Major trauma critical pathway: preliminary results from the monitoring system in the regional network and in a hub center in Rome metropolitan area.

OBJECTIVE: The aim of this study is to collect the two years' data regarding the Integrated Trauma Management System (SIAT) by capturing the activity of its three Hubs in the Italian Lazio Region and test the performance of one of the Hubs' (Fondazione Policlinico Universitario A. Gemelli - IRCCS, FPG -IRCCS) Major Trauma Clinical Pathway's (MTCP) monitoring system, introducing the preliminary results through volume, process and outcome indicators. MATERIALS AND METHODS: A retrospective analysis on SIAT was conducted on years 2016 to 2018, by collecting outcome and timeliness indicators through the Lazio Informative System whereas the MTCP was monitored through set of indicators from the FPG - IRCCS Informative System belonging to randomly selected clinical records of the established period. RESULTS: Hubs managed 11.3% of the 998,240 patients admitted in SIAT. All patients eligible for MTCP were "Flagged", and 83% underwent a CT within 2 hours; intra-hospital mortality was 13% whereas readmission rates 16.9%. CONCLUSIONS: SIAT converges the most severe patients to its Hubs. The MTCP monitoring system was able to measure a total of 9 out of 13 indicators from the original panel. This research may serve as a departing point to conduct a pre-post analysis on the performance of the MTCP.

[Abdominal compartment syndrome: patophysiologic and clinic remarks]. / La sindrome compartimentale addominale: rilievi fisiopatologici e clinici.

The abdominal compartment syndrome is a high grade abdominal hypertension with clinical evidence of multiorgan failure (MOF). It is more and more frequently observed in intensive-care units as a complication in critical patients, but especially in traumatology and surgery. The incidence is highly variable according to the different trials but the severity of scores is the common factor. All the possible mechanical, haemorrhagical, inflammatory and traumatological causes act but do not enable the stability of the abdominal content, abdominal compliance and parietal tension. The initial triad of effects consists in diaphragm elevation and visceral and vascular compression and therefore triggers a physio-pathological way that leads to a respiratory, renal and cardiovascular dysfunction and to parietal, hepatic and intestinal ischaemia and consequent bacterial translocation: sepsis and MOF. Burch's classification (1996) reports four levels of gravity from low (<15 mmHg) to severe (>35 mmHg): both of the first grades should be managed in intensive-care units with conservative pharmacological procedures, while for the two others a surgical approach of laparotomy with drainage and temporaneous closure of the abdominal wall should be considered. As mortality is still very high (29-62%), especially when multiorgan failure is already set; bladder pressure of all critical patients should be monitorized to treat immediately any potential abdominal hypertension.

[Packing: current concepts of "life-saving" surgery]. / Packing: attuali concetti di una chirurgia "salvavita".

Abdominal packing is a lifesaving technique for temporary control of severe injury and it is used in Damage Control Surgery schedule. Technically bleeding from abdominal cavity can generally be achieved by applying pressure with several large abdominal packs. It's possible too applying packs in organ-specific techniques (early abdominal packing). A wide review of the literature has allowed to emphasize the most common problem of this technique, the adequacy of the particular indications, their evolution, timing, the results in general and particular which multiple critical situations and not always predictable when an intensive diagnostic and methodological approach is necessary in. The principal indications are when complex anatomic lesions are diagnosed with not ruleable hemorrhages, in presence of metabolic failure--like hypothermia < 35 degrees C, acidosis > 7.2, coagulopathy PTT > 16 seconds: these three derangements become established quickly in the exsanguinating trauma patient and, once established, form a vicious circle which may be impossible to overcome. The results are encouraging and we can evaluate a median survival of the 60%, certainly superior to the obtainable survival with immediate surgical repair. Immediate failures are substantially due to bleeding, especially in "underpacking" case, and remote: these last can be premises, fundamentally septic and bound at the time of stay (above the 72 hours) and associated by the coexistence of lesions; in these situations is possible a MOF syndrome due to excessive intraabdominal pressure (overpacking) or to an abdominal compartment syndrome.

[Abdominal "packing": indications and method]. / Il packing addominale: indicazioni e metodo.

Abdominal packing is a lifesaving technique for temporary control of severe injury and it is used in damage control surgery schedule. Technically bleeding from abdominal cavity can generally be achieved by applying pressure with several large abdominal packs. Its possible too applying packs in organ-specific techniques (early abdominal packing). A wide review of the literature has allowed to emphasize the most common problem of this technique, the adequacy of the particular indications, their evolution, timing, the results in general and particular which multiple critical situations and not always predictable when an intensive diagnostic and methodological approach is necessary in. The principal indications are when complex anatomic lesions are diagnosed with not ruleable hemorrhages, in presence of metabolic failure (hypothermia < 35 degrees C, acidosis > 7.2, coagulopathy PTT > 16 seconds: These three derangements become established quickly in the exsanguinating trauma patient and, once established, form a vicious circle which may be impossible to overcome. The results are encouraging and we can evaluate a median survival of the 70%, certainly superior to the obtainable survival with immediate surgical repair. Immediate failures are substantially due to bleeding, especially in "underpacking" case, and remote: these last can be premises, fundamentally septic and bound at the time of stay (above the 72 hours) and associated by the coexistence of lesions: in these situations is possible a MOF syndrome due to excessive intra-abdominal pressure (overpacking) or to an Abdominal Compartment Syndrome.

[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.

[Damage control surgery: the technique]. / Damage control surgery: le tecniche.

Abdominal packing and planned reoperation is a lifesaving technique for temporary control of haemorrhage in severely injured patients. Morbidity and mortality, however, remain significant. The purpose of this study is to evaluate all surgical technique and our results during 31 years of trauma surgery. In the last 12 years the Authors have performed 11 packing. They stressed fully "damage control technique" in trauma surgery in the last four years. Overall mortality was 45.5%.

