Severe traumatic brain injury: management and prognosis.

AIM: The aim of the study is to assess the efficacy of early treatment in severe traumatic brain injury by evaluating patients' survival and functional recovery. METHODS: We subdivided 184 patients into 2 groups (Group A: patients admitted to hospital within the first hour of injury; Group B: patients admitted after the first hour of injury). In order to maintain the mean arterial pressure (MAP) >90 with cerebral perfusion pressure (CPP) >70 mmHg, we used plasma expanders; in 76 patients with MAP >90 mmHg, we administered dopamine, and in 5 cases noradrenaline. In 157 patients we used mechanical ventilation (MV). For orotracheal intubation and sedation/analgesia, we administered: propofol (a bolus of 2 mg/kg+1 mg/kg/h)+midazolam (0.03 mg/kg/h) + cisatracurium besilate (0.2 mg/kg) in 113 patients, or thiopentone sodium (a bolus of 4 mg/kg + 1-2 mg/kg/h)+cisatracurium besilate (0.2 mg/kg) in 44 patients with endocranial hypertension without bleeding and convulsions. After muscle relaxation we administered remifentanyl (0.075 microg/kg/min). Surgical decompression was performed in 57 cases. Data were analysed with Student's t-test. RESULTS: The number of deaths was significantly lower in Group A (P<0.05): 9 patients from Group A and 21 patients from Group B died within 24 h (P<0.05), while 15 patients from Group A and 16 patients from Group B died after the first 24 h period. After the recovery of critical life functions, 53 patients from Group A and 34 patients from Group B were transferred to a medical ward (P<0.0001), while 15 patients from Group A and 21 patients from Group B were transferred to a rehabilitation facility (P<0.05). CONCLUSIONS: Prevention, early treatment of complications and maintenance of homeostasis lead to a better prognosis in terms of survival, functional recovery and to a reduction in economic and social costs.

[Hemorrhagic adrenal pseudocyst: case report]. / Pseudocisti emorragica del surrene: caso clinico.

INTRODUCTION: Adrenal cysts are usually asymptomatic; they are usually identified occasionally during ultrasound or C.T. scans (incidentaloma). Among adrenal cysts the most common types are epithelial cysts and pseudocysts. Intracystic haemorrhage is one of the possible complications of adrenal pseudocysts. CASE REPORT: We report a case of a young woman with right superior abdominal pain, fever and acute anemia. A C.T. scan showed a 10 cm. mass between the liver and the right kidney. To be sure of the nature of this mass also M.R., urography and C.T.-guided biopsy were carried out. This latter only let us make the final diagnosis of hemorrhagic adrenal pseudocyst. Thereafter, a laparotomic right adrenalectomy was performed, with full recovery of the patient. DISCUSSION: Adrenal cysts may cause differential diagnostic problems with masses of contiguous organs like kidney, liver and gallbladder. For this reason, ultrasound and C.T. scans may not be sufficient and must be completed by M.R., urography and/or C.T.-guided biopsy. Intracystic hamorrhage, spontaneous or post-traumatic, may cause to the patient acute anemia which, as soon as the diagnosis is confirmed, indicates surgery. The operation usually is a laparotomic adrenalectomy, since the laparoscopic approach is not sufficient to control large masses with active bleeding inside.

[Peritonitis secondary to gastrointestinal perforations]. / Le peritoniti da perforazioni gastro-intestinali.

BACKGROUND: The study was designed to check the etiopathogenesis of gastrointestinal perforations and to indicate possible factors determining better results in terms of mortality and morbidity. METHODS: A retrospective study was carried out on 128 patients operated during the last 10 years for gastrointestinal perforation at our Department of Emergency Surgery, where about 600 abdominal surgical operations are performed every year. In this study patients with perforated acute appendicitis and patients with postoperative anastomotic leakage were excluded. Surgical techniques were essentially of three types: drainage of the collection, suture of the perforation (with or without proximal stoma), resection with or without immediate anastomosis. RESULTS: 89% of the patients had an uneventful recovery, 9 patients (7%) died, and 5 (4%) had local infective complications cured by conservative measures (antibiotics, percutaneous drainage). CONCLUSIONS: Better results have been observed during the last years in patients operated for gastrointestinal perforation probably because of the more frequent use of sophisticated diagnostic examinations (especially ultrasound and CT scan) and also because of better timing and technique of surgery (more frequent use of Hartmann procedure as well as mechanical staplers).

[Pancreatic pseudocysts. Clinical contribution]. / Le pseudocisti del pancreas. Contributo clinico.

Aim of this study was to compare, taking into consideration data from the literature, the various diagnostic examinations and therapeutic modalities nowadays available to manage patients affected by pancreatic pseudocysts. Personal experience regarding three patients with post-necrotic pancreatic pseudocysts is reported; these patients complained of epigastric pain with nausea and tenderness in the upper abdominal quadrants. Diagnosis was made by CT. In one case a progressive decrease of the pseudocyst was observed; the second patient was treated by a pseudocyst-jejunostomy; the last patient initially underwent a trans-gastric percutaneous drainage for infection of the pseudocyst and afterwards an open pseudocyst-gastrostomy. All patients were cured, even if the second patient during the postoperative course developed a pleuric effusion, which was treated by thoracentesis. Pancreatic pseudocysts in 20% of cases resolve spontaneously, as observed in one of our patients. In other cases, a surgical operation is needed, now feasible through an endoscopic, percutaneous, laparotomic or laparoscopic approach. The endoscopic and percutaneous approach are indicated only in selected cases, so that the "gold standard" treatment is still the laparotomic one, especially by a pseudocyst-jejunostomy, which also in our experience has given the best result. Very promising also, according to the latest data from the literature, seems the laparoscopic approach, by which a wide communication between the stomach and the pseudocyst is obtained.