G. Shelat 37 , 38 ,
• Edward Tan 39 ,
• Giovanni D. Tebala 40 ,
• George Velmahos 41 ,
• Dieter G. Weber 42 ,
• Vanni Agnoletti 43 ,
• Yoram Kluger 44 ,
• Gianluca Baiocchi 45 ,
• Fausto Catena 3 &
• Federico Coccolini 46  

World Journal of Emergency Surgery volume  18 , Article number:  47 ( 2023 ) Cite this article

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Enhanced perioperative care protocols become the standard of care in elective surgery with a significant improvement in patients’ outcome. The key element of the enhanced perioperative care protocol is the multimodal and interdisciplinary approach targeted to the patient, focused on a holistic approach to reduce surgical stress and improve perioperative recovery. Enhanced perioperative care in emergency general surgery is still a debated topic with little evidence available. The present position paper illustrates the existing evidence about perioperative care in emergency surgery patients with a focus on each perioperative intervention in the preoperative, intraoperative and postoperative phase. For each item was proposed and approved a statement by the WSES collaborative group.

Introduction

Enhanced recovery after surgery (ERAS®) protocol refers to a standardized multimodal approach based on the application of structured protocols in perioperative patients' management. The main goal of these interventions is patient management optimization during the perioperative period under all aspects of perioperative care, not only about the surgical technique, by reducing surgical stress, minimizing the physiological response to surgery, and improving postoperative recovery. The key element of the ERAS protocol is the multimodal and interdisciplinary approach targeted to the patient, focused on a holistic approach [ 1 ].

Perioperative care protocols are structured as a bundle of interventions to be applied during the preoperative, intraoperative and postoperative periods. Each intervention is linked to the others and shares the common goal of reducing the burden of perioperative patient stress (Fig.  1 ). For this reason, it is very difficult to evaluate the efficacy of a single item without considering the effect of all the others, applied as a bundle. Designing studies to evaluate and demonstrate the effect of every single intervention is therefore a major challenge, markedly limiting the available scientific evidence.

Enhanced perioperative care items and interventions

The effectiveness and safety of ERAS protocols in elective surgery are now widely established. Several meta-analyses comparing standard care and fast-track approach show that ERAS protocols in elective surgery lead to a reduction in length of stay and in the rate of postoperative non-surgical complications [ 2 , 3 , 4 , 5 ]. Most of the available studies focused on the postoperative phase, considering the main “surgical” items as study outcomes, with relatively small attention being devoted to preoperative and intraoperative interventions. However, main postoperative items such as oral feeding, urinary drain removal and mobilization should also be considered as compliance indicators rather than only interventions to be implemented [ 6 ]. From a methodological standpoint, there is a clear difference between adherence and compliance to an enhanced recovery protocol. Adherence should identify the percentage of items applied throughout the perioperative care process, while postoperative compliance also reflects how the patient follows the enhanced recovery process. For example, patients’ compliance to a postoperative pathway including early oral feeding and mobilization can be obtained easier if there is good adherence to a preoperative and an intraoperative enhanced pathway (and not only for a medical decision).

Based on the beneficial effect of enhanced perioperative care protocols in elective surgery, the implementation of structured protocols for emergency general surgery patients has also been advocated after the promising results of some studies [ 7 , 8 ]. However, enhanced perioperative care in emergency general surgery remains a “grey area” with little evidence available and great debate.

Patients undergoing elective surgery should be normothermic, euvolemic, clean, and “healthy”, and surgery per se represents their main stressful factor. Emergency surgery represents a more complex scenario where surgery is at the same time a stressful factor but also the key-intervention to solve the pre-existing physiologic imbalance secondary to the acute underlying disease (Fig.  2 ).

Perioperative diagram of patient’s homeostasis in elective and emergency general surgery

The diagram (Fig.  2 ) shows the impact of the pre-existing acute disorder causing a marked decline of the physiological reserve. The importance of the preoperative phase (re-equilibration) seems intuitive. Despite emergency surgery by definition does not allow schedulable interventions, some preoperative optimization is still possible in the emergency setting, though with much reduced time. The time available between patient presentation and surgery should be optimized to improve the patient’s physiological status to promote post-surgical recovery. In this complex scenario, also the timing of surgery should be carefully evaluated. One of the most intriguing and difficult challenges is to identify the right balance between hastening surgery to directly "face" the acute disease and delaying surgery in trying to improve the patient's condition.

Evidence supporting enhanced perioperative care in emergency general surgery.

Currently, available studies about enhanced perioperative care in emergency general surgery are few, sparse and very heterogeneous. In addition, the perioperative care protocol derived from the elective ERAS protocol but with several and substantial differences [ 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 ]. Tables 1 and 2 show in detail the protocols adopted in the evaluated studies. A single perioperative care protocol cannot be identified through the existing literature, and each study applied different interventions.

Huddart et al. demonstrated that the introduction of a bundle evidence care protocol decreased mortality among patients undergoing emergency laparotomy, with a reduction in delayed diagnosis, increased implementation of goal-directed fluid therapy, and improved restoration of biochemical homeostasis [ 29 ]. The bundle protocol consisted in an accurate preoperative assessment with early warning score, early broad-spectrum antibiotics, prompt resuscitation using goal-directed techniques and postoperative ICU admission for all high-risk patients.

Tandberg and colleagues introduced a standardized perioperative care protocol in patients undergoing high-risk emergency abdominal surgery [ 9 ]. The study protocol included consultant-led attention and care, early resuscitation and high-dose antibiotics, surgery within 6 h, perioperative stroke volume-guided volume status optimization, standardized analgesic treatment, early mobilization and early oral feeding. Compared with a historical cohort from the same department, the introduction of the protocol lead to a significant reduction in mortality from 21.8 to 15.5%.

An Italian observational multicentric study demonstrated that adherence to the intraoperative protocol items was low. Major determinants of postoperative compliance were minimally invasive surgery and low intraoperative fluid infusions [ 22 ].

Several other studies investigated the introduction of enhanced perioperative care protocols in emergency general surgery [ 10 , 12 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 22 , 23 , 27 ]. Each study applied a different protocol in different subsets of patients with contrasting results. Some studies adopted a modified ERAS protocol in patients with obstructive colorectal cancer [ 13 , 14 , 16 , 19 ], others on patients with perforated peptic ulcer [ 10 , 15 , 17 ], others on major emergency laparotomy and trauma [ 12 , 18 , 20 , 22 ]. Most of the published enhanced recovery programs in emergency surgery focus on the intra- and postoperative phases of the program, reporting no substantial differences in the preoperative care of patients enrolled in ERAS protocols versus standard “not-ERAS” patients. The majority of the existing studies did not report results on adherence to the protocol items; moreover, also data on compliance to the postoperative pathway were lacking.

The results of some of these studies were included in a meta-analysis published by Hajibandeh et al. published in 2020 [ 30 ]. Despite the great heterogeneity and the poor quality of the evidence, the results showed a reduction in length of stay, pulmonary complications, postoperative ileus and wound infections. No differences were observed in 30-day rehospitalization and 30-day mortality rates.

