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A 16-year-old girl suffered blunt abdominal trauma. Clinically, a severe motor impairment with paraesthesia of the legs was found. Posterior osteosynthesis in T10-L1 with laminectomy in T10-T12 and posterolateral arthrodesis in T11-T12 was performed because of a dorsal traumatic vertebral fracture. On hospital day 7, because of an acute abdomen, surgical laparoscopic exploration showed sterile bloody fluid without any evident hemorrhagic injury. On hospital day 11, the patient was reoperated on by the laparoscopic approach for increasing abdominal pain and fever: a peritoneal biliary fluid was aspirated. After conversion to open surgery, cholecystectomy was performed. Intraoperative cholangiography was considered as normal. On arrival at our institution 13 days after injury, the patient was operated on for a biliary peritonitis. Intraoperatively, a trans-cystic cholangiography showed a biliary leakage of the common bile duct; a T-tube was placed into the common bile duct; a subhepatic drainage was placed too. On postoperative day 30, a T-tube cholangiography showed a normal biliary tree, without any leakage, and the T-tube was subsequently removed. The patient had a complete recovery. [ABSTRACT FROM AUTHOR]

The article presents a research in the U.S. on the protocol-driven approach to bleeding abdominal and pelvic trauma. Accordingly, abdominal and pelvic trauma patients with unstable hemodynamics who were admitted during a 16-month period have been reviewed. However, after a thorough research, it is found out that this study suggests some considerations in the strategy of managing severely injured patients with abdominal and pelvic trauma and evidence of acute bleeding.

Preventable trauma deaths are defined as deaths which could be avoided if optimal care has been delivered. Studies on preventable trauma deaths have been accomplished initially with panel reviews of pre-hospital and hospital charts. However, several investigators questioned the reliability and validity of this method because of low reproducibility of implicit judgments when they are made by different experts. Nevertheless, number of studies were published all around the world and ultimately gained some credibility, particularly in regions where comparisons were made before and after trauma system implementation with a resultant fall in mortality. During the last decade of century the method of comparing observed survival with probability of survival calculated from large trauma registries has obtained popularity. Preventable trauma deaths were identified as deaths occurred notwithstanding a high calculated probability of survival. In recent years, preventable trauma deaths studies have been replaced by population-based studies, which use databases representative of overall population, therefore with high epidemiologic value. These databases contain readily available information which carry out the advantage of objectivity and large numbers. Nowadays, population-based researches provide the strongest evidence regarding the effectiveness of trauma systems and trauma centers on patient outcomes. [ABSTRACT FROM AUTHOR]

Electric scooter (ES)-related injuries are increasing but poorly described. Clinicians need more information to be prepared for these patients. We supposed two prevalent patterns of patients: mildly injured (predominant upper-limb injuries) and severely injured (predominant head trauma). This study aims to understand the frequency of ES-related injuries and patients' characteristics despite the heterogeneity of data currently available. A systematic review with a proportion meta-analysis was conducted on studies with a multidisciplinary description of ES-related injuries in adult patients (PROSPERO-ID: CRD42022341241). Articles from inception to April 2023 were identified in MEDLINE, Embase, and Cochrane's databases. The risk of bias was evaluated using ROBINS-I. Twenty-five observational studies with 5387 patients were included in the meta-analysis, depending on reported data. Upper-limb (31.8%) and head (19.5%) injuries are the most frequent (25/25 studies included). When injured while riding, 19.5% of patients are intoxicated with drugs/alcohol, and only 3.9% use a helmet, increasing the possibility of severe injuries. About 80% of patients are victims of spontaneous falls. Half of the patients self-present to the ED, and 69.4% of cases are discharged directly from the ED. Studies' limitations include an overall moderate risk of bias and high heterogeneity. Electric scooter-related accidents are commonly associated with upper-limb injuries but often involve the head. Spontaneous falls are the most common mechanism of injury, probably related to frequent substance abuse and helmet misuse. This hot topic is not adequately investigated due to a lack of data. A prospective registry could fill this gap. [ABSTRACT FROM AUTHOR]

Background: The 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. Methods: Data 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. Results: From 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. Conclusions: We 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. [ABSTRACT FROM AUTHOR]

Iatrogenic urinary tract injury (IUTI) is a severe complication of emergency digestive surgery. It can lead to increased postoperative morbidity and mortality and have a long-term impact on the quality of life. The reported incidence of IUTIs varies greatly among the studies, ranging from 0.3 to 1.5%. Given the high volume of emergency digestive surgery performed worldwide, there is a need for well-defined and effective strategies to prevent and manage IUTIs. Currently, there is a lack of consensus regarding the prevention, detection, and management of IUTIs in the emergency setting. The present guidelines, promoted by the World Society of Emergency Surgery (WSES), were developed following a systematic review of the literature and an international expert panel discussion. The primary aim of these WSES guidelines is to provide evidence-based recommendations to support clinicians and surgeons in the prevention, detection, and management of IUTIs during emergency digestive surgery. The following key aspects were considered: (1) effectiveness of preventive interventions for IUTIs during emergency digestive surgery; (2) intra-operative detection of IUTIs and appropriate management strategies; (3) postoperative detection of IUTIs and appropriate management strategies and timing; and (4) effectiveness of antibiotic therapy (including type and duration) in case of IUTIs. [ABSTRACT FROM AUTHOR]

"Stabilize the Unstable": Treatment Pathophysiology in Bleeding Trauma Patients, from the Field to the ICU. Moreover, hemostasis is upheld by early platelet transfusion that improves outcomes in acutely bleeding trauma patients and cryoprecipitate that provide a source of fibrinogen, Factor VIII, and von Willebrand factor with an additional benefit to the endothelium [[11]]. Moreover, the GBD reported the nonfatal sequelae (disabilities and handicaps) among trauma patient survivors, who are often healthy young individuals that will suffer lifelong disabilities as a result of the injuries sustained [[1]]. Thus, the management of haemodynamically unstable trauma patients continues to represent a challenge for clinicians who face a time-dependent condition in which critical injuries causing organ failure should be quickly recognized and controlled. [Extracted from the article]

• In Italy, spinal injuries are most frequently caused by road accidents (59.9%, mainly cervico-thoracic) than by falls (35.1%, mainly lumbar). • Most patients with spinal injuries (70.7%) have a high injury severity score patients, i.e. ISS≥16. • Trauma patients have more severe spinal injuries in fall cases (40.1%) compared to RA (21.9% to 26.3%). • A spinal cord injury (SCI) complicated 13.7% fractures. SCI decreased with aging and extremities associated injuries but increased at higher ISS. • Among upper cervical injuries, the probability of a severe fracture increased by 5.95 times in the presence of facial associated injuries. Traumatic spinal injuries are frequent and their management is debated, especially in major trauma patients. This study aims to describe a large population of major trauma patients with vertebral fractures to improve prevention measures and fracture management. Retrospective analysis of 6274 trauma patients prospectively collected between October 2010 and October 2020. Collected data include demographics, mechanism of trauma, type of imaging, fracture morphology, associated injuries, injury severity score (ISS), survival, and death timing. The statistical analysis focused on mechanism of trauma and the search of predictive factors for critical fractures. Patients showed a mean age of 47 years and 72.5% were males. Trauma included 59.9% of road accidents and 35.1% of falls. 30.7% patients had at least a severe fracture, while 17.2% had fractures in multiple spinal regions. 13.7% fractures were complicated by spinal cord injury (SCI). The mean ISS of the total population was 26.4 (SD 16.3), with 70.7% patients having an ISS≥16. There is a higher rate of severe fractures in fall cases (40.1%) compared to RA (21.9% to 26.3%). The probability of a severe fracture increased by 164% in the case of fall and by 77% in presence of AIS≥3 associated injury of head/neck while reduced by 34% in presence of extremities associated injuries. Multiple level injuries increased with ISS rise and in the case of extremities associated injuries. The probability of a severe upper cervical fracture increased by 5.95 times in the presence of facial associated injuries. The mean length of stay was 24.7 days and 9.6% of patients died. In Italy, road accidents are still the most frequent trauma mechanism and cause more cervico-thoracic fractures, while falls cause more lumbar fractures. Spinal cord injuries represent an indicator of more severe trauma. In motorcyclists or fallers/jumpers, there is a higher risk of severe fractures. When a spinal injury is diagnosed, the probability of a second vertebral fracture is consistent. These data could help the decisional workflow in the management of major trauma patients with vertebral injury. [ABSTRACT FROM AUTHOR]

