Operative and non-operative treatment of injury to solid abdominal organs in adult patients: a single center experience.

BACKGROUND: In major trauma, lesions of the parenchymatous organs are subject of a controversy as regards the choice between an operative management (OM) in the operating room and a non-operative management (NOM) associated or not with angiography/angioembolization (AG/AE). METHODS: Retrospective study of all consecutive data of patients coded as "traumatic pathology" in the period between 2011 and 2021. Were enrolled 13740 entries of adult patients with abdominal injuries, including at least: either hepatic or splenic or renal injury of AAST-OIS I. The primary outcome was to establish the rate of efficacy, respectively of OM and NOM. The secondary outcome is to analyze General (CG) and Specific (CS) complications, mean ward and intensive care unit (ICU) hospital stays. RESULTS: One hundred sixty-two patients were included with 89 splenic injuries, 70 hepatic and 50 renal lesions; 35 treated with OM and 127 with NOM±AG/AE. The CGs registered in OM patients are seven (20%); seven SCs (20%); four GCs+SCs (11.4%). The average hospital stay was 24.91 days; mean ICU hospital stay of 10.74; five deaths. The CGs registered are 22 (17%); 12 SCs (9.4%); three GCs+SCs (2.3%). Average hospital stays 18 days; mean ICU hospital stay of 3.15; 6 deaths. Failure of the NOM strategy was recorded in nine patients with a success rate of 92.91%. CONCLUSIONS: In OM the presence of numerous high-grade lesions leads to a rapid stabilization. The NOM has reduced the hospital stay and UTI hospitalization in a feasible and safe way in selected CT.

Management and treatment of Fournier's gangrene. Our Emergency Department Experience and literature review.

Fournier's Gangrene (FG) is an extremely serious condition of necrotizing soft tissue infection. The treatment of this critical condition is urgent but much debated, especially as regards the management of larger defects and wound closure, with various techniques being described in the current literature. Through a case series we aimed to present our surgical management of FG treated successfully with Negative Pressure Wound Therapy (NPWT) and performing a loop colostomy. KEY WORDS: Fournier's gangrene, Loop colostomy, Negative Pressure Wound Therapy.

Repercussions of COVID-19-related national lockdown on Emergency Surgery Department: a longitudinal cohort monocentric study.

BACKGROUND: COVID-19 lockdown restrictions in conjunction with the pervasive hospital fear endured by the vast majority of the population played a fundamental role in discouraging access to emergency departments (EDs). We aimed at investigating whether and how the COVID-19 outbreak limited the access to ED and affected urgent surgical activities during and immediately after the 2-month pandemic-related national lockdown. METHODS: Data regarding patients who accessed to the surgical ED were retrospectively collected. Analyzed time-periods included: "pre-COVID-19 era," "COVID-19 era" considered as the period of full national lockdown and "post-COVID-19 era" after easing of lockdown measures. Consecutive emergency surgical procedures and ED admissions before, during and after COVID-19-lockdown were retrieved and analyzed. RESULTS: There was a significant decrease in overall ED admissions and in all-specialty surgical consultations (P<0.01) throughout the outbreak. Once national lockdown was eased, we recorded a subsequent rebound 5-fold rise of emergency surgical procedures compared to COVID-19 group (P=0.011). Time-to-surgery was significantly greater in "COVID-19 era" and "post-COVID-19 era" compared to "pre-COVID-19" group (22.56±4.78, 75.99±15.89 and 16.73±1.76 hours, respectively) (P<0.01). A raised incidence of postoperative complications emerged in the "COVID-19 era" group (37.5%) compared to pre- and post-COVID groups (9.1% and 12.5%, respectively; P<0.001). Mortality rate in the "COVID-19 era" was 31.3% and 7.5% in "post-COVID-19" group (<0.0001). CONCLUSIONS: This study demonstrates the major reduction of emergency surgical procedures and overall, ED admissions caused by COVID-19 pandemic. The raised rate of postoperative complications and mortality might be likely due to the superior severity of surgical conditions observed in the "COVID-19 era" subjects together with a probable deferred pursuit of medical attention.

