[Traumatic lesions of the diaphragm]. / Le lesioni traumatiche del diaframma.

The Authors studied 30 cases of diaphragmatic traumatisms from 1972 to 2003 to stress the difficulty to achieve an early diagnosis and the need of their immediate treatment: 26 of these patients were male and 4 female (6.5:1); the pathogenesis was in 50% of cases an open trauma and in 50% a closed trauma. The mean age was 36.6 years (33.4 in the open trauma and 41.4 in the closed). The left hemi-diaphragm was affected more frequently (63%) than the right (37%). The associated lesions were mainly of the parenchymatous abdominal organs (spleen 43.3% and liver 49%), while in the thorax lung was involved in 20% of cases and heart in 3.3%. All patients underwent plastic surgical intervention of the diaphragm. In only one case, particularly severe, the operation consisted in placing a pleuric drain and death occured a few hours later. Mean mortality was 30% (33.3% in open and 26.6% in closed traumas) and mean hospital stay was 36.2 days. Accurate diagnosis in emergency is difficult because of the frequent associated lesions, typical of these patients. Despite of the optimisation of the rescue and the new imaging technologies, the gold standard for treatment is not yet reached. There is still a considerable amount of misdiagnosis, a relevant mean hospitalization, a high mortality and a very high morbidity. The best approach to thoraco-abdominal traumas is still to fear a diaphragmatic lesion up to contrary demonstration, in order to achieve precocious diagnosis and surgical treatment, to avoid complications of delayed treatment.

[Surgical management of trauma: from the "golden hour" to the "Golden Day"]. / La gestione chirurgica del trauma: dalla "golden hour" al "Golden Day".

The treatment of the "trauma" has individualized objective therapeutic to reach in the first phase of clinical management defined by Mattox in the concept of the Golden Hour, that consist to transport the patient to the fittest hospital and to recognize and to treat the priorities "ABCDE", identifies in ATLS Guideline. The evolution of the organization for the treatment of the trauma has developed the concept of Trauma System to whose apex there are of the structures devoted define Trauma Center, with specificity of structures and functions, personal devoted fully grown with a specific run. In the Trauma Center is possible to get a therapeutic planning according to the priorities of the case in few times so that to not only achieve the objective to treat in emergency the vital lesions, but to do the necessary treatments precociously to prevent the compliances of the patient, that is checked in environment then multidisciplinary intensive care. This systematic treatment by objective it allows to identify some Guideline of surgical treatment for priority in once defined Golden Day.

[Use of adhesives in emergency surgery]. / L'uso dei collanti in chirurgia d'urgenza.

In a prospective study, the Authors present an analysis on the use of surgical adhesives in the wounds treatment. In sixteen months we have treated 157 patients exclusively with a surgical tissue adhesive 2-octylcianoacrylate to repair traumatic wounds and surgical ones. In the Emergency Department were treated 110 patients (70%) with 2-octylcianoacrylate for skin incisions, lacerations and the length of lesion. We have paid attention to prepare regular wound edges, irrigation and debridement when appropriate to reduce skin tension at the site of laceration. Forty-seven patients (30%) whit surgical skin incisions for thyroidectomy, appendicectomy, hernio-plastic and safenectomy were treated with 2-octyl-cianoacrylate. In both groups of patients, the surgical adhesive has made possible a simple and quick wounds repair as well as good aesthetic results. No relevant complications have been arisen. The writers recommend the surgical adhesive in Emergency Department to abridge waiting time and to avoid the psychological impact caused by local anaesthesia, suture and medications especially in the treatment of all wounds types in children.

[Spontaneous biliodigestive fistulae. The clinical considerations, surgical treatment and complications]. / Fistole bilio-digestive spontanee. Considerazioni cliniche, trattamento chirurgico e complicanze.

To reevaluate the current feature of spontaneous bilioenteric fistula we reviewed 81 cases who had been treated for biliary fistula between 1948 and 1998. After a review of the literature on this subject, the multiple problems relate to pathological anatomy, pathogenesis and physiopathology are discussed. Of 81 patients, 55 were women and 26 were men with the average age of 54.5 years. The most common type of fistula was cholecysto-duodenal (55 cases--68%), followed by cholecysto-colonic (11 cases--13.6%), choledocho-duodenal (7 cases--8.6%), cholecysto-gastric (4 cases--4.9%) and duodeno-left hepatic duct fistula (4 cases). The authors have found in 41 cases the gallstone ileus complications, in 12 cases inflammatory disease of biliary three, in 8 cases hemobilia, gallstone ileus with perforation and digestive hemorrhage compliances respectively. All the patients were treated with surgery. A first procedure consists of enterolithotomy, in gallstone ileus cases, followed by biliary surgery. In 14 patient the general or local conditions argued against one-stage procedure and two-stage procedure had been considered. In 63 patients a cholecystectomy was done, 15 were treated with enterolithotomy and 8 with intestinal resection. Seven patients with gastroduodenal ulcer based fistula have required a gastroduodenal resection. The mortality was 13.6% (11 cases).