Background: A structured approach involves systematic management of trauma patients. We aim to conduct an overview of reviews about the clinical efficacy and safety of structured approach (i.e., primary and secondary survey) by guideline checklist compared to non-structured approach (i.e. clinical examination); moreover, routine screening whole-body computer tomography (WBCT) was compared to non-routine WBCT in patients with suspected major trauma. Methods: We systematically searched MEDLINE (PubMed), EMBASE and Cochrane Database of Systematic Reviews up to 3 May 2022. Systematic reviews (SRs) that investigated the use of a structured approach compared to a non-structured approach were eligible. Two authors independently extracted data, managed the overlapping of primary studies belonging to the included SRs and calculated the corrected covered area (CCA). The certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. Results: We included nine SRs investigating two comparisons in stable trauma patients: structured approach vs non-structured approach (n = 1) and routine WBCT vs non-routine WBCT (n = 8). The overlap of included primary studies was generally high across outcomes (CCA ranged between 20.85 and 42.86%) with some discrepancies in the directions of effects across reviews. The application of a structured approach by checklist may improve adherence to guidelines (e.g. Advanced Trauma Life Support) during resuscitation and might lead to a reduction in mortality among severely injured patients as compared to clinical examination (Adjusted OR 0.51; 95% CI 0.30–0.89; p = 0.018; low certainty of evidence). The use of routine WBCT seems to offer little to no effects in reducing mortality and time spent in emergency room or department, whereas non-routine WBCT seems to offer little to no effects in reducing radiation dose, intensive care unit length of stay (LOS) and hospital LOS (low-to-moderate certainty of evidence). Conclusions: The application of structured approach by checklist during trauma resuscitation may improve patient- and process-related outcomes. Including non-routine WBCT seems to offer the best trade-offs between benefits and harm. Clinicians should consider these findings in the light of their clinical context, the volume of patients in their facilities, the need for time management, and costs. [ABSTRACT FROM AUTHOR]

Background: Trauma is the leading cause of morbidity and mortality in the pediatric population. During the COVID-19 pandemic (COVID-19), different trends for pediatric trauma (PT) were described. This study aims to explore the trend over time of PT in our center, also considering the effects of COVID-19, focusing on trauma mechanisms, violence-related trauma (VRT) and intentionality, especially suicide attempts (SAs). Methods: All PT patients accepted at Niguarda Trauma Center (NTC) in Milan from January 2015 to December 2020 were retrospectively analyzed. We considered demographics and clinical variables and performed descriptive and year comparison analyses. Results: There were 684 cases of PT accepted at NTC: 84 in 2015, 98 in 2016, 125 in 2017, 119 in 2018, 114 in 2019 and 144 in 2020 (p < 0.001), 66.2% male, mean age 9.88 (±5.17). We observed a higher number of traffic-related, fall-related injuries and an increasing trend for VRT and SAs, peaking in 2020. We report an increasing trend over time for head trauma (p = 0.002). The Injury Severity Score did not significantly change. During COVID-19 we recorded a higher number of self-presenting patients with low priority codes. Conclusions: NTC is the adult level I referral trauma center for the Milan urban area with pediatric commitment. During COVID-19, every traumatic emergency was centralized to NCT. In 2020, we observed an increasing trend in SAs and VRT among PT patients. The psychological impact of the COVID-19 restriction could explain this evidence. The long-term effects of COVID-19 on the mental health of the pediatric population should not be underestimated. Focused interventions on psychological support and prevention of SAs and VRT should be implemented, especially during socio-demographic storms such as the last pandemic. [ABSTRACT FROM AUTHOR]

The rapid identification of patients at risk for massive blood transfusion is of paramount importance as uncontrolled exsanguination may lead to death within 2 to 6 h. The aim of this study was to analyze a cohort of severe trauma patients to identify risk factors associated with massive transfusion requirements and hypocalcemia. All major trauma (ISS > 16) presented directly from the scene to the Niguarda hospital between 1 January 2015 and 31 December 2021 were analyzed. A total of 798 patients were eligible out of 1586 screened. Demographic data showed no significant difference between hypocalcemic (HC) and normocalcemic (NC) patients except for the presence of crush trauma, alcohol intake (27% vs. 15%, p < 0.01), and injury severity score (odds ratio 1.03, p = 0.03). ISS was higher in the HC group and was an independent, even if weak, predictor of hypocalcemia (odds ratio 1.03, p = 0.03). Prehospital data showed a lower mean systolic arterial pressure (SAP) and a higher heart rate (HR) in the HC group (105 vs. 127, p < 0.01; 100 vs. 92, p < 0.001, respectively), resulting in a higher shock index (SI) (1.1 vs. 0.8, p < 0.001). Only retrospective studies such as ours are available, and while hypocalcemia seems to be an independent predictor of mortality and massive transfusion, there is not enough evidence to support causation. Therefore, randomized prospective studies are suggested. [ABSTRACT FROM AUTHOR]

Aims: Laparoscopic appendectomy (LA) for acute appendicitis (AA) is one of the most performed procedures. The effects of peritoneal lavage (PL) and the reasons to perform it have not been cleared and all meta-analyses didn't show a statistical advantage to prevent infectious complications. This study aims to investigate surgeons' perceptions during LA, comparing intraoperative findings with histological results, and exploring how surgeons' subjectivity influences the decision-making process on PL. Methods: Data were extracted from the two-year data lock from REsiDENT-1 registry, a prospective resident-led multicentre observational trial. This study investigates the relationships between PL and postoperative intraabdominal abscesses (pIAA) introducing a classification for AA to standardize the intraoperative grading. We included pre, intra, and postoperative variables. We applied our classification proposal, used a five-point Likert scale (Ls) to assess subjective LA difficulty and ran a concordance analysis between the assessment of AA and histology. Subsequently, a multivariate logistic regression model was built to find factors influencing PL. Results: 561 patients were enrolled from twenty-one hospitals and 51 residents. 542 procedures were included in the logistic regression analysis and 441 in the concordance analysis, due to missing data. PL was used in 222 LA (39, 6%). We discovered a moderate positive monotonic relationship between surgical evaluation and histology, p < 0.001. Despite this, the reliability of the surgeon's assessment of appendicitis is progressively lower for gangrenous and perforated forms. The increasing grade of contamination, the increasing grade of subjective difficulty and the intraoperative finding of a gangrenous or perforated appendicitis were independent predictors of PL. Conclusion: This study shows how surgeons' evaluation of AA severity overestimated more than half of gangrenous or perforated appendices with the perception of a challenging procedure. These perceptions influenced the choice of PL. We proved that the evaluation during LA could be affected by subjectivity with a non-negligible impact on the decision-making process. [ABSTRACT FROM AUTHOR]

Background: Bicycle-related trauma has increased during the last decades, mainly due to the antipollution environmental policies. This study investigates the outcome of bicycle-related trauma in our level-one trauma center over a period of eight years. Methods: Data from 446 consecutive bicycle-related trauma patients admitted to our trauma center from 2011 to 2019 were selected and retrospectively analyzed. The sample was divided into three age groups: <18 years, 18–54 years, and ≥55 years. Mortality rates were obtained for the overall population and patients with an Injury Severity Score (ISS) ≥ 25. Month and seasonal patients' distribution was described to provide an epidemiological overview of bike-related trauma over the years. Results: Patients ≥ 55 years showed a lower pre-hospital and in-hospital GCS (p ≤ 0.001), higher levels of lactates (p < 0.019) and higher ISS (p ≤ 0.001), probability of death (p ≤ 0.001), and overall mortality (p ≤ 0.001). The head and chest Abbreviated Injury Scale (AIS) ≥ 3 injuries were predictors of mortality, especially in patients over 55 years (p < 0.010). Bicycle-related trauma was more frequent during the summer (34%), particularly in July and August. Conclusions: Age over 55 years old, head and chest injuries, and an ISS > 25 were independent predictors of mortality. [ABSTRACT FROM AUTHOR]

