World Society Of Emergency Surgery Research Articles

Anatomy and Classification of Pelvic Trauma

Pelvic fracture is one of the most complex injuries in trauma treatment. Bleeding continues to be one of the primary causes of death from pelvic fracture, and the severity of bleeding is not necessarily correlated with the fracture pattern. The priorities in managing pelvic fractures include controlling bleeding. Historically, classification systems only consider the anatomical fracture pattern, which does not correlate with the outcomes. The World Society of Emergency Surgery (WSES) classification considers both the pelvic fracture pattern and the hemodynamic condition of the patient. Vascular injuries caused by pelvic fractures are potentially lethal because they often manifest as non-compressible multifocal venous bleeding (80–85% of pelvic bleeding) and less frequently as arterial bleeding (15–20% of pelvic bleeding). The presence of vascular injury and open pelvic fractures are independent factors contributing to mortality. Another fundamental factor in the management of pelvic vascular trauma is time [1]. In this context, the assessment of potentially significant vascular injury and timely hemorrhage control should be the highest priorities in the acute management of these injuries. Classification of pelvic injuries that considers both the fracture pattern and the hemodynamic status of the patient, such as the WSES classification, appears to have greater utility in clinical practice compared to the diffused anatomical classification.

Use of jejunal serosal patch and pyloric exclusion in the management of complex duodenal injury.

Duodenal injuries are relatively rare but remain a management challenge with a high incidence of postoperative complications. Guidelines from the World Society of Emergency Surgery and American Association for the Surgery of Trauma favour a primary repair for less-complex injuries, but the management of more complex duodenal trauma remains controversial with varying techniques supported, including pyloric exclusion, omental or jejunal patch closure, gastrojejunostomy and pancreatoduodenectomy. We describe the techniques used in one case of complex duodenal trauma. The duodenum is approached via a standard laparotomy with Kocherisation. Primary repair of the duodenal perforations is performed using a 3/0 polydioxanone suture (PDS), followed by mobilisation of a loop of mid-jejunum against the area of duodenal trauma over the primary repair as a jejunal serosal patch. The antimesenteric jejunal serosal border is sutured to the serosa of the duodenum (serosa only) using a 3/0 PDS. Pyloric exclusion is then performed through an anterior gastrostomy, to control the volume of gastric juice entering the duodenum. The pylorus is sutured closed using an absorbable suture followed by closure of the anterior gastrostomy using a GIA stapling device.

A Clinical Review and Experience of Splenic Trauma in North India: A Retrospective Observational Study.

The spleen is one of the frequently injured solid organs in abdominal blunt trauma. The standard of care is nonoperative nowadays depending on the hemodynamic stability (World Society of Emergency Surgery (WSES) grade I-III) of the patient due to advancements in treating modalities. Operative interventions are required in hemodynamically unstable patients or failure of nonoperative management. The study was planned to find the clinical spectrum of abdominalblunt trauma, specifically those having splenic trauma, and their subsequent management in an institution. This is a retrospective observational study. All included patients with blunt abdominal injuries were treated in a level 1 trauma center between July 2021 and December 2022. Data regarding demographic profile, blood transfusion, pre- and postoperative findings, and management including the period of hospital stay, morbidity, and mortality were collected and analyzed. One hundred sixty-four patients were analyzed, of which 142 were males and 22 were females. The commonest mechanism of injury was motor vehicle collision, followed by falls. Grade III splenic injury was the most common injury, while the predominantly associated injury was rib fracture. The patients were managed preferably through nonoperative management, followed by angioembolization and operative management. The commonest postoperative complication was pneumonia. Nonoperative management of splenic trauma has evolved as the standard of care replacing operative management in order tosustain its immune function, thereby preventing overwhelming post-splenectomy infection.

Are we ready for "green surgery" to promote environmental sustainability in the operating room? Results from the WSES STAR investigation

BackgroundThe importance of environmental sustainability is acknowledged in all sectors, including healthcare. To meet the United Nations Sustainable Development Goals 2030 Agenda, healthcare will need a paradigm shift toward more environmentally sustainable practices that will also impact clinical decision-making. The study investigates trauma and emergency surgeons’ perception, acceptance, and employment of environmentally friendly habits.MethodsAn online survey based on the most recent literature regarding environmental sustainability in healthcare and surgery was created by a multidisciplinary committee and endorsed by the World Society of Emergency Surgery (WSES). The survey was advertised to the 917 WSES members through the society’s website and Twitter/X profile.Results450 surgeons from 55 countries participated in the survey. Results underline both a generally positive attitude toward environmental sustainability but also a lack of knowledge about several concepts and practices, especially concerning the potential contribution to patient care.DiscussionThe topic of environmental sustainability in healthcare and surgery is still in its infancy. There is a clear lack of salient guidance and knowledge, and there is a critical need for governments, institutions, health agencies, and scientific societies to promote, disseminate, and report environmentally friendly initiatives and their potential impacts while employing an interdisciplinary approach.