Despite the promising results, the implementation of an enhanced perioperative care protocol in emergency general surgery may encounter several obstacles. Patients receiving urgent care typically present to medical teams with a complex situation: their conditions at the time of admission are not optimal and they have extremely heterogeneous characteristics [ 31 , 32 ]. The acute illness often leads to several physiological derangements secondary to fasting, vomiting, dehydration, augmented capillary permeability, and metabolic imbalance.

Columbus et al. [ 33 ] have identified two main critical issues concerning the urgent care field: the diversification of patients and the wide range of possible settings and operative contexts (including the hospital organization and the medical team management). Therefore, efforts should focus on improving the structural and organizational aspects. Dedicated medical personnel training and a widespread standardization of the diagnostic and therapeutic process may improve medical performance and, ultimately, the clinical outcome. A recent study demonstrated that the familiarity between surgeon and anesthetist used to work together improve patients’ outcome [ 34 ]. Unfortunately, emergency general surgery is rarely managed by a dedicated staff. Emergency care requires a higher number of specialists and personnel turnover and, therefore, it would lead to wider cross-collaborations and variability in staff composition. In addition, patients undergoing emergency surgery are rarely managed by enhanced recovery-trained anesthetists, surgeons and nurses (working in abdominal surgery), making the development of new treatment protocols very difficult.

The availability of resources is another central tenant to the safe and optimal delivery of surgical care in the emergency setting. For example, laparoscopic facilities or advanced hemodynamic monitoring systems are not universally available, and reported unavailable by some authors, due to logistical issues, timing of surgical interventions (e.g., in office hours vs. after hours), and higher costs [ 18 , 35 ].

The WSES panel promoted the development of this position paper. The work process consisted of two different phases. The first phase was a review of the existing literature about enhanced recovery protocol in emergency general surgery. The second phase was the identification of enhanced recovery protocol items and the development of position statements for each perioperative intervention. This position paper was written according to the WSES methodology [ 36 ]. All the statements contained the level of evidence (LoE) available about the topic, graded according to the GRADE methodology. The consensus on the position paper statements was assessed through a web survey (by Google Form) open to all the members of the steering committee and the experts’ panel, as well as the board of governor members of the WSES. The consensus was reached if a statement was associated with ≥ 70% of the agreement. Otherwise, the statement was re-discussed by email or videoconference, modified, and resubmitted to the experts’ vote until consensus was reached. Table 3 summarizes approved statements.

Preoperative interventions

Education and counseling, patient counseling and education should be encouraged and implemented to explain perioperative risks and post-operative pathway (loe d).

Relieving patient anxiety through preoperative counseling is of utmost importance, especially in an emergent situation. Full preoperative counseling, which is known to reduce post-operative stress, pain and anxiety, may not be possible in the emergency setting. Nevertheless, information such as details of the procedure, possible perioperative complications, the need for the creation of a stoma and length of hospitalization should be communicated with patients and their families before the procedure [ 30 , 37 ]. A recent meta-analysis focusing on the implementation of enhanced recovery protocols in emergency abdominal surgery reported that adapted preoperative counseling was carried out in all of the six included studies. No data about adherence to this counseling were reported [ 30 ]. Depending on the urgency of surgery, preoperative education/counseling may not be possible. However, a recently published multidisciplinary experience reported very high compliance (more than 90% 1 year after implementation) with items such as standardized preoperative patient information and bilateral ostomy marking in patients undergoing emergency general surgery [ 11 , 38 ]. In the case of stoma creation, the implementation of patient education reduced stoma complications and improved postoperative quality of life, reducing the average hospital stay [ 39 ]. However, although it seems feasible and of some utility to appropriately counsel patients before emergency procedures, evidence in support of this hypothesis has not been produced yet and the degree of benefit in terms of postoperative recovery has not been measured.

Fluid balance and volemic status

Volemic status should be evaluated and corrected with goal-directed fluid therapy as soon as possible in the pre-operative phase (loe b).

The majority of emergency general surgery patients present with fluid derangements, mostly related to acute illness, underlying sepsis, prolonged fasting and vomiting. In this setting, preoperative evaluation of the patient should focus on the volemic assessment to rapidly correct alterations in patients' homeostasis, including stress response, gut dysfunction, insulin resistance, electrolyte imbalances, fluid shifts, SIRS and sepsis with varying degrees of organ dysfunction. Although complete optimization of medical conditions cannot be fully achieved in the emergency setting, adequate intravenous fluid resuscitation in emergency general surgery is crucial and feasible, and it should be attempted in all patients. A prospective randomized trial demonstrated better postoperative outcomes when patients were preoperatively managed with a fixed protocol to reach homeostasis [ 40 ]. The adopted protocol defined three targets for the goal-directed crystalloid resuscitation: central venous pressure of 8–12 cmH 2 O, mean arterial pressure > 65 mmHg and urinary output > 0.5 mL/Kg/h. The initial resuscitation should be titrated to the clinical response, such as fluid responsiveness, and not solely guided by a predetermined protocol, with particular attention to the underlying disease. Despite restoring homeostasis should be considered a goal, surgical treatment should not be delayed. According to the indications from the 2016 Surviving Sepsis Guidelines, resuscitation from sepsis-induced hypoperfusion should require at least 30 ml/kg of intravenous crystalloid fluids within the first 3 h [ 41 ]. However, in the updated 2021 version of the Guidelines, the strength of this recommendation was downgraded from “strong” to “weak” (quality of evidence: low) and the recommendation was modified in a suggestion [ 42 ]. Massive fluid therapy has been challenged in the enhanced recovery approach [ 9 ]. Fluid overload should be avoided since it is associated with higher rates of respiratory complications ( i.e., pneumonia, pleural effusion, and respiratory failure) and secondary anastomotic leaks. Early, i.e., preoperative, goal-directed fluid therapy in sepsis was the treatment of the experimental arm in a randomized clinical trial enrolling septic patients published in 2001 [ 43 ]. Excluding patients who needed immediate surgery from the trial, in-hospital mortality was 30.5% in the group assigned to early goal-directed therapy, as compared with 46.5% in the group assigned to standard therapy ( P  = 0.009). Tendberg et al. developed a perioperative protocol for emergency high-risk abdominal surgery in which stroke volume-guided hemodynamic optimization before surgery was a key element. The study has shown a significant reduction in mortality as well as postoperative length of ICU stay after the introduction of the standardized protocol [ 9 ]. Therefore, patients should be carefully evaluated and goal-directed fluid resuscitation should be implemented as soon as possible.

Metabolic balance

Glycemic control should be implemented in all emergency surgery patients to prevent both hypo- and hyperglycemia (loe c).