Purpose: To identify preoperative predictive factors for technically challenging laparoscopic appendectomy (LA) and the need for external help to laparoscopically complete the procedure. Methods: We analysed data from a two-year data lock on the Resident-1 multicentre registry. The operator classified each procedure following a five-grade Likert scale to define technical difficulty. We performed univariate analysis comparing Grade 1–3 versus 4–5 procedures and then built a logistic regression model to identify independent predictors of Grade 4–5 procedures defined as needing external help to complete a LA. Results: 561 patients were recruited from 2019 to 2021, and 485 patients were included in the final analysis due to missing data. A BMI > 30 kg/m2, preoperative CT scan, and the AIR score were independent preoperative predictors of complex LA with the need for external help to be completed. Patients undergoing such procedures were more affected by CA, had longer operative times, and had the worst postoperative outcomes. Conclusion: The preoperative identification of technically demanding LA could be helpful in optimising the preoperative planning, maximise surgeons' preparedness, and include expert surgeons in the procedure earlier. Creating a scoring system for the technical difficulty of LA is desirable. [ABSTRACT FROM AUTHOR]

Background: Traumatic diaphragmatic injuries (TDI) are wounds or ruptures of the diaphragm due to thoraco-abdominal trauma. Nowadays, CT-scan is considered the gold standard for TDI diagnosis. The aim of this study was to assess the current diagnostic accuracy of CT-scan in the diagnosis of TDI and describe the management of this type of injury.Methods: A systematic review was conducted according to the 2009 Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Two independent reviewers searched the literature in a systematic fashion using online databases, including Medline, Scopus, Embase, and Google Scholar. Human studies investigating the diagnosis and the following management of TDI were included. Pooled estimates of sensitivity, specificity, and positive/negative likelihood (with corresponding 95% confidence intervals) were analyzed based on the bivariate model for blunt TDI. The Newcastle-Ottawa scale for cohort studies was used for the quality assessment of selected articles. The PROSPERO registration number was as follows: CRD42022301282.Results: Fifteen studies published between 2001 and 2019 were included. All included studies reported a contrast-enhanced computed tomography as the preferred method to obtain diagnostic imaging. Left-sided TDI was the type of injury most frequently found. False negative TDI at CT-scan were more frequent than false positive TDI (11.13 ± 23.24 vs. 2.66 ± 6.65). Six studies on blunt TDI were included in the meta-analysis, showing a high sensitivity [0.80 (95%CI 0.65-0.90)] and specificity [0.98 (95%CI 0.89-1.00)] of the CT-scan in detecting TDI. Overall, 7 articles reported laparotomy as the method of choice to repair TDI. Only 3 studies reported a laparoscopic and/or thoracoscopic approach to TDI repair.Conclusion: CT-scan has a good sensitivity and specificity for blunt TDI diagnosis. However, TDI diagnosis and management are often delayed. The use of water-soluble contrast in CT-scan should be considered when the diagnosis of TDI is not defined after the first scan, and clinical suspicion is still high. In this context, a highly trained trauma team is essential for trauma management and correct imaging interpretation. [ABSTRACT FROM AUTHOR]

Patients with acute pancreatitis (AP) often require ICU admission, especially when signs of multiorgan failure are present, a condition that defines AP as severe. This disease is characterized by a massive pancreatic release of pro-inflammatory cytokines that causes a systemic inflammatory response syndrome and a profound intravascular fluid loss. This leads to a mixed hypovolemic and distributive shock and ultimately to multiorgan failure. Aggressive fluid resuscitation is traditionally considered the mainstay treatment of AP. In fact, all available guidelines underline the importance of fluid therapy, particularly in the first 24–48 h after disease onset. However, there is currently no consensus neither about the type, nor about the optimal fluid rate, total volume, or goal of fluid administration. In general, a starting fluid rate of 5–10 ml/kg/h of Ringer's lactate solution for the first 24 h has been recommended. Fluid administration should be aggressive in the first hours, and continued only for the appropriate time frame, being usually discontinued, or significantly reduced after the first 24–48 h after admission. Close clinical and hemodynamic monitoring along with the definition of clear resuscitation goals are fundamental. Generally accepted targets are urinary output, reversal of tachycardia and hypotension, and improvement of laboratory markers. However, the usefulness of different endpoints to guide fluid therapy is highly debated. The importance of close monitoring of fluid infusion and balance is acknowledged by most available guidelines to avoid the deleterious effect of fluid overload. Fluid therapy should be carefully tailored in patients with severe AP, as for other conditions frequently managed in the ICU requiring large fluid amounts, such as septic shock and burn injury. A combination of both noninvasive clinical and invasive hemodynamic parameters, and laboratory markers should guide clinicians in the early phase of severe AP to meet organ perfusion requirements with the proper administration of fluids while avoiding fluid overload. In this narrative review the most recent evidence about fluid therapy in severe AP is discussed and an operative algorithm for fluid administration based on an individualized approach is proposed. [ABSTRACT FROM AUTHOR]

Fournier's gangrene (FG) is a Necrotizing Soft Tissue Infection (NSTI) of the perineal region characterized by high morbidity and mortality even if appropriately treated. The main treatment strategies are surgical debridement, broad-spectrum antibiotics, hyperbaric oxygen therapy, NPWT (Negative Pressure Wound Therapy), and plastic surgery reconstruction. We present the case of a 50-year-old woman with an NSTI of the abdomen, pelvis, and perineal region associated with a rectal fistula referred to our department. After surgical debridement and a diverting blow-out colostomy, an NPWT system composed of two sponges connected by a bridge through a rectal fistula was performed. Our target was to obtain healing in a lateral-to-medial direction instead of depth-to-surface to prevent the enlargement of the rectal fistula, promoting granulation tissue growth towards the rectum. This eso-endo-NPWT technique allowed for the primary suture of the perineal wounds bilaterally, simultaneously treating the rectal fistula and the perineum lesions. A systematic review of the literature underlines the spreading of NPWT and its effects. [ABSTRACT FROM AUTHOR]

Thoracic trauma occurs in 20–25% of all trauma patients worldwide and represents the third cause of trauma-related mortality. Retained hemothorax (RH) is defined as a residual hematic pleural effusion larger than 500 mL after 72 h of treatment with a thoracic tube. The aim of this study is to investigate risk factors for the development of RH in thoracic trauma and predictors of surgery. A retrospective, observational, monocentric study was conducted in a Trauma Hub Hospital in Milan, recording thoracic trauma from January 2011 to December 2020. Pre-hospital peripheric oxygen saturation (SpO2) was significantly lower in the RH group (94% vs. 97%, p = 0.018). Multivariable logistic regression analysis identified, as independent predictors of RH, sternum fracture (OR 7.96, 95% CI 1.16–54.79; p = 0.035), pre-admission desaturation (OR 0.96; 95% CI 0.77–0.96; p = 0.009) and the number of thoracic tube maintenance days (OR 1.22; 95% CI 1.09–1.37; p = 0.0005). The number of tubes placed and the 1° rib fracture were both significantly associated with the necessity of surgical treatment of RH (2 vs. 1, p = 0.004; 40% vs. 0%; p = 0.001). The risk of developing an RH in thoracic trauma should not be underestimated. Variables related to RH must be taken into account in order to schedule a proper follow-up after trauma. [ABSTRACT FROM AUTHOR]

Background: Tissue regeneration is a complex process that allows wounds to heal. Many options are currently available to help human skin repair and to reduce the recurrence of hernias. The aim of this study is to analyze the best decellularization protocol for allogenic human dermal tissues. Methods: Dermal flaps from donors were used and compared with a control group. Each flap was subjected to seven different decellularization protocols and washed with a sequence of five solutions. The samples were then subjected to four control tests (such as Nile Red), and long-term contacts were analyzed to assess whether the decellularized dermis samples could support the growth of human fibroblasts. Results: All the samples had an average residual viability of 60%. Except for one sample, the decellularization treatments were able to reduce cell viability significantly. The Nile Red test showed a significant reduction in phospholipid content (mean 90%, p-value < 0.05) in all treatments. The cell growth increased in a linear manner. As described in the literature, sodium-dodecyl-sulfate (SDS) caused an interference between the test and the detergent. Conclusions: This paper shows the first step to finding the best decellularization protocol for allografting human dermal tissues. Further biocompatibility tests and DNA quantification are necessary. [ABSTRACT FROM AUTHOR]