Early management of adult traumatic spinal cord injury in patients with polytrauma: a consensus and clinical recommendations jointly developed by the World Society of Emergency Surgery (WSES) & the European Association of Neurosurgical Societies (EANS)

BackgroundThe early management of polytrauma patients with traumatic spinal cord injury (tSCI) is a major challenge. Sparse data is available to provide optimal care in this scenario and worldwide variability in clinical practice has been documented in recent studies.MethodsA multidisciplinary consensus panel of physicians selected for their established clinical and scientific expertise in the acute management of tSCI polytrauma patients with different specializations was established. The World Society of Emergency Surgery (WSES) and the European Association of Neurosurgical Societies (EANS) endorsed the consensus, and a modified Delphi approach was adopted.ResultsA total of 17 statements were proposed and discussed. A consensus was reached generating 17 recommendations (16 strong and 1 weak).ConclusionsThis consensus provides practical recommendations to support a clinician’s decision making in the management of tSCI polytrauma patients.

Antibiotic prophylaxis in trauma: Global Alliance for Infection in Surgery, Surgical Infection Society Europe, World Surgical Infection Society, American Association for the Surgery of Trauma, and World Society of Emergency Surgery guidelines.

Trauma is a complex disease, and the use of antibiotic prophylaxis (AP) in trauma patients is common practice. However, considering the increasing rates of antibiotic resistance, AP use should be questioned and limited only to specific cases. Antibiotic stewardship is of paramount importance in fighting resistance spread. Definitive rules or precise indications about AP in trauma remain unclear. The present article describes the indications of AP in traumatic lesions to the head, brain, torso, maxillofacial, extremities, skin, and soft tissues endorsed by the Global Alliance for Infection in Surgery, Surgical Infection Society Europe, World Surgical Infection Society, American Association for the Surgery of Trauma, and World Society of Emergency Surgery.

Bladder trauma: a guideline of the guidelines.

To identify and review the most up-to-date guidelines pertaining to bladder trauma in a unifying document as an updated primer in the management of all aspects relating to bladder injury. In accordance with the PRISMA statement, the most recent guidelines pertaining to bladder injury were identified and subsequently critically appraised. An electronic search of PubMed and Scopus databases was carried out in September 2023. A total of six guidelines were included: European Association of Urology (EAU) guidelines on urological trauma (2023), EAU guidelines on paediatric urology (2022), Urotrauma: American Urological Association (AUA) (2020), Kidney and Uro-trauma: World Society of Emergency Surgery and the American Association for the Surgery of Trauma (WSES-AAST) guidelines (2019), Management of blunt force bladder injuries: A practice management guideline from the Eastern Association for the Surgery of Trauma (EAST) (2019), and EAU guidelines on iatrogenic trauma (2012). Recommendations were summarised with the associated supporting level of evidence and strength of recommendation where available. Several widely recognised professional organisations have published guidelines relating to the diagnosis, investigation, classification, management, and follow-up related to bladder injury. There is consensus amongst all major guidelines in terms of diagnosis and management but there is some discrepancy and lack of recommendation with regards to the follow-up of bladder injuries, iatrogenic bladder injury, paediatric bladder trauma, and spontaneous bladder rupture. The role of increasing minimally invasive techniques seem to be gaining traction in the select haemodynamically stable patient. Further research is required to better delineate this treatment option.

