Emergency surgery damage control procedures: which, when and how?—a narrative review of the literature

Introduction

The damage control surgery (DCS) concept has been used by surgeons for decades to treat trauma patients. This method aims to ensure the survival of the hemodynamically unstable patient through two basic principles: stop the bleeding and control contamination (1,2). Although many of the DCS techniques were known and used way before World War II, the DCS principles were officially formalized in 1983 thanks to Stone et al. (1,3). The term “damage control” was introduced in 1992 by Rotondo and Schwab, and it was taken from the United States Navy, where it is defined as “the capacity of a ship to absorb damage and maintain mission integrity” (4,5). In this paper, Rotondo and Schwab also outlined the sequential approach to the hemodynamically unstable trauma patient that encloses three steps: abbreviated laparotomy along with control of bleeding and contamination (i.e., DC I), resuscitation in the Intensive Care Unit (ICU) to restore physiology (i.e., DC II), and re-exploration and definitive surgery (i.e., DC III) (4). Similarly, Moore et al. defined DCS as a five-phase sequence: first, identification of the injury pattern and pathophysiology of the patient; second, abbreviated laparotomy to stop the bleeding and control contamination; third, reassessment of physiology in the operating room; fourth, continuous resuscitation in the ICU until physiology restoration; fifth, definitive repair and abdominal closure (6).

In 2002, this approach was implemented by Johnson and Schwab with a new step, the so-called “Damage Control Ground Zero” (i.e., DC 0), which focuses on recognizing the patients in need of DCS, thus minimizing time spent in the pre-hospital setting and in the emergency department (7).

The main principle lying behind DCS is the “physiology over anatomy” concept. Trauma patients may present with the association of acidosis, hypothermia, and coagulopathy, the known “lethal triad”. The physiological derangements of these patients cannot be corrected by providing the anatomic repairs of the “traditional surgery”. The “lethal triad”, once triggered, creates a vicious cycle that, if not promptly treated, rapidly brings patients to death. In this setting, surgery is not the appropriate treatment, resuscitation is. So, ending the surgical procedure as soon as possible allows the start of resuscitation in the ICU suited to reverse the ongoing “lethal triad” (1,8).

Since the introduction of DCS and its standardized four-step approach, it has rapidly become the gold standard in the management of physiologically compromised trauma patients, allowing a seven-fold improvement in mortality (11% to 77%) and an overall survival rate of about 60% (2,4). The success DCS has gained over the years has brought some authors to explore its application in other settings, such as emergency general surgery (9-11). We present this article in accordance with the Narrative Review reporting checklist (available at https://ales.amegroups.com/article/view/10.21037/ales-24-21/rc).

Methods

A review of the existing literature was carried out using PubMed and Google Scholar between January and March 2024. The terms used to research the literature were damage control surgery, emergency general surgery, septic shock, and hemorrhagic shock. Case reports and case series were not considered for inclusion. Only studies published in English were selected.

The research and selection process was conducted independently by four team members, whereas the remaining two authors checked and oversaw the study methods. The draft of the manuscript was decided, agreed upon, and reviewed by all authors. Table 1 resumes the research strategy adopted.

Damage control in emergency general surgery

Despite DCS being introduced as a novel approach to treating emergency surgical patients with physiological derangements, this population differs greatly from trauma patients. The pathophysiological background of non-trauma patients is represented most often by septic shock (e.g., hollow viscus perforation, obstruction, ischemia) or, only in a smaller part, by hemorrhagic shock (e.g., postoperative bleeding, aortic aneurism rupture). On the contrary, in surgical trauma patients, the underlying problem is mainly hemorrhagic. Moreover, even when bleeding is considered, in emergency surgical patients, unlike trauma patients, it is not associated with tissue injury (10-14).

The first study reporting the use of DCS techniques in non-trauma patients goes back to 2004 when Finlay et al. showed how its use in these circumstances decreased mortality (15).

