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.

Abstract-Human adipose tissue has been shown to produce plasminogen activator inhibitor type 1 (PAI-1). However, the importance of adipose tissue in the regulation of the PAI-1 plasma level is not known. The aim of this study was to investigate the relation between the production of PAI-1 by adipose tissue, plasma PAI-1 level, and variables related to the insulin resistance state. The link between the production of PAI-1 inducers such as tumor necrosis factor-␣ and transforming growth factor-␤ and the production of PAI-1 by adipose tissue was also evaluated. Blood samples were obtained as soon as possible to the induction of anesthesia from 30 patients undergoing elective abdominoplasty. PAI-1 antigen levels measured in conditioned media after a 19-hour incubation period of adipose tissue explants were significantly correlated with plasma PAI-1 antigen levels (rϭ0. Key Words: PAI-1 Ⅲ humans Ⅲ adipose tissue Ⅲ TNF-␣ Ⅲ TGF-␤ I nsulin resistance is a common metabolic disorder that includes a cluster of abnormalities such as hyperinsulinemia, hypertriglyceridemia, a decrease in HDL cholesterol, and obesity with a predominant fat distribution in the upper part of the body. The insulin resistance syndrome is associated with an increased risk of ischemic heart disease. 1 Among the mechanisms explaining this relation, an increase in type 1 plasminogen activator inhibitor (PAI-1) concentration in plasma has been invoked. 2 PAI-1 is a specific inhibitor of plasminogen activators. Its modulation in vivo affects fibrin deposition and smooth muscle cell migration, 2 mechanisms involved in atherosclerosis development. Clinical and epidemiological studies conducted in healthy populations or in patients with coronary heart disease suggest that an increased plasma PAI-1 level is a biological risk factor for the development of atherosclerosis complications, mainly in patients with insulin resistance. 3 Indeed, the ability of PAI-1 to predict such sequelae disappears after adjustment for parameters belonging to the insulin resistance syndrome. 3 The mechanisms responsible for this original association between a metabolic situation and a fibrinolytic inhibitor remain unclear. Several studies conducted in humans and animals have underlined the importance of fat mass in explaining such a relation. 4 -14 We have recently contributed to this discussion by demonstrating the synthesis of PAI-1 by human adipose tissue, this production being higher in omental than in subcutaneous tissue. 15 Furthermore, Eriksson et al 16 have shown that this production is higher in the fat of obese individuals and is related to the size of the adipocytes. To evaluate the relevance of this phenomenon in patients, we have investigated the relation between the production of PAI-1 by adipose tissue, the plasma PAI-1 level, and variables related to the insulin resistance state. To observe this relation, blood and adipose tissue samples were taken nearly simultaneously. Tumor necrosis factor-␣ (TNF-␣) and transforming growth factor-␤ (TGF-␤) are potent inducers...

Iatrogenic colonoscopy perforation (ICP) is a severe complication that can occur during both diagnostic and therapeutic procedures. Although 45–60% of ICPs are diagnosed by the endoscopist while performing the colonoscopy, many ICPs are not immediately recognized but are instead suspected on the basis of clinical signs and symptoms that occur after the endoscopic procedure. There are three main therapeutic options for ICPs: endoscopic repair, conservative therapy, and surgery. The therapeutic approach must vary based on the setting of the diagnosis (intra- or post-colonoscopy), the type of ICP, the characteristics and general status of the patient, the operator’s level of experience, and surgical device availability.Although ICPs have been the focus of numerous publications, no guidelines have been created to standardize the management of ICPs. The aim of this article is to present the World Society of Emergency Surgery (WSES) guidelines for the management of ICP, which are intended to be used as a tool to promote global standards of care in case of ICP. These guidelines are not meant to substitute providers’ clinical judgment for individual patients, and they may need to be modified based on the medical team’s level of experience and the availability of local resources.