Offering Surgical Definitive Options For Sigmoid Volvulus: Lessons From WSES (World Society of Emergency Surgery) Consensus Guidelines

Abstract Aim This study evaluates the quality of care provided to patients with sigmoid volvulus and assess compliance with the World Society of Emergency Surgery (WSES) Consensus Guidelines regarding offering definitive surgical intervention. Methods All emergency surgical admissions involving individuals aged 65 or older, diagnosed with sigmoid volvulus between 2021 and 2023, were retrospectively included. The evaluation was conducted in conjunction with five critical WSES recommendations, encompassing the assessment strategy and diagnostic imaging for sigmoid volvulus, initial flexible endoscopy, and the decision-making process for urgent or elective sigmoid resection in all initial presentations. Adherence to these standards was assessed in each domain and subsequently categorized as Red (Urgent Attention Needed), Amber (Room for Improvement), or Green (Satisfactory Compliance). Results The study included a total of 20 patients. Compliance with the recommendation to offer sigmoid colectomy for the prevention of recurrent volvulus after successful endoscopic decompression was found to be in the Red category, scoring at 25%. In contrast, the remaining recommendations demonstrated satisfactory levels of compliance. Conclusion 25% of our patients have not been offered the option of definitive surgical resection, highlighting an area for urgent need of attention. Given that the recurrence rate of sigmoid volvulus after endoscopic detorsion and conservative management ranges from 45% to 71%, and offering sigmoid colectomy to prevent recurrent volvulus is crucial, even during the index admission. In cases where frailty is identified, there should be documented consideration of best interest during the planning of definitive care. We envisage a better compliance to WSES recommendations.

Surgical Techniques for Severe Liver Injury: A Comprehensive Review of Current Approaches and Advancements

In abdominal trauma, the liver is the most injured organ and treatment is usually determined by hemodynamics. Severe liver injury with extensive parenchymal injury and uncontrollable bleeding may rapidly evolve into the lethal triad of death (acidosis, hypothermia, and coagulopathy), requiring damage control surgery (DCS). Damage control resuscitation for trauma treatment reduces the need for DCS by enabling rapid control of massive bleeding. Thus, definitive surgery can be completed in one operation. Despite the systematic application of damage control resuscitation, definitive surgery cannot be achieved in severe, and extensive liver injuries. Therefore, understanding, and acquiring damage control surgical techniques is necessary to achieve DCS for severe liver injury. The Western Trauma Association and the World Society of Emergency Surgery have proposed algorithms for the nonoperative and operative management of blunt hepatic trauma. The algorithms list several surgical skills, including electrocautery or argon beam, manual compression, perihepatic packing, the Pringle maneuver, liver suture, omental packing, selective hepatic artery ligation, balloon tamponade, hepatic vascular isolation, and the shunt operation. These techniques require a multidisciplinary approach and individual honing of skills by the surgeon. Trauma surgeons, even hepatobiliary surgeons, must practice damage control techniques in severe liver injury models (animals or cadavers).

EGS P40 Validating the Alvarado Score as a Diagnostic Tool for Acute Appendicitis in a UK District General Hospital

Abstract Background Acute appendicitis (AA) remains one of the most common causes of an acute abdomen, requiring surgery. However, ruling out AA remains clinically challenging and has both economic and medico-legal implications for hospital trusts. The 2019 World Society of Emergency Surgery (WSES) guidelines endorsed the use of the Alvarado score to limit diagnostic uncertainty. Particularly, a score below 5 was deemed sufficiently sensitive to exclude AA without imaging. This audit aimed to retrospectively assess the use of the Alvarado score to exclude AA in patients referred with suggestive symptoms to the on-call general surgery team at a UK District General Hospital. Methods All patients referred to the on-call general surgery team between 2nd January 2023 and 5th February 2023 with right-lower-quadrant (RLQ) abdominal pain or an incidental diagnosis of AA were included. Patient demographics, clinical data, and an admission Alvarado score were retrospectively collected. An average admission Alvarado score was calculated for patients with confirmed AA and those without. As recommended in the WSES guidelines, a cut-off score of < 5 was employed. The sensitivity and specificity were then calculated in order to validate the Alvarado score’s use as a diagnostic tool in patients with suspected AA. Results Of the 63 patients referred with RLQ abdominal pain, one self-discharged and 11 (17.7%) had confirmed AA on imaging or histology (Figure 1). The average Alvarado score was 4.9 (95% CI 4.2 – 5.5). In patients with confirmed AA, the average score was 7.5, statistically significantly ≥ 5 (p-value <0.01). Patients without AA averaged a score of 4.3, statistically significantly < 5 (p-value = 0.013). The sensitivity and specificity were 91% (95% CI 58.7% – 99.8%) and 47% (95% CI 32.9% – 61.5%), respectively. The positive and negative predictive values were 27% (95% CI 13.8% – 44.1%) and 96% (95% CI 79.7% – 99.9%), respectively. Conclusions This retrospective audit highlighted that the Alvarado score could have been safely used to exclude AA in patients with scores below 5, avoiding the need for further investigations and treatment. A second, prospective study will aim to further validate and implement the routine use of the Alvarado score in the department to improve the diagnostic work-up of patients with suspected AA. The economic impact of its use should also be investigated with a health economics multi-centric study.