The septic patient

In septic patients, according to the Sepsis-3 guidelines, resuscitation must be started within one hour from the diagnosis of sepsis and the immediate care bundle must be completed within 3 hours (Table 2). These strict timeframes reflect the great importance of early diagnosis of septic patients in order to improve survival (16). In this context, it is acceptable for the source of sepsis to be searched for, identified, and addressed after the initial resuscitation (17-21). Moreover, source control in patients presenting with septic shock is not strictly surgical. Endoscopy and interventional radiology allow in many cases to obtain adequate source control with a minimally invasive approach, leaving surgery as the last resort, when the other techniques cannot be employed or fail (22). If the patient does not respond to the initial resuscitation, maintaining a mean arterial pressure <65 mmHg and serum lactate level >2 mmol/L, vasopressors should be added, defining the case as septic shock (17).

The DCS management in septic patients determines greatly the time to surgery compared to hemorrhagic patients. Where in hemodynamically unstable trauma patients surgery must be carried out upfront along with resuscitation, in patients in septic shock source control (e.g., surgery) comes after resuscitation and additional imaging (e.g., computed tomography) (23-26). Furthermore, decompensated septic patients do not activate the “lethal triad” generally used by trauma surgeons to guide their surgical approach. This leaves this group of patients without clear physiologic parameters that may guide the intraoperative decisions. According to Becher et al., several criteria may be used as indications for DCS, such as septic shock, lactate ≥3, acidosis (pH ≤7.25), age ≥70 years old, male gender, and pre-existing comorbidities (≥3). In this group of patients, the use of DCS improves survival and avoids unplanned re-laparotomies which affects about 50% of septic patients undergoing a primary fascial closure (27).

The non-traumatic bleeding patient

Non-traumatic bleeding has some differences compared to traumatic hemorrhage: it has the absence of extensive tissue injury, it comes from a single source of bleeding, and its source is usually well known. These basic and intuitive differences open the possibility of treating hemorrhagic patients with less invasive procedures than surgery. Nowadays, techniques such as endoscopy and angioembolization are adequate, not to say better, measures to treat bleeding patients. It is consequential that if the bleeding spot is known and single, the probability of success of these methods increases drastically (28-30). It has to be said that recently the possible use of angioembolization in hemodynamically unstable patients has been under evaluation with interesting results (31,32).

Open abdomen (OA)

The managing of an OA after a damage control laparotomy can be done with several techniques. The main goals of any management strategy are easier and quicker access to the abdominal cavity, without damaging the integrity of abdominal wall tissues, and the achievement of a low abdominal wall tension.

An OA requires the creation of a temporary abdominal closure (TAC). The main objectives of TAC can be summarized as follows: protection of the intra-abdominal viscera, prevention of evisceration, reduction of the risk of abdominal compartment syndrome (ACS), limitation of dehydration and heat dispersion, stimulation of tissue repair and reduction of intra-abdominal inflammation/infection, preservation of the integrity of the abdominal wall and prevention of the lateral retraction of the oblique musculature, reduction of the formation of peritoneal adhesions and drainage of abdominal fluids (33).

In this setting, the TAC can be associated with other therapeutic options, for example:

• Modified Wittmann’s Patch (MWP): this method consists of creating median traction of the fascial flaps with a polypropylene prosthesis, opened medially and progressively closed. This technique prevents fascial retraction, and it can be used in case of elevated risk of developing ACS or when the probability of numerous surgical revisions is high (34,35);
• Direct peritoneal resuscitation (DPR): continuous irrigation of the abdominal cavity using hypertonic solutions, usually those employed during peritoneal dialysis. This technique reduces visceral edema, promotes microcirculation, reduces bacterial load, and local and systemic inflammation. The technique is usually used in cases of acute mesenteric ischemia (AMI) or sepsis (36,37).

