Towards a tailored approach for patients with acute diverticulitis and abscess formation. The DivAbsc2023 multicentre case-control study.

BACKGROUND: This multicentre case-control study aimed to identify risk factors associated with non-operative treatment failure for patients with CT scan Hinchey Ib-IIb and WSES Ib-IIa diverticular abscesses. METHODS: This study included a cohort of adult patients experiencing their first episode of CT-diagnosed diverticular abscess, all of whom underwent initial non-operative treatment comprising either antibiotics alone or in combination with percutaneous drainage. The cohort was stratified based on the outcome of non-operative treatment, specifically identifying those who required emergency surgical intervention as cases of treatment failure. Multivariable logistic regression analysis to identify independent risk factors associated with the failure of non-operative treatment was employed. RESULTS: Failure of conservative treatment occurred for 116 patients (27.04%). CT scan Hinchey classification IIb (aOR 2.54, 95%CI 1.61;4.01, P < 0.01), tobacco smoking (aOR 2.01, 95%CI 1.24;3.25, P < 0.01), and presence of air bubbles inside the abscess (aOR 1.59, 95%CI 1.00;2.52, P = 0.04) were independent predictors of failure. In the subgroup of patients with abscesses > 5 cm, percutaneous drainage was not associated with the risk of failure or success of the non-operative treatment (aOR 2.78, 95%CI - 0.66;3.70, P = 0.23). CONCLUSIONS: Non-operative treatment is generally effective for diverticular abscesses. Tobacco smoking's role as an independent risk factor for treatment failure underscores the need for targeted behavioural interventions in diverticular disease management. IIb Hinchey diverticulitis patients, particularly young smokers, require vigilant monitoring due to increased risks of treatment failure and septic progression. Further research into the efficacy of image-guided percutaneous drainage should involve randomized, multicentre studies focussing on homogeneous patient groups.

Successful Needle Aspiration of a Traumatic Pneumothorax: A Case Report and Literature Review.

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.

Retrospective Analysis of Retroperitoneal-Abdominal-Pelvic Ganglioneuromas: An International Study by the Transatlantic Australasian Retroperitoneal Sarcoma Working Group (TARPSWG).

OBJECTIVE: The Transatlantic Australasian Retroperitoneal Sarcoma Working Group conducted a retrospective study on the disease course and clinical management of ganglioneuromas. BACKGROUND: Ganglioneuromas are rare tumors derived from neural crest cells. Data on these tumors remain limited to case reports and single-institution case series. METHODS: Patients of all ages with pathologically confirmed primary retroperitoneal, intra-abdominal, and pelvic ganglioneuromas between January 1, 2000, and January 1, 2020, were included. We examined demographic, clinicopathologic, and radiologic characteristics, as well as clinical management. RESULTS: Overall, 328 patients from 29 institutions were included. The median age at diagnosis was 37 years with 59.1% of patients being female. Symptomatic presentation comprised 40.9% of cases, and tumors were often located in the extra-adrenal retroperitoneum (67.1%). At baseline, the median maximum tumor diameter was 7.2 cm. One hundred sixteen (35.4%) patients underwent active surveillance, whereas 212 (64.6%) patients underwent resection with 74.5% of operative cases achieving an R0/R1 resection. Serial tumor evaluations showed that malignant transformation to neuroblastoma was rare (0.9%, N=3). Tumors undergoing surveillance had a median follow-up of 1.9 years, with 92.2% of ganglioneuromas stable in size. With a median follow-up of 3.0 years for resected tumors, 84.4% of patients were disease free after resections, whereas recurrences were observed in 4 (1.9%) patients. CONCLUSIONS: Most ganglioneuromas have indolent disease courses and rarely transform to neuroblastoma. Thus, active surveillance may be appropriate for benign and asymptomatic tumors particularly when the risks of surgery outweigh the benefits. For symptomatic or growing tumors, resection may be curative.

Surgeons' attitudes during laparoscopic appendectomy: do subjective intraoperative assessments affect the choice of peritoneal irrigation? A spin-off analysis from the REsiDENT-1 multicentre prospective observational trial.

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.

Learning curve of laparoscopic cholecystectomy: a risk-adjusted cumulative summation (RA-CUSUM) analysis of six general surgery residents.