The burden of the knowledge-to-action gap in acute appendicitis

BackgroundThe burden of emergency general surgery (EGS) is higher compared to elective surgery. Acute appendicitis (AA) is one of the most frequent diseases and its management is dictated by published international clinical practice guidelines (CPG). Adherence to CPG has been reported as heterogeneous. Barriers to clinical implementation were not studied. This study explored barriers to adherence to CPG and the clinico-economic impact of poor compliance.MethodsData were extracted from the three-year data lock of the REsiDENT-1 registry, a prospective resident-led multicenter trial. We identified 7 items from CPG published from the European Association of Endoscopic Surgery (EAES) and the World Society of Emergency Surgery (WSES). We applied our classification proposal and used a five-point Likert scale (Ls) to assess laparoscopic appendectomy (LA) difficulty. Descriptive analyses were performed to explore compliance and group comparisons to assess the impact on outcomes and related costs. We ran logistic regressions to identify barriers and facilitators to implementation of CPG.ResultsFrom 2019 to 2022, 653 LA were included from 24 centers. 69 residents performed and coordinated data collection. We identified low compliance with recommendations on peritoneal irrigation (PI) (25.73%), abdominal drains (AD) (34.68%), and antibiotic stewardship (34.17%).Poor compliance on PI and AD was associated to higher infectious complications in uncomplicated AA. Hospitalizations were significantly longer in non-compliance except for PI in uncomplicated AA, and costs significantly higher, exception made for antibiotic stewardship in complicated AA. The strongest barriers to CPG implementation were complicated AA and technically challenging LA for PI and AD. Longer operative times and the use of PI negatively affected antibiotic stewardship in uncomplicated AA. Compliance was higher in teaching hospitals and in emergency surgery units.ConclusionsWe confirmed low compliance with standardized items influenced by environmental factors and non-evidence-based practices in complex LA. Antibiotic stewardship is sub-optimal. Not following CPG may not influence clinical complications but has an impact in terms of logistics, costs and on the non-measurable magnitude of antibiotic resistance. Structured educational interventions and institutional bundles are required.

1028 Why Is Changing Old Habits So Hard?

Abstract Aim Acute uncomplicated diverticulitis (AUD) has been traditionally managed by inpatient admission for bowel rest, intravenous antibiotics, and fluids. World Society of Emergency Surgery (WSES) updated their guidelines in 2020 recommending that patients with AUD with no significant co-morbidities or immunocompromise should be treated in an ambulatory setting. This full audit cycle aimed to assess the compliance with these guidelines at our trust. Method Retrospective data collection was conducted from June 2021 to July 2021 (1st cycle). Inclusion criteria was applied: CT proven AUD, patients below the age of 80 with the ability to tolerate oral intake, had full mental capacity and were not immunocompromised. Educational sessions for clinicians and nurses were implemented to inform of current guidelines. Data was re-audited from June 2022 to July 2022 (2nd cycle). Results The first cycle included a total of 31 patients with AUD matching our inclusion criteria where 45% of patients were treated via ambulatory care. Two patients had re-presented but didn’t require admission. The second cycle had a total of 19 patients 47% of which were managed ambulatory. Average length of hospital stay between the inpatient and outpatient groups were 2-3 days versus 4.5 hours. Conclusions The compliance rate with current guidelines increased by 2%, however remained low. With low re- presentation rates and re-admission rates, this audit shows that patients with AUD could be safely managed in ambulatory setting. Shifting engrained mindsets and improving compliance with the current guidelines could greatly save NHS resources and alleviate existing bed pressures.