Perioperative hyperglycemia has been demonstrated to be associated with adverse clinical outcomes [ 44 ]. The correction of hyperglycemia with insulin administration and the management of glycemia with the implementation of glycaemic control protocols have been shown to reduce hospital complications and decreases mortality in elective general surgery patients [ 45 ]. Pre-existing diabetes mellitus, acute illness and physiologic changes accompanying a surgical procedure contribute to the worsening of glycemic control. The resulting hyperglycemia due to an abnormal glucose balance is a risk factor for postoperative complications that include poor wound healing and postoperative infections as well as an increase in morbidity, mortality, intensive care unit admission, and hospital length of stay [ 46 ]. Preoperative hyperglycemia has been demonstrated to have a role in postoperative compliance to an enhanced recovery pathway also in emergency surgery patients [ 22 ]. However, in emergency general surgery and in critically ill patients the role of hyperglycemia is more debated and less certain. Hyperglycemia could be considered a marker of organ failure and disease severity. A recent network meta-analysis comparing four different target blood glucose concentrations (< 110, 110–144, 144–180, and > 180 mg/dL) in terms of the benefit and risk of insulin therapy found no significant difference in the risk of mortality and infection among four target blood glucose ranges in critically ill patients, but indicated that target blood glucose levels of below 144 mg/dL were associated with a higher risk of hypoglycemia [ 47 ]. Although a proactive approach to avoid both hyper- and hypoglycemia should be suggested in emergency patients, close glycemic control is advisable and Institutions should develop their own protocols to treat both hyper and hypoglycemia in critically ill patients.

Intraoperative interventions

Postoperative nausea and vomiting (ponv) prevention, ponv prevention with a multimodal approach in an emergency setting should be implemented (loe d).

Prevention of PONV in elective general surgery has become a key element of enhanced recovery protocols [ 48 ]. PONV is very common after general anesthesia and it may negatively impact recovery and short-term outcomes [ 49 ]. Several factors are linked to the occurrence of PONV; however, its exact pathophysiology is still unclear [ 50 ]. Some risk factors are patient-related such as advanced age, female gender, non-smoking status, pain, and anxiety. Other risk factors are related to the type of operative gastro-intestinal manipulation and vagal stimulation, anesthetics, and opioids [ 50 , 51 , 52 ]. Few data are available on emergency patients who frequently complain of nausea and vomiting before surgery in association with anxiety and pain. Several studies investigated the role of different drugs to prevent PONV. The commonest antiemetic drugs are dopamine and serotonin antagonists (e.g., ondansetron) and corticosteroids (e.g., dexamethasone) [ 53 , 54 , 55 , 56 ]. Pre-emptive anesthesia was associated with better pain control and reduction in PONV [ 57 , 58 ].

Other suggested interventions are opioid-sparing anesthesia and avoidance of volatile anesthetics. Unfortunately, the vast majority of evidence is based on elective surgery and very few data are available on emergency general surgery. The emergency setting is associated with more fear, anxiety, pain and, probably, nausea even before surgery. Nevertheless, prevention of PONV should be implemented also in emergency general surgery. Among the interventions suggested, there are opioid-sparing anesthesia, avoidance of volatile anesthetics and a multimodal approach to pharmacological prevention.

Anesthesia and analgesia

General anesthesia warrants proper analgesia, amnesia and muscle relaxation. The ideal general anesthesia protocol should target all these goals, but it should also reduce the need for intraoperative fluids, reduce post-operative residual effects, such as PONV and delirium and it should permit rapid awakening. Several interventions have been implemented to optimize the intraoperative management of the patient. Whether anesthesia should be maintained by a totally intravenous approach or with inhalation drugs still remains uncertain and no recommendations can be made [ 59 ]

Benzodiazepines

Benzodiazepines should be avoided in the emergency anesthetic protocol, in particular in older patients, to reduce delirium risk in the postoperative period (loe c).

The incidence of delirium in the postoperative period has an important impact on clinical outcomes including higher mortality, functional decline, prolonged hospitalizations and risk for institutionalization [ 60 ]. Upon the several risk factors for development, that include acute illness and pain management, medications adopted also for general anesthesia play an important role [ 61 ]. For these reasons, anesthetic protocols should focus on reducing the use of these medications. Benzodiazepines have been linked with the development of delirium in the postoperative period, with a marked effect in elderly and frail patients [ 62 , 63 ]. Despite the potential beneficial effects in treating preoperative anxiety, these drugs should be avoided.

Opioid use should be limited to short-acting drugs in the perioperative period (LoE D)

Opioids are related to several adverse effects such as nausea, vomiting, respiratory depression, sedation and postoperative ileus. Despite their important role in pain management, the undesired effects may impact negatively on patients' recovery. Some experiences exist about opioid-free anesthesia, with the claim of more patient safety [ 64 ]. For this reason, opioids use should be limited to short-acting drugs avoiding morphine to minimize residual effects and to warrant rapid recovery [ 65 ].

Anesthesia depth monitoring

Anesthesia depth monitoring should be implemented in the emergency setting, to minimize anesthesia side effects such intra-operative hypotension, increased need for fluids and postoperative delirium (loe c).

To reduce all the detrimental effects of general anesthetics, such as cognitive effects and vasoactive depressing activity, titrating the minimal needed drug dose guided by the depth of anesthesia monitoring has been recommended. Monitoring of anesthesia depth could be guided by the bispectral index (BIS) or other techniques based on electrical brain activity (EEG). Anesthesia depth monitoring has been demonstrated to be associated with a lower incidence of postoperative delirium and with decreased morbidity [ 66 , 67 , 68 ]. Moreover, depth monitoring has been demonstrated to be associated also with a higher intraoperative mean arterial pressure, possibly reducing the need for fluid administration to maintain adequate systemic perfusion [ 69 ].

Neuromuscular blockade monitoring

Neuromuscular blockade monitoring should be implemented to reduce post-operative morbidity (loe c).

Neuromuscular blockade is needed during abdominal surgery to improve surgical exposure. A post-operative residual neuromuscular block is a risk factor for morbidity and mortality, conditioning weakness of airway muscles, airway obstruction and aspiration with consequent increased postoperative pulmonary complications [ 70 ]. Residual neuromuscular block has been reported in up to 40% of patients treated with neuromuscular blocking agents [ 71 ]. Adopting strategies such as the qualitative monitoring of the peripheral muscular blockade as the train of four (TOF) has been demonstrated to significantly reduce the residual blockade at the end of anesthesia [ 72 ]. Monitoring of the neuromuscular blockade is therefore recommended to avoid potential side effects.

Multimodal pain control

Multimodal analgesia, with a combination of systemic and loco-regional approaches, should be encouraged in the emergency setting to improve pain control and reduce the need for analgesics and opioids (loe c).

Pain is one of the limitations to patient recovery after surgery. Standard general anesthesia warrants analgesia during surgery, but has no effect on pain control after surgery, requiring drug administration with possible detrimental effects such as opioids. Multimodal analgesia has been proposed to manage pain with several different treatments reducing the need for systemic opioids and avoiding their potential side effects [ 73 ]. The association of general and locoregional analgesia has been demonstrated also to reduce the incidence of postoperative delirium [ 74 ].