BACKGROUND: Laparoscopic cholecystectomy (LapC) is one of the most frequently performed surgical procedures worldwide. Reaching technical competency in performing LapC is considered one essential task for young surgeons. Investigating the learning curve for LapC (LC-LapC) may provide important information regarding the learning process and guide the training pathway of residents, improving educational outcomes. The present study aimed to investigate LC-LapC among general surgery residents (GSRs). METHODS: Operative surgical reports of consecutive patients undergoing LapC performed by GSRs attending the General Surgery Residency Program at the University of Milan were analysed. Data on patient- and surgery-related variables were obtained from the ICD-9-CM diagnosis codes and gathered. A multidimensional assessment of the LC was performed through Cumulative Sum (CUSUM) and Risk-Adjusted (RA)-CUSUM analysis. RESULTS: 340 patients operated by 6 GSRs were collected. The CUSUM and RA-CUSUM graphs based on surgical failures allowed to distinguish two defined phases for all GSRs: an initial phase ending at the peak, so-called learning phase, followed by a phase in which there was a significant decrease in failure incidence, so-called proficiency phase. The learning phase was completed for all GSRs at most within 25 procedures, but the trend of the curves and the number of procedures needed to achieve technical competency varied among operators ranging between 7 and 25. CONCLUSIONS: The present study suggested that at most 25 procedures might be sufficient to acquire technical competency in LapC. The variability in the number of procedures needed to complete the LC, ranging between 7 and 25, could be due to the heterogeneous scenarios in which LapC was performed, and deserves to be investigated through a prospective study involving a larger number of GSRs and institutions.

The burden of the knowledge-to-action gap in acute appendicitis.

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.

Delayed Gastric Emptying After Multivisceral Resection for Retroperitoneal Sarcoma.

INTRODUCTION: Delayed gastric emptying (DGE) is a common complication in surgery, but incidence and relevance following multivisceral resection are unknown. METHODS: Data from 100 consecutive patients treated for primary retroperitoneal sarcoma (RPS) were analyzed from our institutional prospectively maintained database from January 2019 to April 2020. DGE severity was graded according to the International Study Group of Pancreatic Surgery and classified as primary or secondary to other complications. The primary outcome was incidence and grade of clinically relevant DGE (grades B-C). Secondary outcomes were correlation with patient, tumor, and treatment characteristics, and non-DGE morbidity [Clavien-Dindo (CD) grade ≥ 3]. RESULTS: Forty-two patients developed DGE and 28 had clinically relevant DGE. DGE was primary in 10 patients and secondary in 18 patients; the most common associated complications were: infections (11/18, 61.1%), pancreatic leak (7/18, 38.9%), bleeding (6/18, 33.3%), and bowel leak (6/18, 33.3%). DGE was related to longer length of hospital stay (P < 0.001), ICU admission (P = 0.004), ICU length of stay (P = 0.001), postoperative complications (CD [Formula: see text] 3 in 14/28 in DGE patients vs 11/72 in no-DGE; P = 0.04), and re-operation (P = 0.03). With multivariate analysis, the independent risk factors for DGE were patient comorbidities (OR 1.05; 95% CI 1.01-1.1; P = 0.04) and tumor size (OR 1.05; 95% CI 1.0-1.1; P = 0.02). DISCUSSION: Following multivisceral resection, DGE is a clinically relevant event that can be caused by an underlying complication. Prompt diagnosis and treatment of both DGE and any underlying complications led to full recovery in all cases.

European society for trauma and emergency surgery member-identified research priorities in emergency surgery: a roadmap for future clinical research opportunities.