143 How Well Are We Managing Acute Pancreatitis?

Abstract Aim To evaluate our practice in comparison with gold standards on the management of acute pancreatitis. Method This retrospective audit evaluated the management of patients with acute pancreatitis admitted to our hospital between 01/04/22 and 30/06/22. The gold standards were guidelines published by the World Society of Emergency Surgery (2019) and British Medical Journal (2018). Data collection focused on prognostic scoring, IV fluid resuscitation, nutrition, monitoring of patients, invasive intervention, and performance of cholecystectomy. Data sources included paper notes, imaging and prescribing software. Results 44 patients presented with acute pancreatitis. A prognostic score was calculated in only 4 patients (9.1%). 40 patients (90.1%) received isotonic IV fluids. However, fluid input and output was poorly documented in 17 patients (38.6%). 14 patients (31.8%) received nutritional support; oral Fortisip supplements in the majority (11 patients, 25%). Regarding outcomes, 5 patients (13.6%) developed single or multi-organ dysfunction (respiratory and/or renal failure): 2 patients (4.5%) required admission to the High Dependency Unit. 2 patients (4.5%) died. Regarding intervention, appropriately, no patients underwent endoscopic or percutaneous drainage of pancreatic collections. Where gallstones were the underlying aetiology (12 patients, 27.3%), 10 patients (22.8%) underwent laparoscopic cholecystectomy during, or within 2 weeks of, the index admission. Conclusions Our compliance with gold standards was variable, and this could negatively impact patient care. Lack of prognostic scoring and fluid balance documentation may undermine ability to recognise deteriorating patients with severe pancreatitis requiring escalation of care. Departmental teaching for surgical doctors is the proposed intervention.

WTP3.7 Are we using antibiotics appropriately in acute pancreatitis?

Abstract Aim To re-evaluate antibiotic use in the management of acute pancreatitis at our hospital. Method This retrospective closed loop audit incorporated patients with acute pancreatitis admitted to our hospital between 01/04/22 and 30/06/22. The initial audit was conducted in 2020. The gold standard was guidelines published by the World Society of Emergency Surgery (2019). Data sources included patient paper notes, and clinical results and prescribing software. Results 44 patients presented with acute pancreatitis during the re-audit period; 80 patients were included in the initial audit. 22 of the re-audit patients (50%) received antibiotics, compared with 47 patients (59.1%) in the initial audit. Co-amoxiclav was the most used antibiotic (10 re-audit patients, 46.2%). 19 of the re-audit patients (86.3%) receiving antibiotics had mild or moderate acute pancreatitis (on Modified Glasgow Score); whereas most patients (29, 61%) in the initial audit had severe pancreatitis. Procalcitonin was not measured prior to commencing antibiotics in either audit. Also, no re-audit patient had CT-confirmed evidence of infected pancreatic necrosis. 5 re-audit patients (21.4%) were treated appropriately with antibiotics for extra-pancreatic infection, including acute cholecystitis and hospital-acquired pneumonia. Conclusion Decisions to commence antibiotics in acute pancreatitis have generally been inattentive to guideline recommendations, with greater focus on clinical impression of patient condition and inflammatory markers, such as C reactive protein. However, inappropriate antibiotic use may not bring patient benefit and negatively affect clinical care, for example yielding Clostridium Difficile infection and antimicrobial resistance. Hence, we will now change practice and measure procalcitonin to inform decision-making about antibiotics in acute pancreatitis.

FTP6.6 Same Day Emergency Care Satisfaction Survey, Patients and Staff Respond

Abstract   Surgical Same Day Emergency Care (SDEC) Satisfaction Survey - SDEC was introduced to the hospital in 2021. Aims Methodology Results Conclusion Abstract presented at World Society of Emergency Surgery, 2022.

[Acute mesenteric ischemia-An overview and recommendations (S2k analogous) of the World Society of Emergency Surgery].

Acute mesenteric ischemia is asevere illness, which if untreated, rapidly leads to a critical condition with sepsis, multiple organ failure and death in affected patients. The diagnosis and initiation of treatment of acute mesenteric ischemia should be performed as early and expeditiously as possible and follows the principle of the shortest possible time to reperfusion. Otherwise, the outcome of the patient rapidly deteriorates. The treatment algorithm should be adapted to the pathogenesis of the ischemia, the clinical condition and symptoms of the patients. With clinical signs of peritonitis, intestinal gangrene must be assumed and the abdomen should be surgically explored to detect and treat possible foci of sepsis at an early stage. The treatment of acute mesenteric ischemia should always be performed by an interdisciplinary team with all surgical and interventional options for intestinal revascularization as well as comprehensive intensive care medicine according to the standards of the Intestinal Stroke Center described in the literature. Ashort duration to revascularization and treatment in this interdisciplinary concept improves the outcome of patients with acute mesenteric ischemia. The World Society of Emergency Surgery provides expert consensus-based recommendations for the diagnosis and treatment of acute mesenteric ischemia; however, there is still asignificant lack of broad high-quality evidence for this critical illness. Recommendations of the German specialist societies are urgently needed to ensure appropriate care, from the initial diagnostics to treatment and aftercare, for patients with suspected mesenteric ischemia in this country.