Thoracic epidural analgesia (TEA) has been demonstrated to be superior to systemic opioids in pain management in open elective abdominal surgery [ 75 ]. A recent Scandinavian population study reported that epidural analgesia was adopted in emergency general surgery in less than one third of patients; epidural analgesia was associated with lower 90-day mortality probably due to a reduction in paralytic ileus and pain that most likely allowed an early mobilization and coughing [ 76 ]. TEA was included in an emergency general surgery enhanced recovery protocol that demonstrated a significant reduction in mortality, despite the adherence to this specific item was not reported [ 9 ]. Spinal analgesia has been proposed as an alternative to epidural analgesia in patients treated with minimally invasive colorectal surgery: the administration of long-acting local anesthetics and opioids warrant pain control in the first postoperative hours allowing early mobilization. Moreover, it has been associated with a lower risk of hypotension and fluid overload [ 77 ]. However, spinal and epidural anesthesia should be considered with caution in septic patients.

Surgical incision is one of the main responsible of postoperative pain. To manage this pain, abdominal wall blockade such as the Transversus abdominis plane (TAP) block has been proposed. The adjunct of abdominal wall blocks to general anesthesia has been demonstrated to have beneficial effects on pain control during the first 24 h and to allow faster recovery and better hemodynamic control in elective abdominal surgery [ 78 , 79 , 80 , 81 ]. Of note, the TAP block can be performed both ultrasound-guided and laparoscopy-guided [ 82 ]. Currently, no studies focus on the performance of the TAP block in emergency general surgery. However, abdominal wall blocks should be considered in a multimodal analgesic approach.

Active warming

Active warming and body temperature monitoring should be encouraged in the emergency setting to reduce postoperative morbidity (loe c).

Body temperature plays an important role in several pathophysiologic mechanisms Hypothermia typically occurs during general and locoregional anesthesia due to vasodilatation and a rapid redistribution of heat from the core to peripheral districts. Moreover, several anesthetic drugs impair thermoregulatory control, further contributing to the maintenance of hypothermia. Finally, the development of hypothermia is facilitated by direct heat loss deriving from the surgical exposure of the abdominal cavity and by the low operating theater temperature. Importantly, perioperative hypothermia implicates an increased risk of surgical site infection, morbidity and mortality. Moreover, hypothermia may alter drug metabolism and it is also associated with an increased risk for coagulopathy and a consequent increased blood loss [ 83 ]. Body temperature monitoring is therefore mandatory and allows temperature correction with active warming. Active warming, ideally starting before the entrance to the operating room, has been recognized as one of the core items of the enhanced recovery pathway and its implementation significantly reduced postoperative morbidity [ 84 , 85 ].

Fluid management

Fluids should be managed within a goal-directed fluid therapy strategy to target the amount of given fluids on patient needs (loe c).

General anesthetics lead to dose-depend myocardial depression and systemic vasodilatation. The associated increased venous capacitance leads to a relative hypovolemia that, along with myocardial depression, might lead to hypotension, and organ hypoperfusion with the related consequences. Therefore, during surgery, fluids are frequently administered to maintain an adequate intravascular volume status and systemic perfusion. However, both hypovolemia and hypervolemia are associated with postoperative morbidity and several studies demonstrated the J-shaped relation between intraoperative fluids administered and postoperative morbidity [ 86 , 87 , 88 ]. Intraoperative fluid management should therefore be balanced, giving the needed amounts of fluids to warrant euvolemia and systemic perfusion, but avoiding fluid overload [ 89 , 90 ]. Fluid overload is associated with several detrimental effects related to tissue edema. Increased interstitial fluids might impair gas exchange with consequent respiratory failure and foster the development of pneumonia. Moreover, fluid overload is associated with bowel edema and postoperative ileus, conditioning a delayed recovery of GI function [ 91 ]. For these reasons in elective surgery, a restrictive fluid strategy has been proposed, with the target of a near-zero fluid balance during surgery and a limited amount of fluids given (generally around 3 mL/Kg/h) [ 92 ]. This approach is valid under the condition that patients arrive at the surgery in perfect homeostasis without fluid derangements.

Several factors may worsen and make fluid management in emergency surgery patients more difficult. Increased vascular permeability related to acute illness, preoperative fasting, preoperative dehydration and blood loss may dramatically increase the need for intraoperative fluids compared to elective surgical patients. In this complex scenario, goal-directed fluid therapy has been proposed to titrate and balance the amount of fluids. Fluid therapy should be guided by hemodynamic monitoring systems, ideally capable of monitoring dynamic parameters, such as cardiac output, stroke volume variation, pulse pressure variation and stroke volume variation [ 93 , 94 ]. The implementation of an intraoperative goal-directed fluid strategy, associated with restrictive fluid regimens and the early adoption of vasopressors to maintain adequate circulating volumes has been demonstrated to significantly reduce perioperative morbidity [ 94 ]. While only few studies exist on fluid management during general emergency surgery, available evidence derived from elective surgery and current pathophysiological understanding strongly underlines the importance of reasoned fluid management during emergency surgery. In the emergency setting, a recent study highlighted the importance of fluid therapy, with a negative correlation between increasing intraoperative fluids given and patients' recovery [ 22 ].

Minimally invasive surgery

Minimally invasive surgery approach in emergency surgery should be encouraged whenever possible and needed skills are available (loe c).

Reducing surgical stress is the cornerstone of an enhanced perioperative care protocol. The use of minimally invasive surgery in elective major surgery has been demonstrated to reduce inflammation, improve pulmonary function, and facilitate GI function with a consequent reduction in morbidity and length of stay [ 95 , 96 , 97 ]. Minimally invasive surgery, even within an enhanced recovery pathway, has been associated with a faster recovery when compared with open surgery [ 98 ]. In emergency major abdominal surgery, such as repair for perforated peptic ulcer and colorectal surgery invasive minimally techniques have been associated with better clinical outcomes with a lower mortality and length of stay [ 99 , 100 , 101 ]. A population study on the commonest abdominal surgical emergencies in the USA demonstrated an increasing trend of a laparoscopic approach. Minimally invasive surgery was associated with lower mortality, surgical site infection rate and length of stay. However, minimally invasive surgery in major interventions such as peptic ulcer repair and small bowel obstruction was adopted in less than 40% and 10%, respectively [ 102 ]. Data from the national emergency laparotomy audit (NELA) from the U.K. demonstrated that laparoscopy is adopted in less than 20% of major surgeries [ 99 ]. Existing data demonstrated the beneficial effect of minimally invasive surgery but also its poor diffusion among surgeons with several difficulties [ 103 ]. A recent prospective study identified minimally invasive surgery as the major determinant of postoperative compliance to an enhanced recovery protocol [ 22 ]. Efforts should be made to implement laparoscopy in emergency general surgery daily practice.

Abdominal drains should be placed for limited indications, including in the presence of gross bacterial contamination and inadequate source control (LoE D)

The routine positioning of a peritoneal drain after elective major colorectal surgery has been demonstrated to be ineffective in preventing surgical complications and is not recommended [ 104 ]. Moreover, the presence of a drain has been identified as one of the main failure predictors of an enhanced recovery pathway, both in elective and emergency surgery [ 22 , 105 ]. Drain in emergency general surgery is justified by a clear rationale, in case of contaminated surgical field and intra-abdominal infections. Few experiences exist about avoiding drains in emergency general surgery: some studies focused on the introduction of enhanced perioperative care protocol on colorectal emergencies (obstructions) demonstrated better results avoiding the drain (along with other interventions) [ 13 , 14 , 16 ]; other studies demonstrated the safety of an early removal in perforated peptic ulcer and trauma [ 15 , 20 ]. Evidence quality is very low to recommend avoiding abdominal drains, but we believe drains should be placed only in case of gross abdominal contamination and high risk for collection and abdominal abscess.

