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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]

• 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]

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: 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]

• 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]

This study investigates the impact of extraperitoneal pelvic packing (EPP) on the definitive surgical treatment of pelvic fractures (PF) in trauma patients. While EPP is recognized as an effective life-saving technique for controlling non-compressible retroperitoneal bleeding, concerns persist about its potential to complicate subsequent surgical interventions. A total of 220 trauma patients treated in a single First Level Trauma Centre from October 2016 to December 2021 were analysed. Demographic data, trauma mechanisms, hemodynamic stability, Injury Severity Scores (ISS), New ISS, PF classification (Tile), surgical timelines, and postoperative complications according to the Clavien-Dindo classification were collected. The study population was divided into two groups: those who underwent EPP (n = 42) and those who did not (n = 178). Statistical analyses included propensity score matching to balance baseline characteristics and reduce selection bias. Key findings show that EPP effectively improved survival rates in hemodynamically unstable patients, achieving a survival rate of 71.43 %. However, EPP was associated with delays in definitive surgical treatment and a higher incidence of major postoperative complications (41.67 % vs. 17.65 %, p = 0.014). Despite these delays, EPP did not significantly limit the possibility of achieving definitive surgery or the choice of fixation technique. Patients who underwent both EPP and open reduction internal fixation did not show a higher rate of severe complications compared to those managed without EPP. The study concludes that while EPP should be considered a practical emergency intervention for critically unstable PF patients, and even though it may affect the timing of definitive PF treatment, it does not prevent further surgical management., Competing Interests: Declaration of competing interest None., (Copyright © 2025 Elsevier Ltd. All rights reserved.)

Background: The current standard of care for mild acute biliary pancreatitis (MABP) involves early laparoscopic cholecystectomy (ELC) to reduce the risk of recurrence. The MANCTRA-1 project revealed a knowledge-to-action gap and higher recurrence rates in patients admitted to medical wards, attributable to fewer ELCs being performed. The project estimated a 35% to 70% probability of narrowing this gap by 2025. This study evaluates the safety of suboptimal ELC implementation and identifies risk factors for recurrent acute biliary pancreatitis (RAP) in patients not undergoing ELC after an MABP episode., Methods: We conducted a post-hoc analysis of the MANCTRA-1 registry, including MABP patients who did not undergo ELC during the index hospitalization, excluding those with related complications. The primary outcome was the 30-day hospital readmission rate due to RAP. We performed multivariable logistic regression to find risk factors associated with the primary outcome., Results: Between January 2019 and December 2020, 1920, MABP patients from 150 centers were included in the study. The 30-day readmission rate due to RAP was 6%. Multivariable logistic regression found the admission to a medical ward (internal medicine or gastroenterology) (OR = 1.95, p = 0.001) and a positive COVID-19 test (OR = 3.08, p = 0.029) as independent risk factors for RAP., Conclusion: Our analysis offers valuable insights into the management of MABP, particularly in centers where ELC cannot be fully implemented due to logistical and clinical constraints, worsened by the COVID-19 pandemic. Regardless of the admitting ward, prompt access to surgical care is crucial in reducing the risk of early recurrence, highlighting the need to implement surgical consultation pathways within MABP care bundles., Competing Interests: Declarations. Conflict of interest: The authors declare no conflict of interest., (© 2025. The Author(s).)

Background: Despite improved awareness of blunt traumatic hollow viscus and mesenteric injuries (THVMI), the accuracy of contrast-enhanced CT (CECT) varies considerably among studies. This systematic review and meta-analysis of test accuracy aims to explore the diagnostic performance of CECT in detecting THVMI in blunt trauma., Methods: The study was conducted according to the Cochrane recommendations searching the PubMed, Scopus, and Cochrane Library datasets from 2000 to 8 September 2023 (PROSPERO ID: CRD42023473041). Surgical exploration, autopsy, and discharge from the hospital after monitoring were set as reference standard. To explore the diagnostic accuracy of CECT in detecting THVMI hierarchical models were developed. The risk of bias in individual studies was assessed with the QUADAS-2 tool. Sensitivity analysis was conducted to detect sources of heterogeneity., Results: Twelve studies, for a total of 4537 patients, were deemed eligible. After identification of outliers and sensitivity analysis, the pooled sensitivity, specificity, positive and negative likelihood ratios, and diagnostic odds ratio were 0.85 (95% CI: 0.69-0.93), 0.94 (95% CI: 0.8-0.98), 14.65 (95% CI: 4.22-50.85), 0.16 (95% CI: 0.07-0.34), 92.3 (95% CI: 29.75-286.34), respectively. The Area under the HSROC curve was 0.95 (95% CI: 0.92-0.96). Meta-regression analysis identified the year of publication as a covariate significantly associated with heterogeneity. A high risk of bias was detected in the "patient selection" domains., Conclusion: CECT has a fundamental role in identifying THVMI with high specificity but suboptimal sensitivity. Clinical criteria are still of paramount importance, especially in cases of ambiguous initial CECT images., Competing Interests: Declarations. Competing interests: The authors declare no competing interests., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