BACKGROUND: European Society for Trauma and Emergency Surgery (ESTES) is the European community of clinicians providing care to the injured and critically ill surgical patient. ESTES has several interlinked missions - (1) the promotion of optimal emergency surgical care through networked advocacy, (2) promulgation of relevant clinical cognitive and technical skills, and (3) the advancement of scientific inquiry that closes knowledge gaps, iteratively improves upon surgical and perioperative practice, and guides decision-making rooted in scientific evidence. Faced with multitudinous opportunities for clinical research, ESTES undertook an exercise to determine member priorities for surgical research in the short-to-medium term; these research priorities were presented to a panel of experts to inform a 'road map' narrative review which anchored these research priorities in the contemporary surgical literature. METHODS: Individual ESTES members in active emergency surgery practice were polled as a representative sample of end-users and were asked to rank potential areas of future research according to their personal perceptions of priority. Using the modified eDelphi method, an invited panel of ESTES-associated experts in academic emergency surgery then crafted a narrative review highlighting potential research priorities for the Society. RESULTS: Seventy-two responding ESTES members from 23 countries provided feedback to guide the modified eDelphi expert consensus narrative review. Experts then crafted evidence-based mini-reviews highlighting knowledge gaps and areas of interest for future clinical research in emergency surgery: timing of surgery, inter-hospital transfer, diagnostic imaging in emergency surgery, the role of minimally-invasive surgical techniques and Enhanced Recovery After Surgery (ERAS) protocols, patient-reported outcome measures, risk-stratification methods, disparities in access to care, geriatric outcomes, data registry and snapshot audit evaluations, emerging technologies interrogation, and the delivery and benchmarking of emergency surgical training. CONCLUSIONS: This manuscript presents the priorities for future clinical research in academic emergency surgery as determined by a sample of the membership of ESTES. While the precise basis for prioritization was not evident, it may be anchored in disease prevalence, controversy around aspects of current patient care, or indeed the identification of a knowledge gap. These expert-crafted evidence-based mini-reviews provide useful insights that may guide the direction of future academic emergency surgery research efforts.

"Stabilize the Unstable": Treatment Pathophysiology in Bleeding Trauma Patients, from the Field to the ICU. State of the Art.

The results of the Global Burden of Disease (GBD) study showed that, in 2019, 8% of deaths worldwide were trauma related [...].

Spinal injury in major trauma: Epidemiology of 1104 cases from an Italian first level trauma center.

INTRODUCTION: 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. PATIENTS AND METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

Increasing Trend in Violence-Related Trauma and Suicide Attempts among Pediatric Trauma Patients: A 6-Year Analysis of Trauma Mechanisms and the Effects of the COVID-19 Pandemic.

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.

Detection of post-traumatic abdominal pseudoaneurysms by CEUS and CT: A prospective comparative global study (the PseAn study)-study protocol.

The success of non-operative management in trauma increased with the availability of new-generation CT scan machines, endoscopy, and angiography, becoming the standard of care in hemodynamically stable trauma patients with abdominal solid organ injuries, with a success rate of 78% to 98%. Post-traumatic pseudoaneurysms (PAs) can develop at any region of an injured artery and they may cause delayed bleeding in splenic or hepatic trauma, with an incidence in patients treated with NOM of 2%-27% and 1.2%-6.1% respectively. Diagnosis is made by angiography, contrast-enhanced computer tomography (CT), or Doppler Ultrasound (US) while the use of contrast-enhanced ultrasound (CEUS), has increased in recent years although few data are available about CEUS feasibility in the follow-up setting. The PseaAn study has been designed to assess the role of CEUS in the follow-up of abdominal trauma by defining its sensitivity, specificity and predictive values compared with abdominal CT scan. The PseAn study is a multi-centric international diagnostic cross-sectional study initiated by the Level I Trauma Center of the Niguarda Ca' Granda Hospital in Milan, Italy. To study the role of CEUS in detecting post-traumatic splenic, hepatic, and renal PAs compared with the gold standard of CT with intravenous contrast at different follow-up time points, and whether it can replace CT scan in the follow-up of solid organ injuries, patients with OIS III and above will undergo a follow-up with both a CEUS and CT scan to detect post-traumatic parenchymal pseudoaneurysm within two to five days from injury. The use of CEUS in the follow-up of abdominal trauma follow-up (particularly blunt trauma) has increased, to minimise the use of ionizing radiation and contrast media and encouraging results have been published during the last decade showing that CEUS is an accurate technique for evaluating traumatic lesions of solid abdominal organs. Conclusions We think that CEUS, which is underused worldwide, is a useful and safe tool that may replace CT scan in follow-up with the major advantage of reduced radiation. Our current study may give stronger evidence to support this view.