The most important indication for OA is the worsening of the patient’s conditions during the stress of the operation, therefore the surgical procedure should be abbreviated (38). The decline of clinical conditions could be indicated by increasing lactate levels, acidosis and/or coagulopathy, or an ongoing transfusion or vasopressor requirement. Another indication for OA is extensive abdominal tissue edema or intra-abdominal hypertension, which precludes fascial closure.

Numerous surgical techniques have been described over the years to perform a TAC. The chosen technique can be performed to achieve static or dynamic support of the abdominal wall.

Static therapies

• Negative pressure wound therapy (NPWT; e.g., Barker’s Vacuum Pack, Commercial Vacuum Pack): application of a first layer directly on the bowel, usually composed of a soft spongy material or a fluffy gauze, followed by another layer of adhesive bandage with a small opening for the connection of a drain system to apply continuous suction. The main advantage of this device is the possibility to associate an irrigation system, which has been suggested to help clear inflammatory cytokines in treating a septic cause for the OA (39,40);
• Mesh bridging: when a massive loss of abdominal wall tissue is found, this device may be necessary to facilitate the coverage of the bowel and promote granulation to allow skin grafting and later reconstruction (41,42).

Dynamic therapies

• Mesh-mediated fascial traction (MMFT): the mesh is applied and sewn to the opposite edges of the fascia and the anterior abdominal wall is progressively tightened (43,44);
• Dynamic retention sutures or abdominal reapproximation anchor (ABRA): this technique involves the use of plastic tubes that are inserted through the abdominal wall, away from the fascial edges, and anchored through an adhesive device. The method guarantees a degree of fascial tension while preserving the fascial edge for delayed closure (45).

Leaving the abdomen open, may also be associated with some complications mainly related to the exposure of the bowel and the abdominal muscle retraction.

Considering the bowel is frequently manipulated and at risk for injury, there is the possibility of developing an entero-cutaneous or entero-atmospheric fistula. These fistulas’ management is challenging, and wound healing is difficult because of the enteric output from the fistula itself. It is interesting to point out that fistula formation is lower with NPWT than with other abdominal closure strategies, especially when specific dressings are applied to protect the bowel (e.g., sponges or Vaseline-impregnated gauze) (46).

Moreover, with a midline OA, the abdominal wall’s muscles retract the fascia laterally. During the following surgeries, the fascia, and sometimes the skin, may not be elastic enough for primary closure, causing the formation of a ventral hernia. The first possible way to prevent this complication is early closure of the abdominal wall. In the alternative, the use of an NPWT may help ease the primary closure of the fascia and skin or, if primary closure is not possible, decrease the size of the hernia itself.

According to the WSES 2018 Guidelines, NPWT with continuous fascial tension is the preferred technique for TAC to prevent fascial shrinkage and retraction, and negative pressure techniques associated with a dynamic strategy guarantee the best outcome for fascial closure, allowing the progressive tightening of the abdomen (47). On the other hand, dynamic sutures can result more often in entero-cutaneous or entero-atmospheric fistula (48).

At the current moment, there are no precise recommendations about the combination of NPWT with fluid instillation. In low-resource settings, TAC without negative pressure (e.g., Bogota bag) may be a suitable option, keeping in mind its burden of lower fascial closure and higher intestinal fistula rates.

Re-explorations in patients with an OA should be carried out no later than 24–72 hours after the previous operation. The goal is to obtain a fascial closure within 4 to 7 days from the index surgery.

If primary fascial closure cannot be achieved within 10–14 days from the index operation, the creation of a “planned ventral hernia” with a skin-only closure, covering the abdominal cavity and the viscera, and leaving the underlying fascia open is the only option to reduce the possible complications of the OA. The definitive reconstruction of the abdominal wall can be planned after 6–12 months (49).

Hollow viscus perforations

Visceral perforation, resulting from acute pathological conditions such as perforated peptic ulcers or diverticulitis, presents a critical surgical emergency. By prioritizing rapid source control and physiological stabilization, DCS offers a structured approach to managing these critical situations (11).