Background: During the COVID-19 pandemic, the centralization of patients allowed trauma and transplants referral centers to continue their routine activity, ensuring the best access to health care. This study aims to analyze how the centralization of trauma is linked with liver allocation in Northern Italy. Methods: Cluster analysis was performed to generate patient phenotype according to trauma-related variables. Comparison between clusters was performed to evaluate differences in damage control strategy procedures (DCS) performed and the 30-day graft dysfunction. Results: During the pandemic period, the centralization of major trauma has deeply impaired the liver procurement and allocation between the transplant centers in the metropolitan area of Milan (Niguarda: 22 liver procurement; other transplant centers: 2 organ procurement). Two clusters were identified the in Niguarda's series: cluster 1 is represented by 17 (27.4%) trauma donors, of which 13 (76.5%) were treated with DCS procedures, and 4 (23.5%) did not; cluster 2 is represented by 45 trauma donors (72.6%), of which 22 (48.8%) underwent DCS procedures. A significant difference was found in the number of DCS procedures performed between clusters (3.18 ± 2.255 vs. 1.11 ± 1.05, p = 0.0001). Comparative analysis did not significantly differ in the number of transplanted livers (cluster1/cluster2 94.1%/95.6% p = 0.84) and the 30-day graft dysfunction rate (cluster1/cluster2 0.0%/4.8% p = 0.34). Conclusions: The high level of care guaranteed by first-level trauma centers could reduce the loss of organs suitable for donation, maintaining the good outcomes of transplanted ones, even in case of multiple organ injuries. The pandemic period underlined that the centralization of major trauma impairs the liver allocation between transplant centers. [ABSTRACT FROM AUTHOR]

Identifying groups of patients with homogeneous characteristics and comparable outcomes improves clinical activity, patients' management, and scientific research. This study aims to define mild, moderate, and severe facial trauma by validating two cut-off values of the Comprehensive Facial Injury (CFI) score and describing their foreseeable clinical needs to create a useful guide in patient management, starting from the first evaluation. The individual CFI score, overall surgical time, and length of hospitalization are calculated for a sample of 1400 facial-injured patients. Receiver Operating Characteristic (ROC) analysis and the corresponding Area Under the Curve (AUC) is tested, and a CFI score ≥4 is selected to discriminate patients undergoing surgical management under general anesthesia (Positive Predictive Value, PPV of 91.4%), while a CFI score ≥10 is selected to identify patients undergoing major surgical procedures (Negative Predictive Value, NPV of 91.7%). These results are enhanced by the consensual trend of Length of Stay outcome. The use of the CFI score allows us to distinguish between the "Mild facial trauma" with a low risk of hospitalization for surgical treatment, the "Moderate facial trauma" with a high probability of surgical treatment, and the "Severe facial trauma" that requires long-lasting surgery and hospital stay, with an increased incidence of Intensive Care Unit admission. [ABSTRACT FROM AUTHOR]

In Italy, a comprehensive regional study of trauma deaths has never been performed. We examined the organization and delivery of trauma care in the city area of Milan, using panel review of trauma deaths. Two panels evaluated the appropriateness of care of all trauma victims occurred during 1 year, applying predefined criteria and judging deaths as not preventable (NP), possible preventable (PP), and definitely preventable (DP). Two hundred and fifty-five deaths were reviewed. Blunt trauma were 78.04% and motor vehicle crashes accounted for over 50%. Most victims (73.72%) died during pre-hospital settings and 91.1% died within the first 6 h, principally because of central nervous system injuries in blunt and hemorrhage in penetrating trauma. Panels judged 57% of deaths NP, 32% PP, 11% DP (inter-panel K-test 0.88). Preventable deaths were higher after in-hospital admission. Main failures of treatment were lack in airway control or intravenous infusions in pre-hospital and mismanagement with missed injuries in emergency department.The high rate of avoidable deaths in Milan supports the need of trained pre-hospital personnel and of well equipped referring hospitals for trauma. [Copyright &y& Elsevier]

Falls from height (FFH) represent a distinct form of blunt trauma in urban areas. This study aimed to identify independent predictors of in-hospital mortality after accidental or intentional falls in different age groups. We conducted a retrospective study of all patients consecutively admitted after a fall in eight years, recording mechanism, intentionality, height of fall, age, site, classification of injuries, and outcome. We built multivariate regression models to identify independent predictors of mortality. A total of 948 patients with 82 deaths were observed. Among the accidental falls, mortality was 5.2%, whereas intentional jumpers showed a mortality of 20.4%. The death rate was higher for increasing heights, age >65, suicidal attempts, and injuries with AIS ≥3 (Abbreviated Injury Scale). Older patients reported a higher in-hospital mortality rate. Multivariate analysis identified height of fall, dynamic and severe head and chest injuries as independent predictors of mortality in the young adults' group (18–65 years). For patients aged more than 65 years, the only risk factor independently related to death was severe head injuries. Our data demonstrate that in people older than 65, the height of fall may not represent a predictor of death. [ABSTRACT FROM AUTHOR]

Background: Motorcyclists are often victims of road traffic incidents. Though elderly patients seem to have worse survival outcomes and sustain more severe injuries than younger patients, concordance in the literature for this does not exist. The aim of the study is to evaluate the impact of age and injury severity on the mortality of patients undergoing motorcycle trauma. Methods: Data of 1725 patients consecutively admitted to our Trauma Center were selected from 2002 to 2016 and retrospectively analyzed. The sample was divided into three age groups: ≤ 17 years, 18–54 years, and ≥ 55 years. Mortality rates were analyzed for the overall population and patients with Injury Severity Score (ISS) ≥ 25. Differences in survival among age groups were evaluated with log-rank test, and multivariate logistic regression models were created to identify independent predictors of mortality. Results: A lower survival rate was detected in patients older than 55 years (83.6% vs 94.7%, p = 0.049) and in those sustaining critical injuries (ISS ≥ 25, 61% vs 83%, p = 0.021). Age (p = 0.027, OR 1.03), ISS (p < 0.001, OR 1.09), and Revised Trauma Score (RTS) (p < 0.001, OR 0.47) resulted as independent predictors of death. Multivariate analysis identified head (p < 0.001, OR 2.04), chest (p < 0.001, OR 1.54), abdominal (p < 0.001, OR 1.37), and pelvic (p = 0.014, OR 1.26) injuries as independent risk factors related to mortality as well. Compared to the theoretical probability of survival, patients of all age groups showed a survival advantage when managed at a level I trauma center. Conclusions: We detected anatomical injury distributions and mortality rates among three age groups. Patients aging more than 55 years had an increased risk of death, with a prevalence of severe chest injuries, while younger patients sustained more severe head trauma. Age represented an independent predictor of death. Management of these patients at a level I trauma center may lead to improved outcomes. [ABSTRACT FROM AUTHOR]

• Italian trauma centers lack formal trauma teams. • Challenges in implementing trauma teams stem from clinical-organizational and political factors. • Structural features like surgical kits and massive transfusion protocols vary across trauma centers. • Anesthesiologists and emergency physicians frequently lead trauma teams in Italy. • Urgent improvements in trauma team education and governance are necessary. Trauma teams play a vital role in providing prompt and specialized care to trauma patients. This study aims to provide a comprehensive description of the presence and organization of trauma teams in Italy. A nationwide cross-sectional epidemiological study was conducted between July and October 2022, involving interviews with 137 designated trauma centers. Centers were stratified based on level: higher specialized trauma centers (CTS), intermediate level trauma centers (CTZ + N) and district general hospital with trauma capacity (CTZ). A standardized structured interview questionnaire was used to gather information on hospital characteristics, trauma team prevalence, activation pathways, structure, components, leadership, education, and governance. Descriptive statistics were used for analysis. Results showed that 53 % of the centers had a formally defined trauma team, with higher percentages in CTS (73 %) compared to CTZ + N (49 %) and CTZ (39 %). The trauma team activation pathway varied among centers, with pre-alerts predominantly received from emergency medical services. The study also highlighted the lack of formally defined massive transfusion protocols in many centers. The composition of trauma teams typically included airway and procedure doctors, nurses, and healthcare assistants. Trauma team leadership was predetermined in 59 % of the centers, with anesthesiologists/intensive care physicians often assuming this role. The study revealed gaps in trauma team education and governance, with a lack of specific training for trauma team leaders and low utilization of simulation-based training. These findings emphasize the need for improvements in trauma management education, governance, and the formalization of trauma teams. This study provides valuable insights that can guide discussions and interventions aimed at enhancing trauma care at both local and national levels in Italy. [ABSTRACT FROM AUTHOR]