Competing Interests: Declarations. Institutional Review Board statement: The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Ethics Committee of ASST GOM Niguarda. All enrolled patients were extracted from our prospectively collected database, including Trauma and Acute Care Surgery Patients, registered within our Ethics Committee Milano Area 3 with the following code: 534–102018 (Dec. 2018). Consent to participate: Informed consent was obtained from all subjects involved in the study. In this registry-based study, patients were informed that their completely anonymized data could be further used for scientific studies. All patients or parents enrolled signed an informed consent to allow data collection for scientific purposes. Conflict of interest: The authors declare no conflict of interest.

Background: The blunt and penetrating abdominal trauma follow-up relies on contrast CT scan to detect solid organ injuries. CEUS is not widely used worldwide, despite its accuracy and feasibility in identifying parenchymal and vascular lesions. This survey aims to define the current use of CEUS in Trauma Centers and the expectations of Emergency Surgeons regarding its role., Methods: We sent an online questionnaire composed of 10 questions to trauma physicians worldwide during the period of September 2022 to March 2023., Results: 59 participants from 53 different centers answered the questionnaire. 76.2% of the enrolled participants have CEUS available at their Institution, and 49.2% think that it can replace CT scan. Contrast-CT scan remains the preferred option in the follow-up of blunt liver (69.5%), spleen (72.9%) and kidney (76.3%) injuries, followed by CEUS which is used in 18.6% for liver, 20.3% for spleen and 15.3% for kidney injuries. The results are similar for penetrating abdominal trauma, with contrast CT scan being the first-line imaging technique (91.5% for liver, 91.5% for spleen and 88.1% for kidney injuries), followed by CEUS (5.1% for liver, 5.1% for spleen and 6.8% for kidney injuries)., Conclusions: Our survey shows that CEUS is still underutilized in the follow-up of abdominal trauma, even though many emergency surgeons consider it as a valid alternative to contrast CT scan., Competing Interests: Declarations. Conflict of interest: The authors declare to have no competing interests. Ethical approval and consent to participate: Not applicable to this publication. Consent for publication: Not necessary for this study., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