Postoperative care

Multimodal analgesia, using different classes of analgesics and avoiding long-acting opioids, should be recommended in the postoperative phase (loe c).

Proper analgesia and pain control are key elements of a patient’s recovery after surgery. The control of pain in the postoperative period is the result of many several factors related to patients' characteristics, invasiveness of surgical intervention, the underlying diagnosis and adopted intra- and post-operative analgesia techniques. Perioperative management should be focused on maximizing the effect of pain control and avoiding the side effects of drugs. The use of long-acting opioids, such as morphine, should be ideally avoided also in the postoperative period. Indeed, avoiding opioids has been demonstrated to facilitate mobilization and to fasten GI function recovery [ 65 ]. The treatment of pain should be multimodal and tailored to patients’ conditions, according to available skills [ 106 ].

Early nasogastric tube removal

The nasogastric tube should be removed as soon as possible, even at the end of surgery (loe d).

According to a reactive policy, the nasogastric tube (NGT) was traditionally removed after GI function recovery to prevent PONV and inhalation. Enhanced recovery protocols recommend the removal of NGT at the end of elective surgery. This practice reduced pulmonary complications and promoted GI function recovery [ 107 ]. Preliminary studies carried out in patients with obstructive colorectal cancer or perforated peptic ulcer reported a high patient compliance to NGT removal at the end of surgery [ 17 , 19 , 108 ]. Other studies suggested removing the NGT when the output was less than 300 ml [ 15 , 18 ]. When patients are managed according to enhanced recovery protocols, the early removal of NGT is safe and should be implemented in clinical practice.

Early mobilization

Early mobilization should be encouraged and stimulated as soon as possible to reduce post-operative morbidity (loe c).

Prolonged immobilization is associated with insulin resistance, thromboembolic events and respiratory complications [ 109 ]. Several studies reported that early mobilization after surgery reduced overall morbidity and shortened the length of hospital stay [ 110 , 111 , 112 , 113 ]. Several factors can negatively impact on patient’s mobilization such as abdominal drain, urinary catheter, suboptimal pain control, prolonged i.v fluids, and patient's motivation. In emergency surgery, different protocols have been proposed targeting mobilization the same day of surgery [ 15 , 18 ] or on postoperative day 1 [ 14 , 16 , 19 ]. According to existing evidence, patient mobilization should be encouraged as early as possible, along with all the interventions that could facilitate it, such as proper pain control, and the early removal of urinary catheter and drains.

Nutrition and early oral feeding

Early oral feeding should be encouraged and promoted as soon as tolerated by patients (loe c).

The close relationship between preoperative nutritional status and surgical outcomes has been extensively reported in elective surgery, where tailored nutritional and prehabilitation programs can be planned before the operation [ 114 ]. Postoperative fasting has been demonstrated to be harmful in elective surgery with delayed recovery and increased complications[ 2 , 115 , 116 ]. Oral feeding can be resumed early after surgery regardless of bowel canalization, whether removal of the nasogastric tube, PONV prophylaxis, near zero fluid balance, early mobilization, and pain control have been carried out according to enhanced recovery protocol. Patients undergoing emergency surgery often have an altered metabolic status, with dehydration and several derangements such as prolonged fasting, vomiting, impairment of GI function, and fluid loss related to the acute illness. The great condition's heterogeneity in emergency surgery patients makes quite impossible to standardize the timing of oral feeding recovery. However, studies carried out in patients with perforated peptic ulcer or obstructive colorectal cancer demonstrated both feasibility and safety of early oral feeding [ 19 , 20 , 117 ]. Perioperative nutritional intervention should be therefore tailored to the patient's conditions adopting as the target the earliest possible recovery.

Urinary catheter removal

Urinary catheter should be removed as soon as possible when urinary output no longer needs to be monitored (loe c).

Urinary output monitoring is a key element to assess patients' volemic status and to guide goal-directed fluid therapy. In emergency surgery patients, the urine output target should be 0.5 ml/Kg/h. Different policies about the timing of catheter removal have been proposed: immediately after surgery in a randomized study on perforated peptic ulcer patients [ 17 ], on postoperative day 1 [ 19 , 20 ] or according to urinary output (> 1 ml/Kg/h) [ 15 , 18 ]. Regardless, the urinary catheter should be removed as early as possible after reaching the minimum urinary output target to facilitate mobilization and reduce infections.

Postoperative fluids

Postoperative intravenous fluids should be minimized and maintained until oral fluid intake is adequate (loe c).

Fluid therapy should be targeted to restore the euvolemic status and to maintain adequate hydration and tissue perfusion until the oral intake can be restarted. As reported for operative management, fluid therapy can be harmful if too many or too few fluids are given [ 86 , 87 , 88 ]. Following elective colorectal surgery i.v. fluids should be stopped on postoperative day one. Studies performed on emergency surgery patients did not report on timing to stop i.v fluids; however, infusions should be tailored to patient conditions, giving the minimum fluid amount to restore and maintain euvolemia and to obtain adequate perfusion.

Antibiotic therapy

Antibiotic therapy should not be continued in case of non-complicated intra-abdominal infections, while a short course antibiotic therapy is indicated in case of complicated infection (LoE A).

A large part of emergency patients undergo surgery for intra-abdominal infections; therefore, antibiotic therapy is a cornerstone of treatment along with surgical source control . The need for antibiotics during the postoperative period may contribute to delaying patient recovery, as an obstacle to active mobilization and i.v. infusions suspension; moreover, prolonged antibiotic therapies may have a role in delaying home return. Postoperative antibiotic therapy should be reserved for patients with complicated intra-abdominal infections. In these patients, a short therapy (3–5 days) after adequate surgical source control is not inferior when compared to longer therapy [ 118 , 119 , 120 ]. In non-complicated infections, antibiotic therapy should be stopped at the end of surgery if the source control is adequate.

The majority of patients presenting with a severe infection who initially require IV therapy can be switched to oral therapy after 24–48 h provided that they are improving clinically and can tolerate an oral formulation. The switch from IV to oral route should be encouraged.

Research agenda

The present position paper highlights the great heterogeneity of protocols adopted and the lack of good-quality evidence supporting the implementation of enhanced recovery pathway in emergency general surgery. Further studies on this topic should address:

The definition of the safety, feasibility and effectiveness of each perioperative intervention.

The definition of a standardized enhanced recovery protocol for emergency general surgery procedures

The selection of patients who may benefit from an enhanced recovery pathway and the clinical scenarios in which enhanced recovery pathway could be applied.

Conclusions

Enhanced perioperative care, similar to elective surgery, should be implemented in emergency general surgery. One of the key elements for the success of the enhanced pathways is the multimodal approach involving surgeons, anesthetists, ICU physicians, nurses, patients and patient families. Available evidence suggests future required research on the implementation of enhanced recovery pathways in clinical practice.