Hepatic abscess: An uncommon complication after laparoscopic appendectomy.

AIM: Laparoscopic appendectomy is currently the treatment of choice for acute appendicitis in emergency setting. When appendicitis is clinically suspected, an appendicolith can be found in 30% of the patients. Retained or dropped appendicoliths are an uncommon complication that may occur as a consequence of stone expulsion from the appendix, before or during laparoscopic appendectomies. This is very rare with only 30 reported cases of intra-abdominal abscess secondary to an appendicolith in the literature over the past 40 years. The objective of this case report is to illustrate an intrahepatic localization of a dropped appendicolith causing liver abscess. CASE PRESENTATION: A 23-year-old female was admitted to the emergency department of our hospital for an acute appendicitis with coprolite obstructing the lumen and periappendicular effusion. Laparoscopic appendectomy was performed. Persistent liver abscess due to appendicolith was a rare complication treated by percutaneous drainage. The appendicolith was successfully removed from the liver parenchyma by Dormia basket recovery system. DISCUSSION: Treatment options include percutaneous, open, or laparoscopic drainage of the abscess and retrieval of the fecalith, as antibiotics and drainage alone are usually insufficient. CONCLUSION: Only a handful of cases of hepatic abscess formation as a result of dropped appendicoliths have been reported in literature. Our proposal of treatment was the percutaneous approach. There was no need for a surgical procedure to remove the intrahepatic appendicolith. KEY WORDS: Dormia basket, Intrahepatic abscess, Laparoscopic appendectomy, Percutaneous drainage.

Effects of levosimendan on mitochondrial function in patients with septic shock: a randomized trial.

Mitochondrial dysfunction is key feature of septic shock and contributes to the development of sepsis related organ dysfunction. It is characterized by a variable reduction of the respiratory chain (RC) activities, altered mitochondrial morphology and reactive oxygen species production. Recent data have reported the efficacy of levosimendan, a calcium sensitizer, in improving heart performance and organ perfusion in critically ill patients. Moreover, it has been demonstrated that Levosimendan has antioxidant properties. Nevertheless, the effects of levosimendan on mitochondrial function are not fully elucidated. The objective of this study was therefore to evaluate the effect of levosimendan on mitochondria performance. Five mitochondrial parameters were screened: the redox status; the amount of scavenging enzymes; the activities of the RC complexes; the mitochondrial content; the steady state levels of the RC subunits; the mitochondrial biogenesis. Our results show that patients treated with levosimendan had a significant reduction of glutathionylated proteins and an increase in the amount of the antioxidant enzyme MnSOD, underlining its antioxidant properties. The activities of the RC complexes I, II and III were unchanged in the mitochondria of patients treated with levosimendan compared to controls whereas the mitochondrial content was significantly higher in levosimendan vs. control patients. Finally, evaluation of mitochondrial biogenesis did not show any significant difference in the two groups, although an overall increase in the amount of the RC subunits was observed in the levosimendan group. In conclusion, our study demonstrated that in septic shock patients, Levosimendan exerts antioxidant action by increasing antioxidant defense and lowering oxidative damage.

Parathyroid carcinoma: the importance of high clinical suspicion for a correct management.

Background. Parathyroid carcinoma is an infrequent clinical entity whose diagnosis is very challenge. Indeed a pre-operative or intraoperative diagnosis of parathyroid carcinoma is reported in less than half cases described in the literature. Patients and Methods. A systematic review of pathological reports of our secondary referral hospital was done. From 2003 to 2011 one hundred and forty-four patients were operated for hyperparathyroidism. One patient with atypical adenoma and three patients with parathyroid carcinoma were included in this paper. Results. An en bloc resection of the tumor was performed in three patients. Two of this patients with diagnosis of parathyroid carcinoma are alive with no evidence of recurrence or metastasis, respectively, 48 and 60 months after the operation; one patient with diagnosis of atypical adenoma died for other disease 16 months after the operation. In the last patient a simple parathyroidectomy was performed. After that histology revealed the diagnosis of parathyroid carcinoma the patient underwent reoperation for left hemithyroidectomy and central compartment lymph node clearance. After 30 months a lung lobectomy was done due to metastasis. Conclusion. Parathyroid carcinoma should be considered in the differential diagnosis of PTH-dependent hypercalcemia because optional outcomes are associated with complete resection of the tumor at the time of initial operation.

