Source control in emergency general surgery: WSES, GAIS, SIS-E, SIS-A guidelines

Abstract

Intra-abdominal infections (IAI) are among the most common global healthcare challenges and they are usually precipitated by disruption to the gastrointestinal (GI) tract. Their successful management typically requires intensive resource utilization, and despite the best therapies, morbidity and mortality remain high. One of the main issues required to appropriately treat IAI that differs from the other etiologies of sepsis is the frequent requirement to provide physical source control. Fortunately, dramatic advances have been made in this aspect of treatment. Historically, source control was left to surgeons only. With new technologies non-surgical less invasive interventional procedures have been introduced. Alternatively, in addition to formal surgery open abdomen techniques have long been proposed as aiding source control in severe intra-abdominal sepsis. It is ironic that while a lack or even delay regarding source control clearly associates with death, it is a concept that remains poorly described. For example, no conclusive definition of source control technique or even adequacy has been universally accepted. Practically, source control involves a complex definition encompassing several factors including the causative event, source of infection bacteria, local bacterial flora, patient condition, and his/her eventual comorbidities. With greater understanding of the systemic pathobiology of sepsis and the profound implications of the human microbiome, adequate source control is no longer only a surgical issue but one that requires a multidisciplinary, multimodality approach. Thus, while any breach in the GI tract must be controlled, source control should also attempt to control the generation and propagation of the systemic biomediators and dysbiotic influences on the microbiome that perpetuate multi-system organ failure and death. Given these increased complexities, the present paper represents the current opinions and recommendations for future research of the World Society of Emergency Surgery, of the Global Alliance for Infections in Surgery of Surgical Infection Society Europe and Surgical Infection Society America regarding the concepts and operational adequacy of source control in intra-abdominal infections.

Keywords: Abdominal; Antibiotic; Emergency; Infections; Mortality; Source control; Stewardship; Surgery; Trauma.

Fig. 1

Acute cholecystitis adequate source control indications (*Patients with major comorbidities unfit for surgery and with stable hemodynamic condition may be managed with percutaneous image-guided drainage)

Fig. 2

Acute Cholangitis adequate source control indications

Fig. 3

Acute appendicitis adequate source control indications (*Patients with major comorbidities unfit for surgery and peri-appendiceal abscess and with stable hemodynamic condition may be managed with percutaneous image-guided drainage)

Fig. 4

Acute left colonic diverticulitis adequate source control indications (*Percutaneous drainage for abscess larger than 5 cm)

Fig. 5

Acute right colonic diverticulitis adequate source control indications

Fig. 6

Small bowel perforation adequate source control indications

Fig. 7

Gastroduodenal perforation adequate source control indications

Fig. 8

Post-traumatic Perforation adequate source control indications

Fig. 9

Severe acute pancreatitis adequate source control indications