Availability of data and materials

Data are available under request to the corresponding author.

Change history

15 october 2023.

The CRUE CSIC TA funding note has been removed

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Marco Ceresoli, Marco Braga, Thomas Langer, Giuseppe Foti & Michele Fogliata

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John Hunter Hospital Trauma Service and School of Medicine and Public Health, The University of Newcastle, Newcastle, AU, Australia

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University of Auckland, Auckland, New Zealand

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Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, Tianjin Medical University, Tianjin, China

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Department of Surgical Sciences and Advanced Technologies, General Surgery Cannizzaro Hospital, University of Catania, Catania, Italy

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PS_SS Weissach im Tal, Weissach im Tal, Germany

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Department of Critical Care and Anesthesia, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy

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Division of Trauma Surgery, School of Medical Sciences (FCM), University of Campinas (Unicamp), Campinas, Brazil

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University of California, Davis, Sacramento, CA, USA

Joseph M. Galante

University of Otago, Dunebin, New Zealand

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Department of General and Thoracic Surgery, University Hospital of Giessen, Gießen, Germany

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Erasmus MC University, Rotterdam, The Netherlands

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General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery, Foothills Medical Centre, Calgary, AB, Canada

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Department of Primary Care and Emergency Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan

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Helsinki University Hospital and University of Helsinki, Helsinki, Finland

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Department of Anesthesia and Intensive Care, Parma University Hospital, Parma, Italy

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Third Department of Surgery, Attikon University Hospital, Athene, Greece

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General Surgery, ASST Papa Giovanni XXIII, Bergamo, Italy

Michele Pisano

Department of Surgical Science, University of Cagliari, Cagliari, Italy

Mauro Podda

RIMU Plovdiv/UMHAT St George Plovdiv, Plovdiv, Bulgaria

Boris E. Sakakushev

Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore

Vishal G. Shelat

Department of Surgery, Brody School of Medicine, East Carolina University, Greenville, NC, USA

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Harvard Medical School - Massachusetts General Hospital, Boston, USA

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Anesthesia and Critical Care Department, Bufalini Hospital, Cesena, Italy

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Department of General Surgery, The Rambam Academic Hospital, Haifa, Israel

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General Surgery, University of Brescia, ASST Cremona, Cremona, Italy

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Ceresoli, M., Braga, M., Zanini, N. et al. Enhanced perioperative care in emergency general surgery: the WSES position paper. World J Emerg Surg 18 , 47 (2023). https://doi.org/10.1186/s13017-023-00519-2

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DOI : https://doi.org/10.1186/s13017-023-00519-2

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World Journal of Emergency Surgery

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• Harvard Library
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Surgery Clerkship

• Finding Classic Papers
• Finding Information
• Online Books
• Visuals/Video
• Board/Exam Info
• Anatomy/Physiology
• Procedures/Instruments/the OR
• Core Journals

How to find a "classic" or "watershed" paper

Here are some suggestions on finding "watershed" or classic papers for your presentation:

- Check the list of Surgical Milestone Papers on to see if it includes your topic.  The times an article has been cited is noted when available.  Citation indexing became available with the publication of Science Citation Index in 1964.  A number of these articles are too early to be included in the SCI database that goes back to 1900 and some of the journals are not indexed in SCI.

- Look at relevant sections of the text Surgery: Basic Science and Clinical Evidence - online and on reserve at Call# WO 100 S9613 2008 . This book is a gold mine. Each chapter gives a summary of the history of surgery for a particular indication including historical vignettes, and an excellent bibliography!

- Other books:

Sabiston's Textbook of Surgery (online) Find the chapter on your topic; some include a brief section on history, look especially at the Selected References at the end of each chapter. As a bonus, these are annotated to explain their value and importance to surgery in this field. 

Landmark papers in general surgery (Online) / edited by Graham J. MacKay, Richard G. Molloy, Patrick J. O'Dwyer. Oxford : Oxford University Press, 2013.

Great Ideas in the History of Surgery. Countway WO11 Z5q There is a bibliography is on page 548, but you will need to read the related section of text on your topic for background on the significance of entry. Use the Index.

Operations that Made History Countway WO11.1 E470 This slim volume covers only 18 surgical procedures but if your topic is there you will find a very concise bibliographies after each.

Surgical Case Histories from the Past. Countway WO11.1 E47s Each case history describes a case which leads to a surgical breakthrough. If you topic is in here the 3-4 references of your section will be valuable.

Surgical oncology : fundamentals, evidence-based approaches, and new technology Countway QZ 268 S961 2012 - superb for oncology topics includes list of "landmark papers" and tables of evidence.

- You can consult other authoritative textbooks on your topic and look at the references to the most relevant chapter . If the authors have done a good job writing the background section of the chapter they should reference the "watershed" papers. Try searching the HOLLIS catalog and/or ask a librarian for help identifying books . It's good to give the "big names" (Schwartz or Sabiston), but also think about texts on the specific topic. For example, Principles and practice of surgical oncology : multidisciplinary approach to difficult problems . OR 50 Studies Every Plastic Surgeon Should Know .  

- Search in Science Citation Index (aka Web of Science) which allows you to search on a topic and then rank articles by the most cited. Be sure to search multiple synonyms since this database has no indexing. It is computer generated so the keywords the author used are what is found. For example if you topic is gastric cancer, I would suggest entering "gastric cancer" OR "stomach neoplasms" OR "stomach cancer" OR "gastric neoplasms" as a start. Be sure to put the phrases in quotes so it will be searched as a unit and to change the field searched to topic. 

When you have the search results, on the right hand side of the screen change the "Sort by" option to "Times Cited" on the drop down menu. This will bring the most cited studies to the top of the list. - Search HOLLIS for works that end with "collected works" OR look for "classic papers" in the title. You might search for "gastrointestinal surgery-collected works to find collections of papers.

Stuck? Not finding what you need? Ask a Librarian for help!

Tips for Specific Presentation Topics

In addition to the broad strategies listed above, here are some suggested sources to consult in your search for classic papers for your presentations. Definitely try the broad strategies in addition to looking at these titles. The suggestions are not comprehensive but they should give you a good start. Please, if you find other valuable sources, let me know so we can expand these lists.

• Acute Abdomen - Sources for classic paper references
• Bariatric Surgery - Finding Important Papers
• Cholangiocarcinoma and Hepatocellular Carcinoma
• ClassisPapersBreastCancerSurgery Tips to help surgery clerkship students find classic papers for Dr. Osteen's presentations
• Gastric Cancer Classic Articles
• Soft Tissue Sarcomas - Suggested sources for classic papers
• Pancreatic Cancer
• Surgical Treatment for Peripheral Artery Disease
• Thyroid Cancer- Sources for Classic Paper

Using PubMed to Find Historical Stuff

PubMed doesn't have any tools to help you find specific landmark papers, but there are specific tools to help you find historical works:

Use the History subset . You can access this search limit by choosing "Show Additional Filters" from the column to the left of your PubMed results. Choose "Subjects" then at the bottom of the new Subjects box, choose customize. Here you can select History to limit your search to historical articles.