Purpose: European training pathways for surgeons dedicated to treating severely injured and critically ill surgical patients lack a standardized approach and are significantly influenced by diverse organizational and cultural backgrounds. This variation extends into the realm of mentorship, a vital component for the holistic development of surgeons beyond mere technical proficiency. Currently, a comprehensive understanding of the mentorship landscape within the European trauma care (visceral or skeletal) and emergency general surgery (EGS) communities is lacking. This study aims to identify within the current mentorship environment prevalent practices, discern existing gaps, and propose structured interventions to enhance mentorship quality and accessibility led by the European Society for Trauma and Emergency Surgery (ESTES)., Methods: Utilizing a structured survey conceived and promoted by the Young section of the European Society of Trauma and Emergency Surgery (yESTES), we collected and analyzed responses from 123 ESTES members (both surgeons in practice and in training) across 20 European countries. The survey focused on mentorship experiences, challenges faced by early-career and female surgeons, the integration of non-technical skills (NTS) in mentorship, and the perceived role of surgical societies in facilitating mentorship., Results: Findings highlighted a substantial mentorship experience gap, with 74% of respondents engaging in mostly informal mentorship, predominantly centered on surgical training. Notably, mentorship among early-career surgeons and trainees was less reported, uncovering a significant early-career gap. Female surgeons, representing a minority within respondents, reported a disproportionately poorer access to mentorship. Moreover, while respondents recognized the importance of NTS, these were inadequately addressed in current mentorship practices. The current mentorship input of surgical societies, like ESTES, is viewed as insufficient, with a call for structured programs and initiatives such as traveling fellowships and remote mentoring., Conclusions: Our survey underscores critical gaps in the current mentorship landscape for trauma and EGS in Europe, particularly for early-career and female surgeons. A clear need exists for more formalized, inclusive mentorship programs that adequately cover both technical and non-technical skills. ESTES could play a pivotal role in addressing these gaps through structured interventions, fostering a more supportive, inclusive, and well-rounded surgical community., Competing Interests: Declarations. Conflict of interest: Stefano P. B. Cioffi, Marit Herbolzheimer, Enrico Marrano, Gabriele Bellio, Wouter Kluijfhout, Frans-Jasper Wijdicks and Annika Hättich are founding members of Young ESTES. Jonathan Tilsed is Chair of the UEMS European Board of Surgery Examination in Emergency Surgery. Diego Mariani is the ESTES Chair of Education, Christine Rey Valcarel is Chair of the ESTES Advisory Council. Shahin Mohseni is Chair of the Visceral Trauma Section of ESTES and is a Section Editor for the European Journal of Trauma and Emergency Surgery (EJTES). Carlos Yanez is Chair of the Emergency Surgery Section of ESTES. Jan P.A.M. Verbruggen is Chair of the Skeletal Trauma and Sports Medicine Section, and President-Elect of ESTES. Frank Hildebrand is Vice-Chair of the ESTES Research Committee and Immediate Past-President of ESTES. Christine Gaarder is President of ESTES. Hayato Kurihara is Vice-President of ESTES. Gary Alan Bass is the ESTES Chair of Research and is a Section Editor for EJTES. All other authors declare no competing interests., (© 2024. The Author(s).)

Traumatic pneumothorax (PTX) occurs in up to 50% of patients with severe polytrauma and chest injuries. Patients with a traumatic PTX with clinical signs of tension physiology and hemodynamic instability are typically treated with an urgent decompressive thoracostomy, tube thoracostomy, or needle decompression. There is recent evidence that non-breathless patients with a hemodynamically stable traumatic PTX can be managed conservatively through observation or a percutaneous pigtail catheter. We present here a 52-year-old woman who presented to the emergency department with a 55 mm traumatic PTX. Following aspiration of 1500 mL of air, a clinical improvement was immediately observed, allowing the patient to be discharged shortly thereafter. In hemodynamically stable patients with a post-traumatic PTX, without specific risk factors or oxygen desaturation, observation or simple needle aspiration can be a reasonable approach. Although the recent medical literature supports conservative management of small traumatic PTXs, guidelines are lacking for hemodynamically stable patients with a significantly large PTX. This case report documents our successful experience with needle aspiration in such a setting of large traumatic PTX. We aimed in this article to review the available literature on needle aspiration and conservative treatment of traumatic pneumothorax. A total of 12 studies were selected out of 190 articles on traumatic PTX where conservative treatment and chest tube decompression were compared. Our case report offers a novel contribution by illustrating the successful resolution of a sizable pneumothorax through needle aspiration, suggesting that even a large PTX in a hemodynamically stable patient, without other risk conditions, can be successfully treated conservatively with simple needle aspiration in order to avoid tube thoracostomy complications.