[Superior vena cava syndrome]. / Sindrome della vena cava superiore.

Superior vena cava syndrome is due to an intrinsic or extrinsic caval obstruction that evolves in acute or subacute way with distinctive clinical feature such as respiratory symptoms and venous stasis. Since 1998 we have treated three cases of spontaneous superior vena cava thrombosis in neoplastic patients who underwent several infusion of chemotherapy, respectively for a breast, uterine and rectum cancer. All patients was female, 52, 58 and 70 years old. The first two cases was treated with locoregional thrombolysis by infusing Urokinase 50,000 UI/h during 24 hours and Urokinase 50,000 UI/h during 12 h the third one. After that, we have positioned a 16/9 wallstent: in the first two cases directly into the superior vena cava, in the third case in the subclavian-anonyma truncus. We had in all cases the complete opening of the stent within the first 48 hours without complications, enabling us to reach a free caval diameter of about 2 cm with resolution of the clinical signs. In patients with high surgical risk, the caval wall-stent is the first choice to solve the vein recanalization.

Intramural mesenteric venulitis. A new cause of intestinal ischaemia.

Venous damage is an uncommon cause of intestinal ischaemia. We report on a 44-year-old woman who presented signs and symptoms of acute intestinal ischaemia requiring surgical treatment. Histological examination of the resected right colon showed features of an intramural lymphocytic venulitis with no other demonstrable causes of ischaemic injury of the bowel. Extramural mesenteric veins appeared dilated and congested, without evidence of thrombotic occlusion or of inflammatory involvement. The patient, who was not taking any long-term medication and had no clinical evidence of collagen-vascular disease, promptly recovered after surgery. Follow-up for 7 months with no recurrences suggested a self-limited or indolent process. We propose the name 'intramural mesenteric venulitis' for this condition and believe that it could represent one extreme (the microscopic variant or intramural phase) of the spectrum comprising entero-colic phlebitis and mesenteric inflammatory veno-occlusive disease. The immunohistochemical evidence of a marked preponderance of T phenotype in the perivenular lymphocytes suggests lymphocyte-mediated vascular damage as the pathogenesis of the lesion.

[Kidney failure during acute pancreatitis. A unique aspect of multiple organ failure]. / Insufficienza renale in corso di pancreatite acuta. Un particolare aspetto della M.O.F.

Eighty-two patients with acute pancreatis observed in the last seven years were included in prospective trial of monitoring protocol comprising: multiple organ failure and non invasive imaging of pancreatic lesion. One organ failure noted in the 60.9%, M.O.F. with three organ failure represented in the 21.9%. Renal failure was confirmed in 18.9%, trough nine clinical and biological index, become with shock in 73% and with extensive necrosis in 53%. ARF appeared with functional picture and normal diuresis in 73.3% and with organic failure in 26.7%. Index of specific mortality was 33.3%, while the comprehensive index of mortality in the study group was 12.9%, with a significant incidence in the half of deaths.

[Surgical treatment of pancreatic pseudocyst]. / Il trattamento chirurgico delle pseudocisti del pancreas.

The review of diagnosis and treatment of 18 pancreatic pseudocysts has led to some conclusions about controversial aspects of the surgical management. The accuracy of imaging techniques in the early detection of the pseudocyst is high and plays a major role in the demonstration of its spontaneous resolution and evolution. The optimal surgical treatment of uncomplicated pseudocysts is the internal drainage, most rarely their resection. The incidence of septic complications was 22%: in this case the pseudocysts are usually best managed by external drainage.

[Primary resection in occlusions caused by cancer of the left colon]. / La resezione primaria nelle occlusioni da cancro del colon sinistro.

Based on a survey of 47 cases of left colonic occlusive cancer operated on at the Emergency Surgery Department-University of Rome "La Sapienza", the authors concluded that in such condition, when the patient is not seriously ill, the Hartmann procedure is a valid alternative to the anastomosis-resection because: a) it solves intestinal obstruction in a short time with consequent improvement of general conditions; b) it allows to perform the second oncologically radical operation early with less risk of neoplastic spread. The latter procedure, therefore, is carried out under better conditions, relative to the stage of the disease and the status of the patient.

Somatostatin infused during acute pancreatitis retains its biological activity.

Somatostatin (SST) is used in the treatment of acute pancreatitis (AP) to inhibit pancreatic exocrine secretion, which represents one of the goals of medical treatment in this disease. Its therapeutic efficacy, however, is poor. One hypothesis, which has not yet been investigated, is that i.v. SST might be broken down by blood proteolytic enzymes. In order to evaluate the structural integrity and biological activity of infused SST, somatostatin-like immunoreactivity (SLI) and levels of pancreatic enzymes were monitored in the blood stream during the infusion of SST-14 (3,5 micrograms/kg/h for 48 h) in eight patients with severe acute pancreatitis. SLI was measured by both radioimmunoassay (RIA) and high-pressure liquid chromatography (HPLC). The results indicate that SLI levels increase promptly after the beginning of infusion, with a slower increase between 6 and 36 h, and a rapid increase again at 48 h. HPLC analysis shows a single peak of SLI with the same retention time as standard SST-14. Total amylase, lipase, and trypsinogen significantly decreased compared with pretreatment values (48, 63.1, and 77.4%, respectively) after 24 h of SST infusion, while a decrease in elastase 1 (62.6%) was observed later at 48 h. These results indicate that in severe AP, somatostatin recovered in plasma retains its biological activity: it inhibits pancreatic circulating enzymes, an action not influenced by breakdown of the peptide, as demonstrated by HPLC of the SLI measured in plasma.