With less fuss, you can just append AND history[sb] to your search. For example

cholecystectomy AND history[sb]

If that returns to much stuff, you can use the history subheading , either on its own or appended to a MeSH term:

cholecystectomy AND history[subheading]

"Cholecystectomy/history"[Majr]

Need more help? Check the PubMed User Guide .

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Rudolf Seemann

4 Medical University of Vienna, Department of Oral and Maxillofacial Surgery, Währinger Gürtel 18-20, A-1090 Vienna, Austria; [email protected]

This systematic review looks at thematic trends in clinical research publications on dental implants. For this purpose, MEDLINE electronic searches as well as additional hand searches of six main journals in the field were conducted. A total of 2875 clinical studies published between 2001 and 2012 met the inclusion criteria and were subjected to statistical analysis. Hot topics in dental implant literature included immediate loading (14.3%), bone substitutes (11.6%), cross-arch full bridges (8.0%), and immediate implant placement (7.5%). A significant increase in scientific interest for immediate loading (+6.3%, p = 0.001), platform switching (+2.9%, p = 0.001), guided implant surgery (+1.9%, p = 0.011), growth factors ( p = 0.014, +1.4%), piezoelectric surgery (+1.3%, p = 0.015), and restorative materials (+0.7%, p = 0.011) was found. A declining scientific interest in onlay grafting (−0.3%, p = 0.042) was recorded. The findings regarding current clinical oral implants research tie in with better-informed consumers and increased patient demands. Our results demonstrate an increasing interest in techniques that avoid complicated procedures such as bone grafting and that reduce treatment duration.

1. Introduction

The present special issue of Dentistry Journal deals with “Advances in Implant Dentistry,” and the following keywords denote hot topics in this field: template-guided implant placement, minimally invasive techniques, short lengths and reduced implant diameters, novel bone grafting techniques, medically compromised patients, peri-implantitis treatment, immediate placement and restoration, transition from a failing dentition, CAD/CAM prosthetics, and optical intraoral impressions. As the first paper in this special issue, the following review aims to provide the background to recent trends and “hot topics” in advanced and minimally invasive oral implant treatment [ 1 ].

The concept of osseointegration of oral implants was introduced by Branemark 40 years ago and set the precedent for new knowledge in oral medicine. Since then, oral implantology has become one of the most investigated topics in dental medicine, with exponential growth in the use of implant products [ 2 ]. Data shows that the number of implants used for oral rehabilitation in the USA increased ten-fold between 1983 and 2002 and also ten-fold from 2000 to 2010 [ 3 ]. While previously the primary aim of research on oral implantology was to find ways to rehabilitate function [ 4 ], many efforts nowadays are focused on the shortening of treatment procedures, simplifying surgical techniques, and esthetic improvement [ 5 ]. It is well known that oral implantology is a prosthetically driven field with a major surgical component [ 6 ]. Therefore, the current state of the art in implant dentistry represents advances in both surgical and prosthodontic techniques [ 5 ].

Keeping pace with research development, the aim of this systematic review was to investigate contemporary issues in oral implantology research and to perform a topical trend analysis of clinical studies published in the time period from 2001 to 2012.

2. Material and Methods

2.1. search strategy.

A MEDLINE electronic literature search was conducted, limited to clinical studies on dental implants published between 2001 and 2012. The search term “dental implant,” sorted by “year of publication” was used in order to capture all relevant articles [ 7 ]. Additional hand searching was performed to examine six main journals in the field: The International Journal of Maxillofacial Implants , Journal of Oral Implantology , Clinical Oral Implant Related Research , Implant Dentistry , European Journal of Oral Implantology , and Clinical Oral Implant Research . Two reviewers independently identified all trials [ 8 ]. The PubMed search initially identified 15,695 publications, and 5048 additional results were identified by hand search. These studies were screened for their relevance based upon a threshold set [ 9 ]:

• inclusion criteria: prospective and retrospective studies, cross-sectional studies, case-control studies, case reports with at least 10 patients
• exclusion criteria: non-English publications, statistical studies, animal studies, finite element analyses, in vitro studies, review articles, and case series with fewer than 10 patients.

A total number of 3695 articles were subjected to abstract review. Where the abstract provided little information, a full text analysis was performed. Authors of potentially relevant publications, which were not available or lacked data, were contacted and asked for cooperation. Ultimately, 2875 clinical studies were identified as meeting the inclusion criteria. Our goal was to investigate how trends change over time as regards the topics examined in modern implant dentistry research. In this respect, we have determined that 31 topics were appropriate: 23 of them concerned surgical issues and 8 dealt with prosthodontic issues ( Table 1 ). First, all relevant publications were screened for the topics listed in Table 1 independently by two reviewers. Thereafter, the results were verified, and all doubtful publications were discussed before the final decision was taken.

Topics sorted by literature coverage. Absolute numbers of publications per year as well as the total percentage of all clinical papers 2001–2012 (* indicates prosthodontic topics).

2.2. Statistical Analysis

As mentioned above, 2875 publications were analyzed. In order to find statistical trends in respect to the relevant topics between 2001 and 2012, Poisson regression analysis was performed, taking the level of significance as p ≤ 0.05, using R-project statistical software version 3.1.0. This statistical test was used to model count data, which in this case was the number of publications. p -values were calculated for every topic, taking into account the relative number publications per topic from the total number of publications.

The surgical and prosthodontic topics of interest were computed as percentages of the total number of publications ( Table 1 ). Among the most covered surgical topics in the literature were immediate loading (14.3%), bone substitutes (11.6%), immediate implant placement (7.5%), simultaneous implant placement with bone augmentation (6.4%), onlay grafting (4.3%), medically compromised patients (4.0%), healing modality (3.7%), transcrestal sinus floor elevation (3.0%), flapless surgery (2.7%), socket grafting (2.6%), and guided surgery (2.4%). Immediate loading (14.3%), cross-arch implant bridges (8.0%), early loading (4.5%), and platform switching (1.7%) were ranked as the most prevalent prosthodontic issues in current oral implant research.

The surgical issues were the more prevalent topics, demonstrating an increasing rate of publications over the time in terms of mean coverage (0.53 ± 0.01) per publication ( Figure 1 ), as compared to prosthodontic issues (0.33 ± 0.05 hits). The mean coverage values were estimated based on yearly ratios: the number of prosthodontic/surgical publications per year in relation to the total number of publications per year. The significant increase in publications on surgical issues over the years was demonstrated by Poisson regression analysis ( p = 0.002).

Literature coverage of surgical (s) versus prosthodontic (p) issues: x-axis indicates year of publication, y-axis indicates the ratio of numbers of publications (surgical/prosthodontic) to the total number of publications per year.