Purpose of Review: This review examines recent advancements in nonoperative management (NOM) of hemodynamically stable blunt abdominal trauma, focusing on expanding patient selection for observation-first strategies, particularly for high-grade solid organ injuries., Recent Findings: Advances include a more deliberate nonoperative approach, allowing for broader patient inclusion in diagnostic and interventional angiography. Strict clinical monitoring and appropriate follow-up strategies are crucial to identify early signs of clinical progression and complications. Repeated contrast-enhanced CT (CECT) scan can be used for close observation of high-risk injuries, while the repetition of CECTs may be avoided for lower-risk cases, such as specific high-grade kidney injuries. The role of contrast-enhanced ultrasound (CEUS) in detecting sequelae of nonoperative approaches is still debated and has lot of potential, with ongoing trials exploring possible advantages., Summary: Multidisciplinary trauma teams play a crucial role in nonoperative management, particularly for high-grade injuries. A careful selection of patients is essential to minimize failure rates. Complications of nonoperative and angiographic approaches should be managed according to local expertise., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: The management of blunt splenic trauma has evolved in the last years, from mainly operative approach to the non-operative management (NOM). The aim of this study is to investigate whether trauma center (TC) designation (level 1 and level 2) affects blunt splenic trauma management., Methods: A retrospective analysis of blunt trauma patients with splenic injury admitted to 2 Italian TCs, Niguarda (level 1) and San Carlo Borromeo (level 2), was performed, receiving either NOM or emergency surgical treatment, from January 1, 2015 to December 31, 2020. Univariate comparison was performed between the two centers, and multivariate analysis was carried out to find predictive factors associated with NOM and splenectomy., Results: 181 patients were included in the study, 134 from level 1 and 47 from level 2 TCs. The splenectomy/emergency laparotomy ratio was inferior at level 1 TC for high-grade splenic injuries (30.8% for level 1 and 100% for level 2), whose patients presented higher incidence of other injuries. Splenic NOM failure was registered in only one case (3.3%). At multivariate analysis, systolic pressure, spleen organ injury scale (OIS) and injury severity score (ISS) resulted significant predictive factors for NOM, and only spleen OIS was predictive factor for splenectomy (Odds Ratio 0.14, 0.04-0.49 CI 95%, P < .01)., Conclusion: Both level 1 and 2 trauma centers demonstrated application of NOM with a high rate of success with some management difference in the treatment and outcome of patients with splenic injuries between the two types of TCs., (Copyright © 2022. Published by Elsevier España, S.L.U.)

Purpose: Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) represents a minimally invasive technique of aortic occlusion (AO). It has been demonstrated to be safe and effective with appropriate training in traumatic hemorrhage with hemodynamic instability; however, its indications are still debated. The aim of this systematic review and meta-analysis is to assess the impact of REBOA on mortality in torso trauma patient with severe non-compressible hemorrhage compared to other temporizing hemostatic techniques., Study Design: The primary outcome is represented by 24-h, and in-hospital mortality. Secondary outcomes are post-procedural hemodynamic improvement (systolic blood pressure-SBP), mean injury severity score (ISS) differences, treatment-related morbidity, transfusional requirements and identification of prognostic factors., Results: A significant survival benefit at 24 h (RR 0.46; 95% CI 0.27-0.79; I 2 : 55%; p = 0.005) was highlighted in patients undergoing REBOA. Regarding in-hospital mortality (RR 0.99; 95% CI 0.75-1.32; I 2 : 73%; p = 0.98) no differences in risk of death were noticed. A hemodynamic improvement-although not significant-was highlighted, with 55.8 mmHg post-AO SBP mean difference between REBOA and control groups. A significantly lower mean number of packed Red Blood Cells (pRBCs) was noticed for REBOA patients (mean difference: - 3.02; 95% CI - 5.79 to - 0.25; p = 0.033). Nevertheless, an increased risk of post-procedural complications (RR 1.66; 95% CI 0.39-7.14; p = 0.496) was noticed in the REBOA group., Conclusions: REBOA may represent a valid tool in the initial treatment of multiple sites subdiaphragmatic hemorrhage with refractory hemodynamic instability. However, due to several important limitations of the present study, our findings should be interpreted with caution., Level of Evidence: Level III according to ELIS (SR/MA with up to two negative criteria)., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

Trauma is the leading cause of death in young people with a considerable socio-economic impact worldwide. A trimodal distribution of trauma mortality was described in the past, but recently different studies underlined a progressive change in trauma mortality distribution linked to improvement in trauma care. This study aimed to analyze the mortality trends in a Level-One Trauma Center in Italy. Data on 6065 patients consecutively admitted to the Trauma Center between 2011 and 2020 were selected and retrospectively analyzed. Causes of Death (CODs) and time of death were stratified in four main groups and the patient sample was further divided into five age groups. Multivariate regression models were then performed to identify independent predictors of mortality. The most common COD in all age groups was Central Nervous System injuries. Immediate deaths (in ED) affected mostly patients over 75 years of age (34.3%). Deaths caused by massive hemorrhage occurred soon upon arrival in the ED, whereas deaths due to other causes (e.g. sepsis, MOF) after the first week. Patients' characteristics, the need for emergency procedures and high trauma severity scores were independent predictors of deaths. This study represented the first analysis on trauma mortality distribution in Italy over a nine-year period. The trimodal distribution described in the past seems to be no longer present in Italy, due to improvements in trauma systems and critical care. However, the high number of immediate and acute deaths underlies a persisting need for efforts in injury prevention and control ., (© 2022. The Author(s).)