Traumatic subclavian arterial rupture: a case report and review of literature.

Subclavian artery injuries represent an uncommon complication of blunt chest trauma, this structure being protected by subclavius muscle, the clavicle, the first rib, and the deep cervical fascia as well as the costo-coracoid ligament, a clavi-coraco-axillary fascia portion. Subclavian artery injury appears early after trauma, and arterial rupture may cause life-treatening haemorrages, pseudo-aneurysm formation and compression of brachial plexus. These clinical eveniences must be carefully worked out by accurate physical examination of the upper limb: skin color, temperature, sensation as well as radial pulse and hand motility represent the key points of physical examination in this setting. The presence of large hematomas and pulsatile palpable mass in supraclavicular region should raise the suspicion of serious vascular injury. Since the first reports of endovascular treatment for traumatic vascular injuries in the 90's, an increasing number of vascular lesions have been treated this way. We report a case of traumatic subclavian arterial rupture after blunt chest trauma due to a 4 meters fall, treated by endovascular stent grafting, providing a complete review of the past twenty years' literature.

Acute emphysematous cholecystitis as a cause of pneumoperitoneum.

The authors report a rare case of acute emphysematous cholecystitis with pneumoperitoneum. Emphysematous cholecystitis is an uncommon variant of acute cholecystitis. Association with pneumoperitoneum is very rare and the finding of a macroscopic perforation of the gallbladder is possible only in a few cases. A review of the literature revealed 15 other cases of this combination. Diagnostic options and treatment modalities in these patients are discussed here.

Perforated jejuneal diverticulosis. Case report and review of literature.

Acquired (non-Meckel's) jejunoileal diverticulosis is an uncommon disease, generally characterised by vague and unspecific symptoms. This rare condition is mainly expressed as acute complications: gastrointestinal haemorrhage, mechanic obstruction of the small intestine or perforated diverticulum, requiring urgent surgical intervention. The authors report a case of this unusual clinical occurrence characterized by a picture of abdominal pain due to perforation of jejuneal diverticulum. The final etiological diagnosis was possible only during surgery.

Iatrogenic intramural hematoma of the duodenum caused by endoscopic therapy of bleeding peptic ulcer. A case report.

The authors report a case of intestinal obstruction resulting from a duodenal intramural hematoma after therapeutic upper digestive endoscopy with injection therapy. Intramural duodenal hematomas are rare clinical entities, mostly caused by blunt traumas. They may also, more rarely, be due to complications of peptic duodenal ulcers, or be the iatrogenic result of an endoscopic biopsy or placement of a percutaneous endoscopic gastrostomy catheter. It has recently become obvious that surgery is not necessary in most patients with duodenal hematomas. The treatment of choice for cases of intramural duodenal hematomas is of a conservative kind. Today we can employ minimally invasive diagnostic and therapeutic techniques for the percutaneous or laparoscopic evacuation of the hematoma, which seem to guarantee optimal results, compared to the high morbidity rate associated with laparatomy evacuation.

Comparison among preoperative single-slice CT and multi-slice CT in simple, closed loop and strangulating bowel obstruction.