[Inhaled foreign bodies: first aid]. / Corpi estranei inalati: il primo soccorso.

In the last 30 years 1,484,576 patients with traumatic lesions of different kind of seriousness were observed and managed. By mean of retrospective investigation, the authors selected and statistically analysed a sample of 95 patients treated for accidental tracheobronchial foreign bodies inhalation: authors' aim was to punctually determinate--step by step--diagnosis and treatment procedure in a "time-saving" frame. Inhalation of foreign bodies is a very dangerous event, particularly in children. In authors' experience, in 60% of cases they were children under 3 years; in 25% of cases children under 10; in 10% patients from 10 to 60 and in 4.5% over 60. As regards the gender of the patients, the male/female ratio has been 2 to 1 in favour of male. Since 85% of the study population was represented by children under 10, its clear that male children in this range of age has a greater statistical risk for accidental tracheobronchial foreign bodies inhalation.

[Deep venous thrombosis and neoplastic pathology: our experience in emergencies]. / Trombosi venose profonde e patologia neoplastica: nostro contributo in urgenza.

Deep vein thrombosis incidence is 1/1000 per year; it is associated with many risk factors which is considered as "thrombophilic states". Its pathogenesis is complex, caused by alterations of hemostasis system. Many studies have established the relation between cancer and subsequent venous thromboembolism, confirming the relationship of neoplastic cell interaction with coagulation system. Forty-seven patients admitted to the hospital from 1987 to 1996 with symptomatic clinically proved deep vein thrombosis were included in a retrospective study. Routine examination at the time of diagnosis of deep vein thrombosis revealed an occult cancer in 8 out of 47 patients; 9 out of 47 patients were admitted in hospital with vein thrombosis and known cancer. The aim of this study is to suggest the best, first treatment of vein thromboembolism in emergency to avoid the dangerous pulmonary embolism complication. The patients affected with deep vein thrombosis and cancer were elderly (over 70 years old, in mean); the neoplasia was of digestive system (8/17) in advanced metastatic stage there was cancer familiarity in 7 out of 47 patients. The high risk of pulmonary embolism associated to deep vein thrombosis suggests the importance of early starting the anticoagulant therapy and placing caval filter.

[Problems in emergency visceral reconstruction in colorectal pathology]. / Problematiche della ricostruzione viscerale in urgenza nella patologia colo-rettale.

A diagnostic-therapeutic protocol for colorectal haemorrhage is suggested. The Authors underline the need to remove inflammatory foci when a perforation of the colon occurs; furthermore, in the acute obstruction due to colorectal carcinoma a resection followed, when possible, by an immediate anastomosis is recommended.

[Chronic splenic tuberculosis. Description of a case]. / La tubercolosi splenica cronica. Descrizione di un caso.

The authors report a case of chronic splenic tuberculosis. They underline the diagnostic difficulties, notwithstanding the remarkable progresses in radiological technics, essentially related to the rarity of this tubercular site and they outlined the exact surgical indication to the splenectomy.

[Indications for and comparisons between transduodenal papillostomy and choledochoduodenostomy]. / Indicazioni e confronti tra papillostomia transduodenale e coledocoduodenostomia.

Biliary lithiasis is still a subject of great interest. The aim of surgical treatment is removing common bile duct stones and assuring a good biliary outflow. In this study the authors report their experience in the surgical treatment of common bile duct stones and the indications for transduodenal papillostomy (PST) and latero-lateral choledochoduodenostomy (CDA). The results are similar to those in the international literature and are surely good for both the procedures. Papillostomy is the procedure of choice, unless there are specific contraindications, in the treatment of common bile duct lithiasis for the following reasons: good immediate and long-term results, low incidence of postoperative complications, prevention of recurrent lithiasis. Choledochoduodenostomy, when clearly indicated, offers good results and, when the anastomosis is large enough, also has a low incidence of postoperative complications. Finally PST and CDA are not alternative procedures but present precise indications. The authors stress the possibility of combining these two techniques, in selected cases, with good results.