The primary indication for DCS in visceral perforation lies in the patient’s hemodynamic instability due to septic shock. As in the trauma scenario, the primary objective is to avoid or interrupt the lethal triad of hypothermia, acidosis, and coagulopathy (50). DCS provides a structured approach to achieve the stabilization of the patient and it is particularly beneficial in situations where the patient’s physiological status precludes a definitive surgical repair in a single operation. This kind of patient may not tolerate prolonged surgical procedures or prolonged anesthesia. However, in non-trauma patients, the factors determining the so-called lethal triad should not be the only ones taken into consideration for the decision to perform DCS. More patients’ related factors should be considered, such as comorbidities, advanced age, systemic inflammatory response, and the American Society of Anesthesiologists (ASA) score (27,51).

Furthermore, DCS proves advantageous in resource-limited settings where access to comprehensive surgical facilities is limited. In the case of perforated colonic diverticulitis complicated by generalized peritonitis, for example, DCS can be performed even by non-colorectal surgeons, postponing the decision to proceed to definitive reconstruction when the patient’s conditions have been optimized and a colorectal surgeon is available for support (52).

During the initial laparotomy (laparoscopic DCS is currently under evaluation), surgeons focus on identifying and temporarily managing visceral injuries using abdominal and temporary sealing techniques like stapling or suture ligation. The precise technical procedure used for source control changes depending on the situation and pathology.

If peritonitis has developed from perforated sigmoid diverticulitis, surgical strategies can be different. Even if this clinical picture is one of the most frequent abdominal emergencies, no consensus has been reached internationally on the best treatment approach (53,54). Resection with primary anastomosis (PRA) and diverting ileostomy seems to be an appropriate approach, though (55). However, when facing surgical real-life conditions, surgeons often tend to prefer the Hartmann procedure (HP) over PRA in ongoing feculent peritonitis) (56). However, the HP is associated with a higher rate of definite stoma, a longer time to stoma closure, and a higher rate of overall complications if the reversal procedure is considered. DCS can be a valid alternative in all conditions where an HP could be avoided, although avoiding a stoma is not the primary aim of the DCS approach (57-60). The surgical strategies in these cases could be a limited resection with blind colonic ends and a PRA with or without diverting ileostomy as a definitive surgery. This approach is preferable to HP in terms of significantly better stoma-free survival but no difference has been found in short-term morbidity and mortality rates (61-65). However, in the case of relevant immunosuppression, bedridden patients, pre-existing fecal incontinence, or end-stage malignant disease, primary HP may be preferable to avoid unnecessary re-operations (66).

If the source of sepsis is a peptic ulcer, the surgical approach is tailored based on the location and the dimension of the ulcer (28,67). A laparoscopic approach with definitive suture repair with or without an omental patch may be adequate only if the ulcer is small (i.e., <2 cm) (68,69). In the case of generalized peritonitis due to a large (i.e., >2 cm) peptic perforation, the surgical approach can be various. In the case of a large gastric ulcer with a high suspicion of malignancy, resection with contextual pathologic examination is suggested. On the contrary, if the perforation is secondary to a large duodenal ulcer, DCS has to be a possible strategy to avoid generalized damage linked to the digestive action of gastro-duodenal secretions. An antrectomy (with or without a D1–D2 resection) can be done if the ampullary region is not involved (70). In the other cases, pyloric exclusion with gastric decompression via a nasogastric tube or a gastrostomy and an external biliary diversion via a T-tube can be done (71). Duodenostomy or gastrostomy should be used only in the presence of giant ulcers with severe tissue inflammation. A definitive surgery in these patients can include a Roux-en-Y gastrojejunostomy or a Whipple procedure.

The abdomen is typically left open post-DCS to prevent ACS and facilitate non-traumatic re-entry.