BACKGROUND/AIMS: The aim of this study is to compare preoperative single-slice CT (SSCT) and multislice-CT (MSCT) accuracy in the evaluation of patients with bowel obstruction and intestinal necrosis. METHODOLOGY: 64 patients were enrolled. We analyzed the SSCT scans of 30 patients and the MSCT scans of 34 patients with clinical and abdominal plain film evidence of bowel obstruction. Presence, site, kind, and cause of the obstruction were evaluated; specific signs of strangulating or closed loop obstruction and wall necrosis were also identified. Three radiologists interpreted the CT scans independently; a consensus review was obtained, indicating the need of emergency or delayed surgery. The results were assayed on the basis of surgical findings. RESULTS: SSCT and MSCT findings of bowel obstruction presented good correlation with the surgical report. Sensitivity, specificity, PPV and NPV were 86.1%; 89.3%; 91.1%; and 83.3% respectively. The k coefficient of interobserver agreement was significant (0.729; p<0.01). A major difference was observed between findings in SSCT and MSCT in detecting intestinal ischemia (p <0.05); a noteworthy statistical difference between these techniques was observed especially in the sensitivity and specificity of the edema, twisting and/or thickening of mesenteric vessels (p<0.05). CONCLUSIONS: The first objective of abdominal CT in patients with bowel obstruction is to evaluate the need for emergency surgery because delayed operations potentially result in high mortality. A CT presenting high correlation to surgical findings allows a correct surgical timing and planning thanks to the correct identification of site, kind, and causes of bowel obstruction. MSCT presents better results compared to SSCT in assessing intestinal necrosis.

[Thyroid surgery: total and partial resection. Analysis of complications and a review of the literature]. / La chirurgia tiroidea: exeresi totale ed exeresi parziale. Analisi in termini di complicanze e revisione della letteratura.

The authors review the recent international literature relating to approximately 36,800 cases of thyroid surgery, analysing the complications associated with total thyroidectomy versus partial resection of the thyroid, with a view to drawing up lines of conduct in terms of indications for surgery of benign disease and suggestions on surgical technique to reduce complications such as recurrent laryngeal nerve injuries (transient and definitive), hypocalcaemia (transient and definitive) and superior laryngeal nerve injuries.

[Conservative approach to IV grade renal trauma]. / Approccio conservativo al trauma renale di IV grado.

A case of grade IV renal trauma is reported and the literature reviewed. A 29-year-old man was admitted in an emergency setting for a grade IV renal and splenic trauma as a result of a motorcycle accident. Since the patient was haemodynamically stable and the retroperitoneal haematoma was neither expanding nor pulsating, a conservative approach was adopted and the renal trauma was managed with interventional radiology. The case shows that major renal traumas can be usefully managed by non-operative treatment, necessarily consisting in a mutidisciplinary approach.

[Classification and management of gynecologic acute abdomen at a secondary level hospital emergency department]. / Inquadramento e gestione dell'addome acuto di origine ginecologica in un Dipartimento di Emergenza ed Accettazione di II livello. Analisi di 103 casi.

This study retrospectively evaluates the preoperative work-up and the classification and operative treatment of acute abdomen caused by gynaecological disorders in emergency admissions to our department. All female patients admitted in the emergency setting and operated on for gynaecological acute abdomen in our emergency department over the period from 1997 to 2002 were included in the study. A total of 103 patients were identified (54 undergoing emergency operations, 9 operated on within 72 hours, and 40 managed conservatively with medical therapy. The 54 emergency operations performed were 24 ovarian resections, 17 salpingectomies, 5 oophorectomies, 4 exploratory laparotomies, 2 uterine polypectomies and 2 hysterectomies. The non-specific presentation of the disease and an inadequate preoperative work-up in these patients often led to a generic diagnosis at admission. This approach tends to increase the number of operations performed on an emergency basis, whereas a wait-and-see type of management should be adopted. A proper use of surgery is mandatory especially in those patients in whom preservation of reproductive capability has a major impact on outcome.

[Multidisciplinary approach to the patient with multiple trauma: a case report]. / Approccio multispecialistico al paziente politraumatizzato: un caso clinico.

A multidisciplinary approach to severe polytraumatized patient is very important for a rapid, uncomplicated recovery. Specialized centres with special beds, monitoring equipment, and a multidisciplinary team are required. The authors report a case of a 26-year-old man admitted to their department in an emergency setting for a crush injury (occupational trauma) of the lumbar, gluteal and perineal areas, complicated with septic shock and gas gangrene of the injured areas. A multidisciplinary approach to the patient, consisting in surgical and plastic surgical therapy, hyperbaric oxygen therapy and the use of a special antidecubitus fluidized bed allowed complete recovery within 7 months without any motor or sphincter disorders.