[Interpretation of the World Society of the Emergency Surgery/the Global Alliance for Infection in Surgery/the Surgical Infection Society-Europe/the World Surgical Infection Society/the American Association for the Surgery of Trauma global clinical pathways for patients with intra-abdominal infections].

Intra-abdominal infections (IAI) is common surgical emergencies and have been reported as major contributors to non-trauma deaths in hospitals worldwide. The principles of IAI management included early diagnosis, adequate source control, appropriate antimicrobial therapy, and prompt physiologic stabilization using critical care resources, combined with an optimal surgical approach. In order to facilitate clinical management, establish a global standard and provide guidance for clinicians, the World Society of Emergency Surgery (WSES), the Global Alliance for Infection in Surgery (GAIS), the Surgical Infection Society-Europe (SIS-E), the World Surgical Infection Society (WSIS), and the American Association for the Surgery of Trauma (AAST) worked together to complete an international multi-society document, which provided the evidence-based clinical pathways. Herein, we made a comprehensive interpretation for the clinical pathways combined with the latest domestic and international research developments, aiming to provide evidence for domestic doctors on the diagnosis and treatment of IAI, and ultimately benefit patients.

[Current WSES-AAST guidelines on anorectal emergencies-Summary and comments].

In 2019, the World Society of Emergency Surgery (WSES) and the American Association for the Surgery of Trauma (AAST) generated consensus recommendations for the treatment of anorectal emergencies in Parma, Italy, and published a guideline in 2021. This is the first global guideline dealing with this important topic for surgeons' everyday work. Seven anorectal emergencies were discussed and the guideline recommendations were given according to the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system.

Time for a paradigm shift in shared decision-making in trauma and emergency surgery? Results from an international survey

BackgroundShared decision-making (SDM) between clinicians and patients is one of the pillars of the modern patient-centric philosophy of care. This study aims to explore SDM in the discipline of trauma and emergency surgery, investigating its interpretation as well as the barriers and facilitators for its implementation among surgeons.MethodsGrounding on the literature on the topics of the understanding, barriers, and facilitators of SDM in trauma and emergency surgery, a survey was created by a multidisciplinary committee and endorsed by the World Society of Emergency Surgery (WSES). The survey was sent to all 917 WSES members, advertised through the society’s website, and shared on the society’s Twitter profile.ResultsA total of 650 trauma and emergency surgeons from 71 countries in five continents participated in the initiative. Less than half of the surgeons understood SDM, and 30% still saw the value in exclusively engaging multidisciplinary provider teams without involving the patient. Several barriers to effectively partnering with the patient in the decision-making process were identified, such as the lack of time and the need to concentrate on making medical teams work smoothly.DiscussionOur investigation underlines how only a minority of trauma and emergency surgeons understand SDM, and perhaps, the value of SDM is not fully accepted in trauma and emergency situations. The inclusion of SDM practices in clinical guidelines may represent the most feasible and advocated solutions.

Endoscopic retrograde appendicitis therapy or antibiotics for uncomplicated appendicitis.

Although laparoscopic appendectomy is the common intervention for uncomplicated acute appendicitis, there are risks1. Guidelines from the World Society of Emergency Surgery suggest that antibiotic therapy is an option2, but recurrence is 15 to 39 percent at 5 years3. A mini-invasive technique called endoscopic retrograde appendicitis treatment (ERAT) was developed for uncomplicated appendicitis instead of antibiotics or surgery4. ERAT aims to relieve the obstruction or stenosis of the appendiceal lumen, to prevent recurrent episodes of the disease (92 to 95 percent have not had a recurrence to date)5–7. This multicentre study assessed ERAT versus antibiotics for the treatment of uncomplicated appendicitis. Data on adult patients treated with ERAT or antibiotics for imaging-confirmed uncomplicated appendicitis from five centres in China (May 2018 to June 2020) was assessed retrospectively. The ERAT procedure was performed as described4 (Appendix S1). The antibiotic group received intravenous metronidazole 500 mg q8h combined with ceftriaxone 2 g q12h, cefoperazone/sulbactam 2 g q12h, or piperacillin–tazobactam 4.5 g q8h. Oral antibiotics (metronidazole 500 mg q8h with levofloxacin 500 mg q24h, ciprofloxacin 500 mg q8h, or amoxicillin–clavulanic acid 625 mg q8h) were taken after a minimum 72 hours of intravenous antibiotics. Patients could take analgesics as needed. Appendicectomy was recommended if there was worsening pain or white cell count.