Background: Gallstone disease is very common afflicting 20 million people in the USA. In Europe, the overall incidence of gallstone disease is 18.8% in women and 9.5% in men. The frequency of gallstones related disease increases by age. The elderly population is increasing worldwide. Aim: The present guidelines aims to report the results of the World Society of Emergency Surgery (WSES) and Italian Surgical Society for Elderly (SICG) consensus conference on acute calcolous cholecystitis (ACC) focused on elderly population. Material and methods: The 2016 WSES guidelines on ACC were used as baseline; six questions have been used to investigate the particularities in elderly population; the answers have been developed in terms of differences compared to the general population and to statements of the 2016 WSES Guidelines. The Consensus Conference discusses, voted, and modified the statements. International experts contributed in the elaboration of final statements and evaluation of the level of scientific evidences. Results: The quality of the studies available decreases when we approach ACC in elderly. Same admission laparoscopic cholecystectomy should be suggested for elderly people with ACC; frailty scores as well as clinical and surgical risk scores could be adopted but no general consensus exist. The role of cholecystostomy is uncertain. Discussion and conclusions: The evaluation of pro and cons for surgery or for alternative treatments in elderly suffering of ACC is more complex than in young people; also, the oldest old age is not a contraindication for surgery; however, a larger use of frailty and surgical risk scores could contribute to reach the best clinical judgment by the surgeon. The present guidelines offer the opportunity to share with the scientific community a baseline for future researches and discussion. [ABSTRACT FROM AUTHOR]

Background: Peptic ulcer disease is common with a lifetime prevalence in the general population of 5–10% and an incidence of 0.1–0.3% per year. Despite a sharp reduction in incidence and rates of hospital admission and mortality over the past 30 years, complications are still encountered in 10–20% of these patients. Peptic ulcer disease remains a significant healthcare problem, which can consume considerable financial resources. Management may involve various subspecialties including surgeons, gastroenterologists, and radiologists. Successful management of patients with complicated peptic ulcer (CPU) involves prompt recognition, resuscitation when required, appropriate antibiotic therapy, and timely surgical/radiological treatment. Methods: The present guidelines have been developed according to the GRADE methodology. To create these guidelines, a panel of experts was designed and charged by the board of the WSES to perform a systematic review of the available literature and to provide evidence-based statements with immediate practical application. All the statements were presented and discussed during the 5th WSES Congress, and for each statement, a consensus among the WSES panel of experts was reached. Conclusions: The population considered in these guidelines is adult patients with suspected complicated peptic ulcer disease. These guidelines present evidence-based international consensus statements on the management of complicated peptic ulcer from a collaboration of a panel of experts and are intended to improve the knowledge and the awareness of physicians around the world on this specific topic. We divided our work into the two main topics, bleeding and perforated peptic ulcer, and structured it into six main topics that cover the entire management process of patients with complicated peptic ulcer, from diagnosis at ED arrival to post-discharge antimicrobial therapy, to provide an up-to-date, easy-to-use tool that can help physicians and surgeons during the decision-making process. [ABSTRACT FROM AUTHOR]

Purpose: To determine whether torso CT can be avoided in patients who experience high-energy blunt trauma but have normal vital signs.Methods: High-energy blunt trauma patients with normal vital signs were retrieved retrospectively from our registry. We reviewed 1317 patients (1027 men and 290 women) and 761 (57.8%) fulfilled the inclusion criteria. All patients were initially evaluated at the emergency room (ER), with a set of tests, part of a specific protocol. Patients with at least one altered exam at initial examination or after six-hour observation received a torso CECT. Sensitivity, specificity, accuracy, positive (PPV) and negative predictive values (NPV), and likelihood ratio (LH) of the protocol were evaluated.Results: Of 761 patients, 354 (46.5%) received torso CECT because of the positive ER test, with 330 being true positive and 24 being false positive. The remaining 407 patients were negative at ER tests and did not receive torso CECT, showing a significantly (P < 0.001) lower Injury Severity Score (ISS). The positive and negative LH of the protocol to detect torso injuries were respectively 16.5 and 0.01 (overall accuracy of 0.96).Conclusions: Torso CT can be avoided without adverse clinical outcomes in patients who experience high-energy blunt trauma, are hemodynamically stable, and have normal initial laboratory and imaging tests. [ABSTRACT FROM AUTHOR]

Background: Hemorrhagic shock (HS) is a major threat to patients with trauma and spontaneous bleeding. The aim of the study was to investigate early effects of vasopressin on metabolic and hemodynamic parameters and endothelium permeability by measuring capillary leakage compared to those of other resuscitation strategies in a HS model. Methods: Forty-five Sprague-Dawley rats were randomized into five groups: S group (n = 5), sham-operated rats without shock or resuscitation; HS group (n = 10), HS and no resuscitation; RL group (n = 10), HS and resuscitation with Ringer’s lactate (RL); RLB group (n = 10), HS and resuscitation with two-third shed blood plus RL; and vasopressin group (n = 10), HS and resuscitation with RL, followed by continuous infusion of 0.04 U/kg/min vasopressin. The effects of resuscitation on hemodynamic parameters [mean arterial pressure (MAP), superior mesenteric artery blood flow (MBF), and mesenteric vascular resistances (MVR)], arterial blood gases, bicarbonate, base deficit, and lactate levels as well as on capillary leakage in the lung, ileum, and kidney were investigated. Capillary leakage was evaluated with Evans blue dye extravasation. Results: In the vasopressin group, the MAP was higher than in the RL and RLB groups (p < 0.001), while MBF was decreased (p < 0.001). MVR were increased only in the vasopressin group (p < 0.001). Capillary leakage was increased in the lungs of the animals in the vasopressin group compared to that in the lungs of animals in the RLB group (p < 0.05); this increase was associated with the lowest partial pressure of oxygen (p < 0.05). Conversely, decreased capillary leakage was observed with vasopressin in the ileum (p < 0.05). Increased capillary leakage was observed in the kidney in the RLB and vasopressin groups (p < 0.05). Lastly, vasopressin use was associated with higher base deficit and lactate levels when compared to the RL and RLB groups (p < 0.001). Conclusion: Although vasopressin was proposed as a vasoactive drug for provisional hemodynamic optimization in the early phase of HS resuscitation, the overall findings of this experimental study focus on the possible critical side effects of vasopressin on metabolic parameters and endothelium permeability. [ABSTRACT FROM AUTHOR]

Background: Currently, both the step-up approach, combining percutaneous drainage (PD) and video-assisted retroperitoneal debridement (VARD), and endoscopic transgastric necrosectomy (ETN) are mini-invasive techniques for infected necrosis in severe acute pancreatitis. A combination of these approaches could maximize the management of necrotizing pancreatitis, conjugating the benefits from both the experiences. However, reporting of this combined strategy is anecdotal. This is the first reported case of severe necrotizing pancreatitis complicated by biliary fistula treated by a combination of ETN, PD, VARD, and endoscopic biliary stenting. Moreover, a systematic literature review of comparative studies on minimally invasive techniques in necrotizing pancreatitis has been provided. Case presentation: A 59-year-old patient was referred to our center for acute necrotizing pancreatitis associated with multi-organ failure. No invasive procedures were attempted in the first month from the onset: enteral feeding by a naso-duodenal tube was started, and antibiotics were administered to control sepsis. After 4 weeks, CT scans showed a central walled-off pancreatic necrosis (WOPN) of pancreatic head communicating bilateral retroperitoneal collections. ETN was performed, and bile leakage was found at the right margin of the WOPN. Endoscopic retrograde cholangiopancreatography confirmed the presence of a choledocal fistula within the WOPN, and a biliary stent was placed. An ultrasound-guided PD was performed on the left retroperitoneal collection. Due to the subsequent repeated onset of septic shocks and the evidence of size increase of the right retroperitoneal collection, a VARD was decided. The CT scans documented the resolution of all the collections, and the patient promptly recovered from sepsis. After 6 months, the patient is in good clinical condition. Conclusions: No mini-invasive technique has demonstrated significantly better outcomes over the others, and each technique has specific indications, advantages, and pitfalls. Indeed, ETN could be suitable for central WOPNs, while VARD or PD could be suggested for lateral collections. A combination of different approaches is feasible and could significantly optimize the clinical management in critically ill patients affected by complicated necrotizing pancreatitis. [ABSTRACT FROM AUTHOR]