A total of eight topics showed significant trends ( p < 0.05) over the years 2001 to 2012 ( Table 2 ). Immediate loading demonstrated the highest increase with a positive change of +6.3% and p = 0.001 ( Figure 2 a). Platform switching (+2.9%, p = 0.001) was the second topic showing a significant increase; however, only one relevant article was detected between 2001 and 2006 ( Figure 2 b). These topics were followed by guided implant surgery (+1.9%, p = 0.011), growth factors (+1.4%, p = 0.014), piezoelectric surgery (+1.3%, p = 0.015), and restorative materials (+0.7%, p = 0.011). The green line represents the percentage of the total number of publications for every year. The black trend line reveals the relationship between the year of publication (x-variable) and the percentage of the total number of publications (y-variable). Since there were no publications on platform switching between 2002 and 2005, there is a negative trend line intercept starting from 2001 ( Figure 2 b). Decreasing scientific interest and a corresponding downward trend were recorded for the topic onlay grafting (−0.3%, p = 0.042).

Trend curves (percentage out of the total number of publications per year) for ( a ) immediate loading; ( b ) platform switching; ( c ) flapless implant surgery; ( d ) guided implant surgery; ( e ) growth factors; ( f ) piezoelectric surgery; ( g )restorative materials; and ( h ) onlay grafting.

Topics demonstrating a significant increase (positive) or decrease (negative change) of scientific interest in the years 2001–2012.

4. Discussion

Comparisons of published clinical trials per year revealed a trend of increasing interest in conducting clinical trials, starting with 137 relevant articles in the year 2001 and reaching the number of 446 publications in the year 2012. However, even the total number of 3695 articles is smaller than the total number of 4655 clinical studies published between 1989 and 1999 reported by Russo et al. [ 10 ]. Given that the number of publications increased with every year, it was considered more appropriate to perform Poisson regression analysis related to percentage-based values rather than related to absolute values for all topics.

Immediate loading proved to be the most studied topic in the last decade ( Figure 2 a). This avid scientific interest can be explained by several advantages it offers, such as shortened treatment protocols, immediate rehabilitation of the function, and high patient satisfaction. Meta-analyses on single-tooth implant placement have shown encouraging results for the immediate loading protocol as a promising alternative to conventional loading, as it may be equally successful and may not significantly affect marginal bone resorption and implant success rates [ 11 , 12 , 13 ]. Another meta-analysis by Papaspyridakos et al. [ 14 ] reported that there was no significant difference between immediate, early, and conventional loading in edentulous patients with fixed prostheses, and all three protocols showed a high level of success. However, other reviewers disagree with this assessment of the unimpaired success of the immediate loading protocol. A meta-analysis of clinical studies comparing the immediate and conventional loading of single tooth implants discovered that immediate loading has a significantly higher risk of implant failure [ 15 ]. Schimmel and coworkers [ 16 ] concluded that, despite the high implant survival rates, the conventional and early loading protocols are superior to immediate loading as better documented protocols, providing better results in the first year of loading. A survey among implantologists from 16 countries all over the world stated that immediate loading was the treatment protocol most accepted by dentists in Australia and Europe [ 17 ]. Based on these controversial statements in the literature, it can be concluded that there is still a lack of well-designed RCTs concerning loading protocol [ 18 ] and immediate loading may well retain its place as a hot topic of discussion over the coming years.

The platform-switching concept arose in 1980 with the introduction of the wide diameter implants. Due to the lack of commercially available matching components for wide diameter implants, the standard-diameter abutments were used. Later, it was found that “platform-switched” implants demonstrated osseointegration with less initial crestal bone loss and were thus superior to the “platform-matched implants” [ 19 ]. However, the first introduction of this concept appeared in 2005 [ 20 ]. Radiographic observation over a period of 13 years demonstrated that platform switching resulted in little or no crestal bone loss as compared to the conventional implants, whereas marginal bone resorption of 1.5 mm on average was accepted as one of the criteria for success of the dental implant [ 21 ]. Our study shows that the increasing publication rate of clinical studies happened to coincide with the first official introduction of this concept, with a positive linear trend for this topic starting in 2005 ( Figure 2 b). Since guided surgery is performed in combination with the flapless procedure in most cases, [ 22 ] the similarity in literature coverage, illustrated in both scatter plots, does not come as a surprise ( Figure 2 c,d).

In contrast to the last decade of the 20th century, when the main progress in the field of oral implant research was made in alveolar bone resorption management to refine the different graft techniques [ 23 ], our findings show that in the 21st century there has been increasing interest in methods developed to overcome the grafting procedures and even a loss of interest in one of the most used augmentation techniques, i.e. , onlay bone grafting. It seems that dental implant scientific work is inspired more by the patient’s appraisals [ 24 ], seeking to improve minimally invasive surgical techniques [ 25 ], diminish patient morbidity, and shorten the treatment time. However, the role of industrial funding for conducting clinical studies should be taken into consideration. 32.4% of the clinical trials are supported by industry as a source of funding, which is a suitable way for companies not only to comply with safety and efficacy standards, but also to introduce their new products to the market [ 26 ]. This industry sponsorship may lead to biased reporting and pro-industry conclusions [ 27 ]. This does have the potential to reflect on ongoing trends in clinical research. In this connection for instance, the relatively innovative technique of guided implant surgery provides less painful and invasive treatment but at the same time is a more difficult and expensive procedure than conventional implant placement, demonstrating the same survival rate. However, a survey by Hof and coworkers [ 28 ] showed that the main priority for the patients when it comes to implant therapy remains the predictability of treatment success. The achievements brought about by ongoing clinical research, such as improved quality, ease of use of implant systems, as well as shorter treatment duration [ 29 ] may provide grounds for future researchers to face the challenge of preserving the perspectives of clinical implant research, and specifically, to enhance the relationship between private practice and science without involving marketing.

In order to adhere to ethical rules on explicit reporting, including also the disadvantages of any study, the researchers are obligated to report their study’s limitations. Undoubtedly, meta-analysis is the “gold standard” for performing any systematic review aiming at assessing treatment effects. Given that the variable investigated in the present study was the number of publications, the Poisson regression was selected as a statistical tool. The Poisson regression is used to model count data (in the present case this is the number of publications) and is an appropriate statistical method for predicting trends. Therefore, no methods estimating risk of bias, quality design, or heterogeneity of the studies provided by the meta-analysis were applied in this study.

A further limitation is presented by the use of only one database source. The findings in the present work are based on analysis, including studies from MEDLINE, and an additional hand search of six journals. However, the search strategy did not consider other databases such as EMBASE and the Cochrane Central Register of Controlled Trials.

In conclusion, the analysis of scientific literature on dental implants revealed several hot topics in the time period between 2001 and 2012. The most frequently covered surgical issues were bone substitutes (11.6%) and immediate implant placement, (7.5%), while the most prevalent prosthodontic topics involved immediate loading (14.3%) and cross-arch full bridges (8.0%). Given that the topics demonstrating the highest increase in interest were prosthodontic topics, i.e. , immediate loading (+6.3%) and platform switching (+2.9%), the interest in researching prosthodontic topics will most likely continue to increase.

Acknowledgments

No funding was received to support the study.

Author Contributions

Bernhard Pommer conceived and designed the experiments; Vesela Valkova and Ceeneena Ubaidha Maheen performed the experiments; Rudolf Seemann analyzed the data; Xiaohui Rausch-Fan contributed analysis tools; Vesela Valkova wrote the paper.

Conflicts of Interest

The authors declare no conflict of interest.