Definitive surgery after DCS will depend on the type of lesion initially found, the DCS undertaken, the patient’s current status, and the local situation. In these cases, a primary role is played by the use of indocyanine green in controlling the perfusion of the stumps before making definitive anastomosis (72).

In conclusion, DCS serves as a crucial strategy in managing visceral perforations. It optimizes patient outcomes in critical scenarios where time is of the essence. However, DCS is not devoid of potential complications such as ACS, sepsis, and delayed complications related to subsequent surgeries.

AMI

AMI is an event caused by the sudden interruption of blood supply to the intestine: it may be occlusive or non-occlusive. The primary etiology comprehends mesenteric arterial embolism (50%), mesenteric arterial thrombosis (15–25%), and mesenteric venous thrombosis (5–15%) (73).

AMI is often misdiagnosed because of its non-specific clinical presentation and imaging findings. Mortality rates are considerably high, exceeding 50%, as the most important prognostic factors are early diagnosis and treatment.

In this setting, a surgical procedure following damage control principles is usually recommended. The treatment involves grossly resection of the infarcted bowel and revascularization.

At the time of diagnosis, contrast angiography is useful to identify the etiology of the occlusion and to plan, when indicated, the revascularization procedure or adequate medical treatment.

If the patient presents with peritonitis, surgical exploration is indicated to directly evaluate the severity and the extent of the bowel ischemia. It is important to remember that ischemia starts from the bowel mucosa; hence, its extent might not be evident during the first surgery (74).

During the index surgical procedure, if the necrotic bowel is not too extensive and the operation can be performed, all the necrotic segments must be resected and the abdomen should be left open with a TAC technique. The main reason to use an OA technique in these patients is to decrease the risk of anastomotic leak. In patients with AMI, the risk of developing a leakage after the first surgery is particularly high for many reasons: these patients are more often in a septic shock, requiring vasopressors; the remaining bowel may seem vital during the index surgery, but it might become necrotic afterward; the bowel is usually very swollen (73). Moreover, leaving the abdomen open for further re-explorations allows to avoid resecting bowel segments with uncertain vitality giving them time to recover, thus reducing the extension of the final resection.

Following a period of resuscitation, a second-look laparotomy is performed, usually after 18–36 hours, to assess if it is necessary the extend the resection and to establish if it is safe to restore bowel continuity. Therefore, any bowel anastomosis or the creation of a stoma should be considered during a delayed re-look laparotomy.

During the first and the following surgeries, one of the most challenging aspects is the intraoperative assessment of the bowel’s vitality to precisely determine the resection margins, aiming to reduce the rate of massive resections, which may lead to short bowel syndrome and permanent parenteral nutrition. A useful and practical technique is indocyanine green fluorescence angiography which can be easily performed during surgery and may provide additional information about bowel vascularization. However, at the moment, the reliability of this method, especially in the emergency setting, still needs more investigation and validation (75).

In selected cases (e.g., mesenteric arterial embolism/thrombosis of the superior mesenteric artery), in hemodynamically stable patients, therapeutic angiographic procedures have been attempted to prevent bowel infarction as an alternative to an open procedure. Endovascular treatment is a less invasive alternative that may potentially result in restoration of the blood flow to avoid infarction (76).

ACS

ACS is a serious condition characterized by increased intra-abdominal pressure (IAP) >20 mmHg associated with new organ dysfunction/failure (i.e., cardiovascular, respiratory, renal, splanchnic, musculoskeletal, and central nervous systems). This condition typically arises from diminished abdominal wall compliance (e.g., severe trauma, abdominal surgery, severe burns), increased intra-luminal contents (e.g., gastroparesis, gastric distention, ileus), increased intra-abdominal contents (e.g., acute pancreatitis, hemoperitoneum/pneumoperitoneum, intra-abdominal infection/abscess, tumors, liver failure), and/or capillary leak/fluid resuscitation (e.g., massive fluid resuscitation or positive fluid balance) (77). ACS can be categorized as primary or secondary based on its etiology. Primary ACS is a condition associated with disease in the abdominopelvic region, secondary ACS refers to conditions that do not originate from the abdominopelvic region.