Background: An option for emergency control of pelvic hemorrhage is Extra-peritoneal Pelvic Packing (EPP), which addresses the retroperitoneal source of exsanguination in pelvic fractures. The aim of this study was to demonstrate the efficacy of early EPP in reducing mortality due to hemorrhage from pelvic fractures, and to evaluate the impact of packing on transfusion requirements within the first 24 h and ICU length of stay (ICU-LOS). All data pertaining trauma patients admitted from October 2002 and December 2103 with hemodynamic instability and pelvic fractures were selected from the Hospital Trauma Registry. Patients with severe brain injury and bleeding from extra-pelvic sources were excluded. Patient population was divided into two groups: EPP group, including patients admitted from 2009 to 2013, with EPP as part of the treatment algorithm, and NO-EPP group, from 2002 to 2008, without EPP as atherapeutic option. Descriptive statistical analysis was performed on allpatients. Twenty-five patients of each group with similar features were matched using Propensity Score Analysis (PSA). Results: Six hundred eighty out of 4659 major trauma (14.6 %) presented a pelvic fracture. In 78 hemodynamically unstable patients (30 in EPP group,48 in NO-EPP group) the major source of bleeding was the pelvis. Among patients selected by PSA early mortality was significantly reduced in EPP group (20 vs 52 %, p = .03) compared to NO-EPP, notwithstanding similar hemodynamic impairment. No difference was observed in transfusion requirements and ICU-LOS. Conclusions: The EPP is a safe and quick procedure, able to improve hemodynamic stabilization and to reduce acute mortality due to hemorrhage in patients with pelvic fracture, in combination with optimized transfusion protocol. EPP may be useful as a bridge for time-consuming procedures, such as angio-embolization. [ABSTRACT FROM AUTHOR]

Trauma, both blunt and penetrating, is extremely common worldwide, as trauma to major vessels. The management of these patients requires specialized surgical skills and techniques of the trauma surgeon. Furthermore few other surgical emergencies require immediate diagnosis and treatment like a ruptured abdominal aortic aneurysm (rAAA). Mortality of patients with a rAAA reaches 85 %, with more than half dying before reaching the hospital. These are acute events demanding immediate intervention to save life and limb and precluding any attempt at transfer or referral. It is the purpose of this position paper to discuss neck, chest, extremities and abdominal trauma, bringing to light recent evidence based data as well as expert opinions; besides, in this paper we present a review of the recent literature on rAAA and we discuss the rationale for transfer to referral center, the role of preoperative imaging and the pros and cons of Endoluminal repair of rAAA (REVAR) versus Open Repair (OR). [ABSTRACT FROM AUTHOR]

The indications for Open Abdomen (OA) are generally all those situations in which is ongoing the development an intra-abdominal hypertension condition (IAH), in order to prevent the development of abdominal compartmental syndrome (ACS). In fact all those involved in care of a critically ill patient should in the first instance think how to prevent IAH and ACS. In case of ACS goal directed therapy to achieve early opening and early closure is the key: paradigm of closure shifts to combination of therapies including negative pressure wound therapy and dynamic closure, in order to reduce complications and avoid incisional hernia. There have been huge studies and progress in survival of critically ill trauma and septic surgical patients: this in part has been through the great work of pioneers, scientific societies and their guidelines; however future studies and continued innovation are needed to better understand optimal treatment strategies and to define more clearly the indications, because OA by itself is still a morbid procedure. [ABSTRACT FROM AUTHOR]

Background: Injury is a public health problem in terms of mortality, morbidity and disability. The implementation of a regionalised trauma system has been proved to significantly reduce the social impact of severe trauma on population. A population-based registry may be useful to obtain reliable epidemiologic data. Aim: To perform an exhaustive analysis of severe trauma patients hospitalised in Lombardia, a region of northern Italy. Materials and methods: The regional Hospital Discharge Registry (HDR) was used to retrieve data of all patients who suffered from serious injuries from 2008 to 2010. ICD9-CM codes of discharge diagnoses were analysed and patients coded from 800.0 to 939.9 or from 950.0 to 959.9 have been retrieved. Femur fractures in elderly and patients with length of hospital stay less than 2 days were excluded. Patients have been considered seriously injured if discharged dead or any of followings: admission or transit in ICU, need of mechanical ventilation, tracheotomy, invasive hemodynamic monitoring. Average reimbursement based on DRG has been evaluated. Statistics: Student's t test, ANOVA for continuous data, chi-square test for categorical data were used, and a p value less than 0.05 was considered significant. Results: The severely injured patients hospitalised in Lombardia in three years were 11704, 391 per million per year. Overall mortality was 24.17% and increased with age. Males aging from 18 to 64 years had more occupational injuries, trauma on the road and violence by others. Females were more susceptible to domestic injuries and self inflicted violence, mostly in older ages. Acute mortality was higher after traffic accidents, while late mortality was increased in domestic trauma. Pediatric cases were unusual. A significant increase (+10.18%) in domestic trauma, with a concomitant decrease (?17.76%) in road-related accidents was observed in the three years study period. Reimbursement paid to hospitals for seriously injured was insufficient with regard to estimated costs of care. Conclusion: Serious injury requiring hospitalisation in Lombardia is still an healthcare problem, with a trend toward a decrease of traffic accidents, increase in domestic trauma and involvement of older people. These results may help to plan a new regionalised Trauma System. [ABSTRACT FROM AUTHOR]

Objective: To compare the effectiveness of normal saline, dextran, hypertonic, and hypertonic-hyperoncotic solutions in hemorrhagic shock.Design: Laboratory investigation.Setting: University hospital, Emergency Surgery and Intensive Care staff.Subjects: Thirty-two large white female pigs.Interventions: Routine care included: anesthesia and sedation (ketamine 10 mg/kg, droperidol 0.25 mg/kg, diazepam 0.7 mg/kg, fentanyl 0.006 mg/kg, 2% enflurane, 20% nitrous oxide, pancuronium bromide 0.13 mg/kg); volume-controlled ventilation (Paco(2) 35-40 torr; 4.7-5.4 kPa); cannulation of right carotid artery and pulmonary artery. Three flow probes (subdiaphragmatic aorta, superior mesenteric artery, right renal artery) and regional venous catheters (superior mesenteric vein, right renal vein) were positioned. Animals were bled to 45 mm Hg for 1 hr and resuscitated with four different fluids and blood to normal aortic blood flow and hemoglobin.Measurements and Main Results: Mean arterial pressure and blood flow through abdominal aorta ([OV0312](aor)), mesenteric artery ([OV0312](mes)), and renal artery ([OV0312](ren)) were continuously monitored. Cardiac output, systemic and regional oxygen delivery ([U1E0A]o(2), [U1E0A]o(2mes), [U1E0A]o(2ren)), and consumption ([OV0312]o(2), [OV0312]o(2mes), [OV0312]o(2ren)) were recorded every 30 mins. Baseline [OV0312](aor) was restored with different amounts of fluids in the four groups: normal saline (91.35 +/- 22.18 mL/kg); dextran (16.24 +/- 4.42 mL/kg); hypertonic (13.70 +/- 1.44 mL/kg); and hypertonic-hyperoncotic (9.11 +/- 1.20 mL/kg). The amount of sodium load was less using dextran and hypertonic-hyperoncotic and sodium levels were only transiently increased after hypertonic infusion. Mean arterial pressure and cardiac output were normalized in all groups. Animals resuscitated with normal saline and dextran showed increased pulmonary artery pressures. [U1E0A]o(2) was significantly higher after hypertonic-hyperoncotic infusion, because of reduced hemodilution. Hypertonic and hypertonic-hyperoncotic normalized [OV0312](mes), [U1E0A]o(2mes), [OV0312]o(2mes), [OV0312](ren), and [U1E0A]o(2ren), whereas normal saline and dextran did not achieve this result. At the end of the experiment, hypertonic-hyperoncotic maintained mean arterial pressure, cardiac output, and [U1E0A]o(2) until the end of observation in contrast to normal saline, dextran, and hypertonic.Conclusions: Resuscitation with a small volume of hypertonic-hyperoncotic solution allows systemic and splanchnic hemodynamic and oxygen transport recovery, without an increase in pulmonary artery pressure. It only transiently increased sodium concentration. [ABSTRACT FROM AUTHOR]

