Economic and clinical benefits of immediate total-body CT in the diagnostic approach to polytraumatized patients: a descriptive analysis through a literature review.

Major trauma is an event causing injuries that may determine an immediate or potential risk to the patient survival. A correct management of major trauma is decisive in reducing disability, which has relevance both from the point of view of the quality of life of the single individual and from the point of view of health expenditure. The primary clinical approach to the polytraumatized patients is managed, in most cases, as outlined in the guidelines of Advanced Trauma Life Support, proposing conventional radiological investigations, such as chest and pelvis x-ray, and of FAST (focused abdominal sonography in trauma)/E-FAST (extended FAST) examinations, followed by selective targeted computed tomography (CT). This approach is questionable and is increasingly common in clinical practice the adoption of the immediate total-body CT in the diagnostic approach to the hemodynamically stable polytraumatized patient. However, the potential advantages of such conduct both in terms of clinical benefits and in terms of cost-effectiveness still need to be discussed. The objective of this review article consists of a descriptive analysis of the economic and clinical benefits of the adoption of immediate total-body CT in polytrauma patients through a literature review.

The additional value of the arterial phase in the CT assessment of liver vascular injuries after high-energy blunt trauma.

PURPOSE: In the literature, no consensus exists about which CT protocol is to be adopted in patients who underwent high-energy blunt trauma. The aim of the study is to evaluate the additional value of the arterial phase in the CT assessment of vascular injuries of the liver. METHODS: Admission CT examinations for patients with traumatic injury of the liver due to high-energy blunt trauma, performed between 2011 and 2017 in two major trauma centres, were retrospectively reviewed. Images were analysed for presence or absence of liver parenchymal injury, intrahepatic contained vascular injuries and active bleeding in the arterial and portal venous phase of the CT study. RESULTS: Two hundred twelve patients have been identified. Parenchymal injuries were detected as isolated in 90.6% of cases, whereas they were associated with vascular injuries in 9.4% of cases: contained vascular injuries in 3.3% and active bleeding in 6.1%. Out of all parenchymal injuries detected on the CT portal venous phase, 90.5% were also detectable in the arterial phases (p < 0.0001). All of the contained vascular injuries were visible in the CT arterial phase, whereas they were detectable in 28.5% of cases also during the venous phase (p = 0.02). All 13 cases of active bleeding were detected on the CT venous phase, and 76.9% of these cases were also revealed in the arterial phase, thus confirming their arterial origin (p = 0.22). CONCLUSION: The addiction of the arterial phase to the venous phase in the CT assessment of patients who underwent high-energy blunt trauma allows an accurate identification and characterization of traumatic vascular injuries, so distinguishing between patients suitable for conservative management and those requiring interventional or surgical treatment.

Preoperative assessment of simple and complex anorectal fistulas: Tridimensional endoanal ultrasound? Magnetic resonance? Both?

PURPOSE: The purpose of the study is to evaluate the diagnostic value of tridimensional endoanal ultrasound (3D-EAUS) and magnetic resonance (MR) in the preoperative assessment of both simple and complex anorectal fistulas. METHODS: All the patients referred for the treatment of anal fistulas were enrolled in this study and underwent, as preoperative assessment, anamnestic evaluation, clinical examination, and unenhanced and H2O2-enhanced 3D-EAUS and MR. The results of imaging evaluation were compared with surgical findings, considered as reference standard. RESULTS: During the study period, 124 patients operated on for anal fistulas underwent complete preoperative imaging assessment. Perfect agreement between 3D-EAUS and surgery in the anal fistulas' severity grading was found (K = 1). The fistulas were classified as simple in 68/126 (53.9%) and complex in 58/126 (46.03%) cases, according to fistulas' Parks' classification and the most recent American Guidelines. In both simple and complex anal fistulas, 3D-EAUS did not show a significantly higher accuracy in the evaluation of internal openings, if compared with MR (P = 0.47; McNemar's Chi-square test). In the complex anal fistulas, MR showed a significantly higher accuracy in the evaluation of secondary extensions if compared with 3D-EAUS (P = 0.041; McNemar's Chi-square test), whereas in the simple anal fistulas, no significant difference was found. CONCLUSION: In the preoperative work-up of patients with anorectal fistulas, 3D-EAUS may represent the first-line diagnostic tool. In cases of fistulas classified as complex by 3D-EAUS, MR may be indicated as adjunctive diagnostic imaging examination, to more carefully describe the fistulas' complete anatomy.

Role of tridimensional endoanal ultrasound (3D-EAUS) in the preoperative assessment of perianal sepsis.

PURPOSE: The aim of this study was to evaluate the accuracy of tridimensional endoanal ultrasound (3D-EAUS) in the diagnosis of perianal sepsis comparing the results with the surgical findings, considered as reference standard. METHODS: From January 2009 to January 2013, all the patients referred for the assessment and treatment of perianal sepsis with suspected anorectal origin were enrolled in the study. All patients gave informed written consent. Prior to surgery, all the patients underwent anamnestic evaluation, clinical examination, and unenhanced and H2O2-enhanced 3D-EAUS. Surgery was performed by a colorectal surgeon blinded to the 3D-EAUS results. RESULTS: A total of 212 patients with suspected perianal suppurations were assessed during the study period. In 12 patients, the H2O2-enhanced 3D-EAUS was not performed, and so, they were excluded from the study. Very good agreement between 3D-EAUS and examination under anesthesia (EUA) in the classification of primary fistula tracts (kappa = 0.93) and in the identification of fistula internal opening (kappa = 0.97) was found. There was a good concordance (kappa = 0.71) between 3D-EAUS and surgery in the detection of fistula secondary extensions. The overall sensitivity and specificity of 3D-EAUS in the diagnosis of perianal sepsis were 98.3 and 91.3% respectively. CONCLUSION: 3D-EAUS is a safe and reliable technique in the assessment of perianal sepsis. It may assist the surgeon in delineating the fistula tract anatomy and in determining the origin of sepsis, supporting the preoperative planning of definitive and appropriate surgical therapy.