When tissue interstitial pressure becomes higher than the capillary one, insufficient blood supply arrives in cells. To revert this situation, urgent intervention may be required. Once diagnosed as ACS, if medical and percutaneous treatments fail, it must be treated as soon as possible with decompressive xiphoid-pubic laparotomy (78). It’s demonstrated that decompressive laparotomy improves hemodynamics, urinary output, and oxygenation (79,80).

Specific consideration should be given in the case of ACS due to severe acute pancreatitis. Indications of surgical decompression are still not clearly defined. IAP should be measured routinely, and it should be considered a target for intervention in all patients with pancreatitis starting from IAP values of 20–25 mmHg, without waiting to reach values of 30–40 mmHg (81,82). Severe acute pancreatitis should be treated as much as possible with intensive medical care, but surgical decompression may be needed when medical management and percutaneous drainage have failed to decrease IAP (83-85). It can be associated with surgical necrosectomy in the case of necrotizing pancreatitis (86).

The most commonly performed decompressive surgery is midline or median xiphoid-pubic laparotomy, although a subcostal transverse incision or a subcutaneous linea alba fasciotomy (SLAF) can be done (87). SLAF consists of an incision of the linea alba without exploring the peritoneum and creating a median laparostomy (88).

The main limitations/complications of surgery in ACS are the high mortality rate despite decompression, the failure in reducing IAP post-decompression, and the onset of reperfusion syndrome leading to hemorrhage and worsening of outcomes.

Bleeding peptic ulcer

Endoscopic control of bleeding ulcers has minimized the role of surgery. The primary indication for DCS in bleeding peptic ulcers lies in the failure of conservative management associated with hemodynamic instability. Another indication is the presence of a coexisting factor needing an operation, such as perforation, obstruction, or suspicion of malignancy. Factors predicting rebleeding and mortality are age greater than 60 years, shock at admission, coagulopathy, active pulsatile bleeding, and concomitant cardiac disease (89). When the initial endoscopy fails to achieve hemostasis and there is refractory bleeding, interventional radiologists can be of some help. In the rare cases when neither endoscopy nor interventional radiology can control the bleeding, DCS can be an efficient strategy. Furthermore, large ulcers (i.e., >2 cm) or ulcers with active bleeding on endoscopy are at higher risk of rebleeding, especially if they are located in the posterior duodenum, and may warrant surgical intervention to achieve definitive hemostasis (90,91). Indications for DCS in bleeding peptic ulcers are similar to those for perforated peptic ulcers, meaning patients with hemorrhagic shock and signs of severe physiological derangement (48).

During the initial laparotomy, the surgeon’s main goal should be to stop the bleeding. The precise technical procedure used to achieve source control will vary depending on the location, the dimension of the ulcer, and the characteristics of the bleeding vessel. A simple oversewing of the bleeding ulcer is suitable for smaller ulcers with minimal tissue damage. In cases where the bleeding ulcer is located at the gastric or duodenal margin, a wedge resection of the affected tissue may be performed to remove the ulcer and surrounding inflamed tissue, thereby eliminating the source of bleeding (92).

If the bleeding cannot be controlled with these techniques, duodenotomy for gastroduodenal artery ligature or gastric resection can be an option. In severe cases of bleeding peptic ulcer or patients with complications such as perforation or gastric outlet obstruction, partial or total gastrectomy may be necessary to remove the diseased portion of the stomach and prevent further complications. In the end, the surgical procedure of vagotomy to reduce gastric acid secretion and decrease the risk of recurrent ulcers can be done (93).

The abdomen may be left open temporarily. The definitive anatomical restoration and abdominal closure may then be performed usually not later than 48 hours after initial surgery.