Background: Organ donation (OD) remains the only therapeutic option for end-stage disease in some cases. Unfortunately, the gap between donors and recipients is still substantial. Trauma patients represent a potential yet underestimated pool of organ donors. In this article, we present our data on OD after damage control strategy (DCS). Materials and Methods: A retrospective, observational cohort study was conducted through a complete revision of data of consecutive adult trauma patients (>18 years old) who underwent OD after DCS between January 2018 and May 2021. Four subgroups were created [Liver (Li), Lungs (Lu), Heart (H), Kidneys (K)] to compare variables between those who donated the organ of interest and those who did not. Results: Thirty-six patients underwent OD after DCS. Six patients (16.7%) were excluded: 2(5.6%) for missing data about admission; 4(11.1%) didn't receive DCS. Mean ISS was 47.2 (SD ± 17.4). Number of donated organs was 113 with an organs/patient ratio of 3.8. The functional response rate was 91.2%. Ten organs (8.8%) had primary nonfunction after transplantation: 2/15 hearts (13.3%), 1/28 livers (3.6%), 4/53 kidneys (7.5%) and 3/5 pancreases (60%). No lung primary nonfunction were registered. Complete results of subgroup analysis are reported in supplementary materials. Conclusion: Organ donation should be considered a possible outcome in any trauma patient. Aggressive damage control strategy doesn't affect the functional response rate of transplanted organs. [ABSTRACT FROM AUTHOR]

Purpose: Complex enteric fistulas (CEF) represent general surgeons' nightmare. This paper aims to explore the impact on failure-to-rescue (FTR) rate of a standardised and integrated surgical and critical care step-up approach. Methods: This was a retrospective observational cohort study. Patients treated for CEF from 2009 to 2019 at Niguarda Hospital were included. Each patient was approached following a three-step approach: study phase, sepsis control and strategy definition phase, and surgical rescue phase. Results: Sixteen patients were treated for CEF. Seven fistulas were classified as complex entero-cutaneous (ECF) and nine as entero-atmospheric fistula (EAF). Median number of surgical procedures for fistula control before definitive surgical attempt was 11 (IQR 2–33.5). The median time from culprit surgery and the first access at Niguarda Hospital to definitive surgical attempt were 279 days (IQR 231–409) and 120 days (IQR 34–231), respectively. Median ICU LOS was 71 days (IQR 28–101), and effective hospital LOS was 117 days, (IQR 69.5–188.8). Three patients (18.75%) experienced spontaneous fistula closure after conversion to simple ECF, whereas 13 (81.25%) underwent definitive surgery for fistula takedown. Surgical rescue was possible in nine patients. Nine patients underwent multiple postoperative revision for surgical complications. Four patients failed to be rescued. Conclusion: An integrated step-up rescue strategy is crucial to standardise the approach to CEF and go beyond the basic surgical rescue procedure. The definition of FTR is dependent from the examined population. CEF patients are a unique cluster of emergency general surgery patients who may need a tailored definition of FTR considering the burden of postoperative events influencing their outcome. [ABSTRACT FROM AUTHOR]

(1) Background: The Gustilo–Anderson (G/A) grading system is a universally accepted tool used to classify high-grade limb open fractures. The purpose of this study is to find early independent predictors of amputation in emergency settings. (2) Methods: A retrospective analysis involving patients treated at our center between 2010 and 2016 was conducted. Patients with at least one G/A grade III fracture or post-traumatic amputation were included. Three groups were identified: G/A IIIA (A group), G/A IIIB-C (BC group), and Amputation group (AMP group). Each group was further divided into two subgroups considering timing of coverage (early vs. delayed). Univariate and multivariate logistic regression models were developed to identify independent predictors of the limb's outcome. (3) Results: One-hundred-six patients with G/A III A-B-C fractures or amputation of the affected limb were selected from the Niguarda Hospital Trauma Registry. The patients were divided into the A group (26), BC group (66), and AMP group (14). The rate of infectious complications following early or delayed coverage was evaluated: A group, 9.1% vs. 66.7% (p > 0.05); BC group, 32% vs. 63.6% (p = 0.03); and AMP group, 22% vs. 18.5% (p > 0.05). After further recategorization, the BC subgroups were analyzed: multivariate logistic regression model identified systolic blood pressure (SBP) <90 mmHg (p = 0.03) and Mangled Extremity Severity Score MESS ≥ 7 (p = 0.001) were determined to be independent predictors of limb amputation. (4) Conclusion: MESS and SBP serve as predictors of amputation. Based on the results, we propose a new management algorithm for mangled extremities. Early coverage is related to lower rates of infectious complications. Referral to high-volume centers with specific expertise is mandatory to guarantee the best results. [ABSTRACT FROM AUTHOR]

This study aims to define possible predictors of the need of invasive and non-invasive ventilatory support, in addition to predictors of mortality in patients with severe thoracic trauma. Data from 832 patients admitted to our trauma center were collected from 2010 to 2017 and retrospectively analyzed. Demographic data, type of respiratory assistance, chest injuries, trauma scores and outcome were considered. Univariate analysis was performed, and binary logistic regression was applied to significant data. The injury severity score (ISS) and the revised trauma score (RTS) were both found to be predictive factors for invasive ventilation. Multivariate analysis of the anatomical injuries revealed that the association of high-severity thoracic injuries with trauma in other districts is an indicator of the need for orotracheal intubation. From the analysis of physiological parameters, values of systolic blood pressure, lactate, and Glasgow coma scale (GCS) score indicate the need for invasive ventilatory support. Predictive factors for non-invasive ventilation include: RTS, ISS, number of rib fractures and presence of hemothorax. Risk factors for death were: age over 65, the presence of bilateral rib fractures, pulmonary contusion, hemothorax and associated head trauma. In conclusion, the need for invasive ventilatory support in thoracic trauma is associated to the patient's systemic severity. Non-invasive ventilation is a supportive treatment indicated in physiologically stable patients regardless of the severity of thoracic injury. [ABSTRACT FROM AUTHOR]

Pelvic trauma continues to have a high mortality rate despite damage control techniques for bleeding control. The aim of our study was to evaluate how Extra-peritoneal Pelvic Packing (EPP) and Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) impact the efficacy on mortality and hemodynamic impact. We retrospectively evaluated patients who sustained blunt trauma, pelvic fracture and hemodynamic instability from 2002 to 2018. We excluded a concomitant severe brain injury, resuscitative thoracotomy, penetrating trauma and age below 14 years old. The study population was divided in EPP and REBOA Zone III group. Propensity score matching was used to adjust baseline differences and then a one-to-one matched analysis was performed. We selected 83 patients, 10 for group: survival rate was higher in EPP group, but not significantly in each outcome we analyzed (24 h, 7 day, overall). EPP had a significant increase in main arterial pressure after procedure (+20.13 mmHg, p < 0.001), but this was not as great as the improvement seen in the REBOA group (+45.10 mmHg, p < 0.001). EPP and REBOA are effective and improve hemodynamic status: both are reasonable first steps in a multidisciplinary management. Zone I REBOA may be useful in patients 'in extremis condition' with multiple sites of torso hemorrhage, particularly those in extremis. [ABSTRACT FROM AUTHOR]