Alcohol and drugs misuse represents an important social problem. There is no agreement about influence of ethanol and drugs on trauma severity and clinical course. The aim of this study was to investigate the impact of alcohol and drugs abuse on road related trauma managed to our Level I Trauma Center. Data of 1067 car or motorcycle drivers consecutively admitted in a 5 years period were retrospectively analyzed. The sample was divided into two groups: patients with alcohol and/or drugs misuse and patients without detectable plasmatic levels or not screened because no clinical suspicion of these substance. Demographic data, mechanism of trauma, severity of injury, daily and season time of trauma distribution, alcohol and drugs levels and outcomes were retrieved. Alcohol or drugs misuse were detected in 242 patients. Heavy alcohols levels were the 62.3%. Among drugs cannabis was the most detected substance. These patients were significantly younger than the overall study population (p = 0.011), with a higher ISS (p = 0.012) a lower RTS (p = 0.047), a lower GCS (p = 0.005) and an higher head injuries severity (p = 0.030). Regarding time distribution, Saturday was the day with the highest percentage of trauma associated with substance misuse (21%). Alcohol/drugs misuse plays a very important role in the epidemiology of road related trauma. Despite the higher severity of trauma scores and the higher incidence of severe head injuries in patients with alcohol or drugs consumption, there were no effects of this substances on mortality of injured patients involved in road crashes., (© 2021. The Author(s).)

High energy blunt trauma patients with normal vital signs are usually investigated with a Contrast Enhanced Computed Tomography (CECT) for torso injuries. CECT involves high levels of radiations, often showing no injuries in patients over-triaged to the trauma center. The aim of our study was to suggest an alternative diagnostic protocol based on Emergency Room (ER) tests (physical exam, blood tests, extended FAST, Chest and Pelvis X-ray) to avoid CECT in selected patients. A prospective cohort study was conducted from September 2018 to September 2019. Five hundred patients fulfilled the inclusion criteria. Patients received torso-CECT scan only if they had at least one positive ER test. The validity of the single component of the protocol and the global validity of the ER tests to detect torso injuries was assessed through sensitivity, specificity, positive (PPV) and negative (NPV) predictive value, positive (+ LR) and negative (- LR) likelihood ratio. Multivariate analysis was performed to identify independent predictors of torso injuries. One hundred and seventy patients received a torso-CECT scan because of positive ER tests. ER tests showed a global sensitivity for torso injuries of 86.96% (95% CI 80.17-92.08) specificity of 83.98%(95% CI 79.79-87.60), PPV of 67.42% (95% CI 61.83-72.54), NPV of 94.41% (95% CI 91.63-96.30) + LR of 5.43 (95% CI 4.25-6.93), - LR of 0.16 (95% CI 0.10-0.24). ER tests in an experienced center seem to be able to identify more severe blunt trauma patients needing CECT. Further studies are advisable to confirm these results., (© 2021. Italian Society of Surgery (SIC).)

Bile duct injury (BDI) is a dangerous complication of cholecystectomy, with significant postoperative sequelae for the patient in terms of morbidity, mortality, and long-term quality of life. BDIs have an estimated incidence of 0.4-1.5%, but considering the number of cholecystectomies performed worldwide, mostly by laparoscopy, surgeons must be prepared to manage this surgical challenge. Most BDIs are recognized either during the procedure or in the immediate postoperative period. However, some BDIs may be discovered later during the postoperative period, and this may translate to delayed or inappropriate treatments. Providing a specific diagnosis and a precise description of the BDI will expedite the decision-making process and increase the chance of treatment success. Subsequently, the choice and timing of the appropriate reconstructive strategy have a critical role in long-term prognosis. Currently, a wide spectrum of multidisciplinary interventions with different degrees of invasiveness is indicated for BDI management. These World Society of Emergency Surgery (WSES) guidelines have been produced following an exhaustive review of the current literature and an international expert panel discussion with the aim of providing evidence-based recommendations to facilitate and standardize the detection and management of BDIs during cholecystectomy. In particular, the 2020 WSES guidelines cover the following key aspects: (1) strategies to minimize the risk of BDI during cholecystectomy; (2) BDI rates in general surgery units and review of surgical practice; (3) how to classify, stage, and report BDI once detected; (4) how to manage an intraoperatively detected BDI; (5) indications for antibiotic treatment; (6) indications for clinical, biochemical, and imaging investigations for suspected BDI; and (7) how to manage a postoperatively detected BDI.