These surgical techniques aim to achieve hemostasis, remove the source of bleeding, and minimize the risk of recurrence while preserving as much healthy tissue as possible. The choice of technique depends on the patient’s clinical presentation, the location and size of the ulcer, and the surgeon’s expertise.

Postoperative bleeding

The management of postoperative bleeding is complex and involves the need for different assessment tools and strategies. Postoperative bleeding is a risk of all surgical procedures, and it is a possible fatal complication. The management may be different depending on various factors, starting from the patient’s characteristics and the type of surgery the patient underwent. The reported incidence of postoperative bleeding varies from 0.9% to 15% and it is associated with high mortality rates (94).

In this setting, pancreatic fistula is an independent predictor of postoperative massive hemorrhage, especially after elective or urgent pancreatic surgery. Postoperative bleeding is caused by the erosion of the vascular wall by the pancreatic enzymes. Post-pancreatectomy hemorrhage (PPH) is classified as early hemorrhage if it occurs within 24 hours from the index operation, and late hemorrhage if occurring after 24 hours. The latter may be associated with pancreatic fistulas, pseudoaneurysms, ulcers, and eroded vessels (95,96).

Therefore, the first step is to assess whether the patient is hemodynamically stable. If the patient is stable, along with the administration of supportive therapy, a diagnostic imaging exam (angiography, computed tomography scan) should be performed, to specifically identify the bleeding site.

A valid and minimally invasive treatment option is endovascular embolization which allows to indirectly intervene in an area that may be subject to anatomical variations and tissue distortion caused by the index surgery. It allows the identification of possible extravasation of contrast dye, the presence of a pseudoaneurysm, or an irregular arterial wall. The procedure is usually performed through the common femoral artery. It avoids damaging the other organs and it appears to be superior to reoperation in terms of survival. If necessary, this kind of procedure can be also used as a temporary measure to gain time for the possible following surgical operation. Conversely, angiography may not be suitable for controlling intermittent, diffuse, or venous bleeding (97).

On the other hand, in unstable patients, who usually suffer from major bleeding events (i.e., active arterial and anastomotic bleeding), laparotomy is indicated and damage control principles are applied. In this event, stapled closure of the bowel, external tube drainage, abdominal packing, and rapid abdominal closure with planned re-laparotomy after resuscitation (18–36 hours) and following definitive repair may be possible options (95).

It should be noted that, in the last few years, the possibility of performing angioembolization in hemodynamically unstable bleeding patients has been explored with promising results (96,97).

In some selected cases, in particular, when an intraluminal bleeding site is identified, endoscopy may be a diagnostic and therapeutic procedure. However, this option must be considered carefully because, during the first postoperative period, it may be unsafe to perform this procedure considering the presence of the pancreatoenteric and bilioenteric anastomoses (98).

Acute cholecystitis

Acute cholecystitis is the most common complication of gallstone disease and typically develops in patients with a history of symptomatic gallstones. The reported mortality of acute cholecystitis is approximately 3%, but the rate increases with age and patient’s comorbidity (99).

The current gold standard treatment is early laparoscopic cholecystectomy. However, in some cases, the severity of the disease and the patient’s comorbidities and surgical risk may not allow the surgical treatment in the first place. In those situations, it can be useful to apply a damage control strategy to solve the acute event and consider, when possible, a definitive treatment.

A valid alternative to surgery is gallbladder drainage. According to the Tokyo Guidelines 2018, the main indication for this procedure is the onset of grade 2 or 3 acute cholecystitis in critically ill patients who are not suitable for surgery and present clinically septic. The main goal of this approach is to optimize the infection source control and improve the clinical conditions. In this setting, gallbladder drainage may also be considered a treatment option after failure of 24–48 hours of conservative management in patients with contraindications for surgery (100,101).