Background: Acute calculus cholecystitis (ACC) has a high incidence in the general population. The presence of several areas of uncertainty, along with the availability of new evidence, prompted the current update of the 2016 WSES (World Society of Emergency Surgery) Guidelines on ACC. Materials and methods: The WSES president appointed four members as a scientific secretariat, four members as an organization committee and four members as a scientific committee, choosing them from the expert affiliates of WSES. Relevant key questions were constructed, and the task force produced drafts of each section based on the best scientific evidence from PubMed and EMBASE Library; recommendations were developed in order to answer these key questions. The quality of evidence and strength of recommendations were reviewed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria (see https://www.gradeworkinggroup.org/). All the statements were presented, discussed and voted upon during the Consensus Conference at the 6th World Congress of the World Society of Emergency Surgery held in Nijmegen (NL) in May 2019. A revised version of the statements was voted upon via an online questionnaire until consensus was reached. Results: The pivotal role of surgery is confirmed, including in high-risk patients. When compared with the WSES 2016 guidelines, the role of gallbladder drainage is reduced, despite the considerable technical improvements available. Early laparoscopic cholecystectomy (ELC) should be the standard of care whenever possible, even in subgroups of patients who are considered fragile, such as the elderly; those with cardiac disease, renal disease and cirrhosis; or those who are generally at high risk for surgery. Subtotal cholecystectomy is safe and represents a valuable option in cases of difficult gallbladder removal. Conclusions, knowledge gaps and research recommendations: ELC has a central role in the management of patients with ACC. The value of surgical treatment for high-risk patients should lead to a distinction between high-risk patients and patients who are not suitable for surgery. Further evidence on the role of clinical judgement and the use of clinical scores as adjunctive tools to guide treatment of high-risk patients and patients who are not suitable for surgery is required. The development of local policies for safe laparoscopic cholecystectomy is recommended. [ABSTRACT FROM AUTHOR]

Early management of critical bleeding and coagulopathy can improve patient survival. The aim of our study was to identify independent predictors of critical bleeding and to build a clinical score for early risk stratification. A prospective analysis was performed on a cohort of trauma patients with at least one hypotensive episode during pre-hospital (PH) care or in the Emergency Department (ED). Patients who received massive transfusion (MT+) (≥4 blood units during the first hour) were compared to those who did not (MT−). Hemodynamics, Glagow Coma Score (GCS), diagnostics and blood tests were evaluated. Using multivariate analysis, we created and validated a predictive score for MT+ patients. The predictive score was validated on a matched cohort of patients of the German Trauma Registry TR-DGU. One hundred thirty-nine patients were included. Independent predictors of MT+ included a prehospital (PH) GCS of 3, PH administration of tranexamic acid, hypotension and tachycardia upon admission, coagulopathy and injuries with significant bleeding such as limb amputation, hemoperitoneum, pelvic fracture, massive hemothorax. The derived predictive score revealed an area under the curve (AUC) of 0.854. Massive transfusion is essential to damage control resuscitation. Altered GCS, unstable hemodynamics, coagulopathy and bleeding injuries can allow early identification of patients at risk for critical hemorrhage. [ABSTRACT FROM AUTHOR]

Noncompressible torso injuries (NCTIs) represent a trauma-related condition with high lethality. This study's aim was to identify potential prediction factors of mortality in this group of trauma patients at a Level 1 trauma center in Italy. Materials and Methods: A total of 777 patients who had sustained a noncompressible torso injury (NCTI) and were admitted to the Niguarda Trauma Center in Milan from 2010 to 2019 were included. Of these, 166 patients with a systolic blood pressure (SBP) <90 mmHg were considered to have a noncompressible torso hemorrhage (NCTH). Demographic data, mechanism of trauma, pre-hospital and in-hospital clinical conditions, diagnostic/therapeutic procedures, and survival outcome were retrospectively recorded. Results: Among the 777 patients, 69% were male and 90.2% sustained a blunt trauma with a median age of 43 years. The comparison between survivors and non-survivors pointed out a significantly lower pre-hospital Glasgow coma scale (GCS) and SBP (p < 0.001) in the latter group. The multivariate backward regression model identified age, pre-hospital GCS and injury severity score (ISS) (p < 0.001), pre-hospital SBP (p = 0.03), emergency department SBP (p = 0.039), performance of torso contrast enhanced computed tomography (CeCT) (p = 0.029), and base excess (BE) (p = 0.008) as independent predictors of mortality. Conclusions: Torso trauma patients who were hemodynamically unstable in both pre- and in-hospital phases with impaired GCS and BE had a greater risk of death. The detection of independent predictors of mortality allows for the timely identification of a subgroup of patients whose chances of survival are reduced. [ABSTRACT FROM AUTHOR]

Background: Laparoscopic appendectomy has progressively gained acceptance as the standard of care for acute appendicitis. Focusing on the incidence of postoperative intra-abdominal abscess after a laparoscopic appendectomy, discordant data have been reported ranging from 1.5 to 20%. Besides, evidence advocating advantages from peritoneal irrigation over suction only are lacking. Most studies are burdened by a high level of heterogeneity regarding the severity of the appendicitis and modalities of peritoneal irrigation. One of the main drawbacks is the lack of an accepted classification for different degrees of appendicitis and peritoneal contamination. The aim of the study is to introduce a classification to clarify the relationship between grade of appendicitis, contamination, and postoperative incidence of IAA considering the surgeon's attitude toward irrigation or suction alone. Preoperative, intra-operative, and postoperative predictive factors for infectious complication will also be assessed. This study is meant to be the first Italian multicenter resident-based observational study. Methods: Patients suffering from acute appendicitis will be enrolled during a 1-year period, according to inclusion and exclusion criteria. Participants will fill an online form reporting all clinical and intra-operative data of each patient undergoing a laparoscopic appendectomy. General surgery residents will be responsible for data collection. Our proposal of classification is based on the histological grade of appendicitis and intra-operative degree of peritoneal contamination. For each grade, a progressively increasing score is assigned. Discussion: The observational nature of this study is mandatory to examine surgeons' attitude toward peritoneal contamination during laparoscopic appendectomy for appendicitis. Identification of different severity grades of acute appendicitis and their relationship with the development of postoperative abscesses is necessary. The resulting classification and score, even considering peritoneal lavage or suction alone, will define risk classes of peri-appendiceal contamination each one related to a specific incidence rate of postoperative IAA. Nowadays, maximum effort should be made to reach the best procedural standardization and surgical decision-making should be supported by solid evidence, especially in an emergency surgery setting. [ABSTRACT FROM AUTHOR]

ᅟ: Obstruction and perforation due to colorectal cancer represent challenging matters in terms of diagnosis, life-saving strategies, obstruction resolution and oncologic challenge. The aims of the current paper are to update the previous WSES guidelines for the management of large bowel perforation and obstructive left colon carcinoma (OLCC) and to develop new guidelines on obstructive right colon carcinoma (ORCC). Methods: The literature was extensively queried for focused publication until December 2017. Precise analysis and grading of the literature has been performed by a working group formed by a pool of experts: the statements and literature review were presented, discussed and voted at the Consensus Conference of the 4th Congress of the World Society of Emergency Surgery (WSES) held in Campinas in May 2017. Results: CT scan is the best imaging technique to evaluate large bowel obstruction and perforation. For OLCC, self-expandable metallic stent (SEMS), when available, offers interesting advantages as compared to emergency surgery; however, the positioning of SEMS for surgically treatable causes carries some long-term oncologic disadvantages, which are still under analysis. In the context of emergency surgery, resection and primary anastomosis (RPA) is preferable to Hartmann’s procedure, whenever the characteristics of the patient and the surgeon are permissive. Right-sided loop colostomy is preferable in rectal cancer, when preoperative therapies are predicted. With regards to the treatment of ORCC, right colectomy represents the procedure of choice; alternatives, such as internal bypass and loop ileostomy, are of limited value. Clinical scenarios in the case of perforation might be dramatic, especially in case of free faecal peritonitis. The importance of an appropriate balance between life-saving surgical procedures and respect of oncologic caveats must be stressed. In selected cases, a damage control approach may be required. Medical treatments including appropriate fluid resuscitation, early antibiotic treatment and management of co-existing medical conditions according to international guidelines must be delivered to all patients at presentation. Conclusions: The current guidelines offer an extensive overview of available evidence and a qualitative consensus regarding management of large bowel obstruction and perforation due to colorectal cancer. [ABSTRACT FROM AUTHOR]