Despite its rarity, traumatic hollow viscus and mesenteric injury (HVMI) have high mortality and complication rates. There is no consensus regarding its best management. Our aim is to evaluate contrast enhanced CT (ceCT) in the screening of HVMI and its capability to assess the need for surgery. All trauma patients admitted to an urban Level 1 trauma center between 2010 and 2018 were retrospectively evaluated. Patients with ceCT scan prior to laparotomy were included. Patients requiring surgical repair of HVMI and a ceCT scan consistent with HVMI were considered true positives. Six ceCT scan criteria for HVMI were used; at least one criterion was considered positive for HVMI. Sensitivity (Sn), specificity (Sp), predictive values (PV), likelihood ratios (LR) and accuracy (Ac) of ceCT of single ceCT criteria and of the association of ceCT criteria were calculated using intraoperative findings as gold standard. Therapeutic time (TT), death probability (DP), and observed mortality (OM) were described. 114 of 4369 patients were selected for ceCT accuracy analysis; 47 were considered true positives. Sn of ceCT for HVMI was 97.9%, Sp 63.6%, PPV 66.2%, NPV 97.6%, + LR 2.69, -LR 0.03, Ac 78%; no single criterion stood out. The association of four or more criteria improved ceCT Sp to 98.5%, PPV to 95.6%, + LR to 30.5. Median TT was 2 h (IQR: 1-3 h). OM was 7.8%-not significantly higher than overall OM. CeCT in trauma has become a reliable screening test for HVMI and a valid exam to select HVMI patients for surgical exploration.

Objectives: Evaluate Alvarado Score's (AS) accuracy related with C-reactive protein (CRP). Evaluate the accuracy rate of ultrasonography (US)., Materials and Methods: We analyzed data on 290 patients admitted to Emergency Department (ED) of Sant'Andrea Hospital (Rome - Italy) presenting abdominal pain in lower quadrants between Jan2009-Apr2015. AS, laboratory tests, images and report from CT-scan and US were collected. Histological examination is considered as Gold Standard. We calculated Specificity(Sp), Sensitivity(Se), Accuracy(Ac), positive predictive value(PPV), and negative predictive value(NPV). We use Exact Fisher Test (EFT) for samples less than 50 units, and Chi square test (χ2). CRP were assessed as possible laboratory marker to be added to AS., Results: Two hundred and forty patients (82%) were enrolled following the inclusion criteria. The variations obtained from the AS with C-reactive protein show no difference. CT-scan vs US results show a higher Sp for US despite CT (p= 0.0509 χ2=3.803. Se and NPV are higher in CT compared to the US (Se: p=0.000315 χ2= 12.88 NVP: p=0.015. We evaluated Ac of US and CT within the individual groups (low(L), Intermediate(I), High(H): L; 37 patients show no statistically significant difference (EFT=1; p>0.05). I: show superiority of CT-scan in Se and NPV (FE:0.0162 p<0.05; FE:0.0432 p<0.05). Regarding H only Se show an acceptable p-value (p<0.0021)., Conclusion: Alvarado score (AS) can be used as the first diagnostic approach in the diagnosis of acute appendicitis (AA). Ultrasound must be considered the first level instrumental examination; necessary and sufficient in low risk patients (0-3 pt) to exclude, with a high reliability rate, the diagnosis of acute appendicitis., Key Words: Acute Appendicitis, Alvarado Score, CT scan, Ultrasound, Peritonitis.

Spleen injuries are among the most frequent trauma-related injuries. At present, they are classified according to the anatomy of the injury. The optimal treatment strategy, however, should keep into consideration the hemodynamic status, the anatomic derangement, and the associated injuries. The management of splenic trauma patients aims to restore the homeostasis and the normal physiopathology especially considering the modern tools for bleeding management. Thus, the management of splenic trauma should be ultimately multidisciplinary and based on the physiology of the patient, the anatomy of the injury, and the associated lesions. Lastly, as the management of adults and children must be different, children should always be treated in dedicated pediatric trauma centers. In fact, the vast majority of pediatric patients with blunt splenic trauma can be managed non-operatively. This paper presents the World Society of Emergency Surgery (WSES) classification of splenic trauma and the management guidelines.