Contrast-enhanced ultrasound (CEUS) in the follow-up of abdominal solid organ trauma: an international survey prior to the PseAn study.

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.

In-Hospital Predictors of Need for Ventilatory Support and Mortality in Chest Trauma: A Multicenter Retrospective Study.

Chest trauma management often requires the use of invasive and non-invasive ventilation. To date, only a few studies investigated the predictors of the need for ventilatory support. Data on 1080 patients with chest trauma managed in two different centers were retrospectively analyzed. Univariate and multivariate analyses were performed to identify the predictors of tracheal intubation (TI), non-invasive mechanical ventilation (NIMV), and mortality. Rib fractures (p = 0.0001) fracture of the scapula, clavicle, or sternum (p = 0.045), hemothorax (p = 0.0035) pulmonary contusion (p = 0.0241), and a high Injury Severity Score (ISS) (p ≤ 0001) emerged as independent predictors of the need of TI. Rib fractures (p = 0.0009) hemothorax (p = 0.0027), pulmonary contusion (p = 0.0160) and a high ISS (p = 0.0001) were independent predictors of NIMV. The center of trauma care (p = 0.0279), age (p < 0.0001) peripheral oxygen saturation in the emergency department (p = 0.0010), ISS (p < 0.0001), and Revised Trauma Score (RTS) (p < 0.0001) were independent predictors of outcome. In conclusion, patients who do not require TI, while mandating ventilatory support with selected types of injuries and severity scores, are more likely to be subjected to NIMV. Trauma team expertise and the level of the trauma center could influence patient outcomes.

Infected pancreatic necrosis: outcomes and clinical predictors of mortality. A post hoc analysis of the MANCTRA-1 international study.

The identification of high-risk patients in the early stages of infected pancreatic necrosis (IPN) is critical, because it could help the clinicians to adopt more effective management strategies. We conducted a post hoc analysis of the MANCTRA-1 international study to assess the association between clinical risk factors and mortality among adult patients with IPN. Univariable and multivariable logistic regression models were used to identify prognostic factors of mortality. We identified 247 consecutive patients with IPN hospitalised between January 2019 and December 2020. History of uncontrolled arterial hypertension (p = 0.032; 95% CI 1.135-15.882; aOR 4.245), qSOFA (p = 0.005; 95% CI 1.359-5.879; aOR 2.828), renal failure (p = 0.022; 95% CI 1.138-5.442; aOR 2.489), and haemodynamic failure (p = 0.018; 95% CI 1.184-5.978; aOR 2.661), were identified as independent predictors of mortality in IPN patients. Cholangitis (p = 0.003; 95% CI 1.598-9.930; aOR 3.983), abdominal compartment syndrome (p = 0.032; 95% CI 1.090-6.967; aOR 2.735), and gastrointestinal/intra-abdominal bleeding (p = 0.009; 95% CI 1.286-5.712; aOR 2.710) were independently associated with the risk of mortality. Upfront open surgical necrosectomy was strongly associated with the risk of mortality (p < 0.001; 95% CI 1.912-7.442; aOR 3.772), whereas endoscopic drainage of pancreatic necrosis (p = 0.018; 95% CI 0.138-0.834; aOR 0.339) and enteral nutrition (p = 0.003; 95% CI 0.143-0.716; aOR 0.320) were found as protective factors. Organ failure, acute cholangitis, and upfront open surgical necrosectomy were the most significant predictors of mortality. Our study confirmed that, even in a subgroup of particularly ill patients such as those with IPN, upfront open surgery should be avoided as much as possible. Study protocol registered in ClinicalTrials.Gov (I.D. Number NCT04747990).

Current trends in the diagnosis and management of traumatic diaphragmatic injuries: A systematic review and a diagnostic accuracy meta-analysis of blunt trauma.

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.

Predictors of Mortality in Bicycle-Related Trauma: An Eight-Year Experience in a Level One Trauma Center.

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.

Failure to Rescue (FTR) and Pitfalls in the Management of Complex Enteric Fistulas (CEF): From Rescue Surgery to Rescue Strategy.

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.

Early Hypocalcemia in Severe Trauma: An Independent Risk Factor for Coagulopathy and Massive Transfusion.

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.