2020 WSES guidelines for the detection and management of bile duct injury during cholecystectomy.

Bile duct injury (BDI) is a dangerous complication of cholecystectomy, with significant postoperative sequelae for the patient in terms of morbidity, mortality, and long-term quality of life. BDIs have an estimated incidence of 0.4-1.5%, but considering the number of cholecystectomies performed worldwide, mostly by laparoscopy, surgeons must be prepared to manage this surgical challenge. Most BDIs are recognized either during the procedure or in the immediate postoperative period. However, some BDIs may be discovered later during the postoperative period, and this may translate to delayed or inappropriate treatments. Providing a specific diagnosis and a precise description of the BDI will expedite the decision-making process and increase the chance of treatment success. Subsequently, the choice and timing of the appropriate reconstructive strategy have a critical role in long-term prognosis. Currently, a wide spectrum of multidisciplinary interventions with different degrees of invasiveness is indicated for BDI management. These World Society of Emergency Surgery (WSES) guidelines have been produced following an exhaustive review of the current literature and an international expert panel discussion with the aim of providing evidence-based recommendations to facilitate and standardize the detection and management of BDIs during cholecystectomy. In particular, the 2020 WSES guidelines cover the following key aspects: (1) strategies to minimize the risk of BDI during cholecystectomy; (2) BDI rates in general surgery units and review of surgical practice; (3) how to classify, stage, and report BDI once detected; (4) how to manage an intraoperatively detected BDI; (5) indications for antibiotic treatment; (6) indications for clinical, biochemical, and imaging investigations for suspected BDI; and (7) how to manage a postoperatively detected BDI.

Successful use of mild therapeutic hypothermia as compassionate treatment for severe refractory hypoxemia in COVID-19.

BACKGROUND: COVID-19 is a disease associated with an intense systemic inflammation that could induce severe acute respiratory distress syndrome (ARDS), with life-threatening hypoxia and hypercapnia. We present a case where mild therapeutic hypothermia was associated with improved gas exchange, facing other therapies' unavailability due to the pandemic. CASE REPORT: A healthy 38-year-old male admitted for COVID-19 pneumonia developed extreme hypoxia (PaO2/FiO2 ratio 42 mmHg), respiratory acidosis, and hyperthermia, refractory to usual treatment (mechanical ventilation, neuromuscular blockade, and prone position), and advanced therapies were not available. Mild therapeutic hypothermia management (target 33-34 °C) was maintained for five days, with progressive gas exchange improvement, which allowed his recovery over the following weeks. He was discharged home after 68 days without significant ICU associated morbidity. CONCLUSIONS: Mild hypothermia is a widely available therapy, that given some specific characteristics of COVID-19, may be explored as adjunctive therapy for life-threatening ARDS, especially during a shortage of other rescue therapies.