The aim of this work was to describe the model and clinical results obtained by the Niguarda Trauma Team referral center for major trauma, in Milan. The Trauma Team is organized as a trauma service, where general surgeons, anesthesiologists, orthopedic surgeons and neurosurgeons work on a 24 hour rotation. When not in duty in the rotations, specialists work in their specific elective activities. The director of the Trauma Team has the responsibility for discussion and application of protocols, clinical assistance, quality assessment and training. The results of 1334 consecutive cases of major trauma during a 51 month period were reviewed using the trauma registry. 39% overtriage, which increased over the years, and 1.12% undertriage were recorded. Mortality of patients with injury severity scores > 15 was 21%, with a progressive decrease over the years. Blunt trauma accounted for 91.75% and were road-related in most cases. Skeletal injuries were the most frequent findings, but brain and thoraco-abdominal injuries were associated with a higher risk of death. 1476 surgical procedures (16.93% general surgery and 111 interventional angiographic studies) were performed. Quality assessment revealed a significant decrease in preventable deaths within the first 72 hours, after excluding patients admitted in extremis. The results presented in this study demonstrate the possibility of realising a model of organized trauma care in an emergency department in Italy, with patient outcomes comparable to those obtained in Trauma Center in other countries.

Paraduodenal hernia is an unusual form of internal hernia that results from a congenital midgut malrotation. It is classified as either right or left, depending on anatomic features, and embryologic origin. Left hernias are three times more common than right. Clinical symptoms may be intermittent and non-specific, as nausea, distension and abdominal pain or sometimes acute small bowel obstruction or ischemia. The average age at diagnosis is usually 38 years. We report a case of right paraduodenal hernia in a 79 years old man admitted to the emergency department with an acute small bowel obstruction.

The Authors present a case of thoracoabdominal trauma from a road accident in a young woman who received care initially in a level II hospital. She was then transferred to a level I Trauma Centre with the onset of haemorrhagic shock due to haemopericardium and haemoperitoneum from liver injuries. A chest CT scan led to the suspicion of aortic dissection, hence a cardiopulmonary bypass (CPB) for life support was instituted just before laparotomy through the femoral vessels. Exploration of the peritoneal cavity was performed as a first step because haemoperitoneum was deemed to be the main cause of shock. One litre of blood was aspirated and hepatosplenic tears were sutured to obtain haemostasis. Subsequently, aortic dissection was ruled out by median sternotomy, while a right atrial disruption was identified and repaired by stitches and a pericardial homologous patch. Nevertheless, the ascending aorta was explored by transverse arteriotomy. The postoperative course was uneventful and the woman has never presented cardiac or abdominal symptoms as a result of trauma or surgery.

Background: Nonoperative management (TNO) of traumatic liver injury is the choice in hemodinamically stable patients without other abdominal injuries requiring celiotomy, apart from liver injury grading and amount of free peritoneal blood. CT-scan and angiographic embolization availability increase TNO feasibility., Aims: To investigate feasibility of TNO in 16-months period consecutive liver injuries., Materials and Methods: All data of severe trauma patients admitted to our facility during the study period were recorded. Clinical decision scheme of our facility indicates TNO in hemodynamically stable patients with liver injury and no need for celiotomy. CT-scan is performed and injury grading evaluated. Angiographic embolization is done if contrast medium extravasation is present at CT-scan. Laparoscopy is suggested if ongoing bleeding with negative CT-scan for blushing., Results: Liver injury was detected in 34 of 452 severe trauma patients. Fifty percents of patients underwent TNO. In this group, bleeding control was achieved by angiographic embolization in 8 cases and by laparoscopy in 1. None of these patients needed celiotomy. None of TNO patients died., Conclusions: In a trauma referral center TNO of liver injury is possible in about 50%. TNO in severe trauma is improved if a correct CT-scan evaluation at the admission is performed and angiography correctly applied. Laparoscopy is an useful adjunctive tool in control of bleeding.