The gallbladder drainage can be performed using various techniques. These procedures are less invasive, shorter in time, and less risky compared with surgical treatment.

However, despite the wide use of this procedure in severely compromised patients, acute care surgeons must always consider the high rate of failure of this approach as demonstrated by the CHOCOLATE trial and must be prepared to switch to a surgical option in case of worsening of clinical conditions (102).

The most common one is Percutaneous Transhepatic Gallbladder Drainage (PTGBD), an interventional radiologic procedure, usually performed under ultrasound guidance, which allows the decompression of the gallbladder and facilitates the resolution of the acute event. This procedure is accomplished with local anesthesia, in order to avoid general anesthesia and the associated risks (103).

Another non-surgical treatment that can be taken into consideration is the Endoscopic Transpapillary Gallbladder Drainage (ENGBD) which is performed using a naso-biliary drainage to guide the bile duct cannulation to reach the cystic duct and place a pigtail drainage tube catheter into the gallbladder. This method is usually performed in patients with specific hepatic diseases in which transhepatic procedures are contraindicated. Endoscopic Transpapillary Gallbladder Stenting (ENGBS) is a similar procedure in which a double pigtail stent is placed instead of a naso-biliary drainage tube (104).

Another possible non-surgical treatment, performed using interventional endoscopic ultrasonography (EUS), is represented by the transenteric drainage of the gallbladder through a specific self-expanding and fully covered metal stent (e.g., Hot AXIOS), mainly positioned through the duodenal bulb. This procedure has a high rate of success in treating cholecystitis in patients not fit for surgery and it is simpler and time-sparing (105).

In patients that are fit to undergo an urgent surgical procedure, it must be assessed whether is safe or not to perform a standard cholecystectomy, after carefully evaluating the anatomy of the surgical site and the gallbladder inflammation. In some cases, it becomes necessary to carry out a laparoscopic subtotal cholecystectomy (or laparoscopic partial cholecystectomy). This is a surgical bail-out procedure indicated when the critical view of safety cannot be obtained, and an inadequate identification of the anatomical structures may significantly increase the risk of main bile duct injury (106-108). Subtotal cholecystectomies can be divided into two different categories, the “fenestrating” and “reconstituting” types, depending on how the residual part of the gallbladder is managed. Subtotal fenestrating cholecystectomy does not close the residual gallbladder pouch, but the cystic duct may be sutured internally. This technique has a higher incidence of postoperative biliary fistula. On the contrary, subtotal reconstituting cholecystectomy closes off the lower end of the gallbladder; thus, reducing the incidence of postoperative biliary fistula. However, the residual gallbladder can cause a recurrence of symptomatic cholecystolithiasis (109). Another option to reduce the risk of main bile duct injuries and the conversion-to-open rates during laparoscopic cholecystectomy performed in difficult cases is the use of near-infrared fluorescent cholangiography with indocyanine green (110-112).

After recovering from the acute event and the patient’s physiological functions are re-established, it should be assessed whether it is safe or not to perform a definitive surgical treatment.

Conclusions

In conclusion, the use of DCS in the emergency general surgery setting is different from what we see and apply in the trauma world. The reasons are multiple: patients are generally septic, hemorrhagic patients have more often well-known bleeding sources, and tissue injury is typically limited. These differences have effects on the patient’s physiology and, consequently, on the best treatment approach reserved.

We all know that the DCS is not a matter of technique, but more likely a way of thinking, a philosophical approach. And this philosophy has always had the good old principle of “to do the less, to obtain the most”. However, maybe, we should start considering different “the most” depending on the situation. In trauma patients “the most” can be translated into reducing the time to access adequate resuscitation in the ICU, limiting as much as possible the surgical maneuvers. On the contrary, in emergency surgical patients, its interpretation lies in preventing surgical postoperative complications secondary to physiological derangements that may impair an already depressed body system.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://ales.amegroups.com/article/view/10.21037/ales-24-21/rc

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