Minimally Invasive Approach to Gastric GISTs: Analysis of a Multicenter Robotic and Laparoscopic Experience with Literature Review.

Background: Gastrointestinal stromal tumors (GISTs) are most frequently located in the stomach. In the setting of a multidisciplinary approach, surgery represents the best therapeutic option, consisting mainly in a wedge gastric resection. (1) Materials and methods: Between January 2010 to September 2020, 105 patients with a primary gastrointestinal stromal tumor (GISTs) located in the stomach, underwent surgery at three surgical units. (2) Results: A multi-institutional analysis of minimally invasive series including 81 cases (36 laparoscopic and 45 robotic) from 3 referral centers was performed. Males were 35 (43.2%), the average age was 66.64 years old. ASA score ≥3 was 6 (13.3%) in the RS and 4 (11.1%) in the LS and the average tumor size was 4.4 cm. Most of the procedures were wedge resections (N = 76; 93.8%) and the main operative time was 151 min in the RS and 97 min in the LS. Conversion was necessary in five cases (6.2%). (3) Conclusions: Minimal invasive approaches for gastric GISTs performed in selected patients and experienced centers are safe. A robotic approach represents a useful option, especially for GISTs that are more than 5 cm, even located in unfavorable places.

Robotic versus open oncological gastric surgery in the elderly: a propensity score-matched analysis.

Although there is no agreement on a definition of elderly, commonly an age cutoff of ≥ 65 or 75 years is used. Even if robot-assisted surgery is a validated option for the elderly population, there are no specific indications for its application in the surgical treatment of gastric cancer. The aim of this study is to evaluate the safety and feasibility of robot-assisted gastrectomy and to compare the short and long-term outcomes of robot-assisted (RG) versus open gastrectomy (OG). Patients aged ≥ 70 years old undergoing surgery for gastric cancer at the Department of Surgery of San Donato Hospital in Arezzo, between September 2012 and March 2017 were enrolled. A 1:1 propensity score matching was performed according to the following variables: age, Sex, BMI, ASA score, comorbidity, T stage and type of resection performed. 43 OG were matched to 43 RG. The mean operative time was significantly longer in the RG group (273.8 vs. 193.5 min, p < 0.01). No differences were observed in terms of intraoperative blood loss, an average number of lymph nodes removed, mean hospital stay, morbidity and mortality. OG had higher rate of major complications (6.9 vs. 16.3%, OR 2.592, 95% CI 0.623-10.785, p = 0.313) and a significantly higher postoperative pain (0.95 vs. 1.24, p = 0.042). Overall survival (p = 0.263) and disease-free survival (p = 0.474) were comparable between groups. Robotic-assisted surgery for oncological gastrectomy in elderly patients is safe and effective showing non-inferiority comparing to the open technique in terms of perioperative outcomes and overall 5-year survival.

Differences between computed tomoghaphy and surgical findings in acute complicated diverticulitis.

BACKGROUND/OBJECTIVE: A preoperative reliable classification system between clinical and computed tomography (CT) findings to better plan surgery in acute complicated diverticulitis (ACD) is lacking. We studied the inter-observer agreement of CT scan data and their concordance with the preoperative clinical findings and the adherence with the intraoperative status using a new classification of diverticular disease (CDD). METHODS: 152 patients operated on for acute complicated diverticulitis (ACD) were retrospectively enrolled. All patients were studied with CT scan within 24 h before surgery and CT images were blinded reanalyzed by 2 couples of radiologists (A/B). Kappa value evaluated the inter-observer agreement between radiologists and the concordance between CDD, preoperative clinical findings and findings at operation. Univariate and multivariate analysis were used to evaluate the predicting values of CT classification and CDD stage at surgery on postoperative outcomes. RESULTS: Overall inter-observer agreement for the CDD was high, with a kappa value of 0.905 (95% CI = 0.850-0.960) for observers A and B, while the concordance between radiological and surgical findings was weak (kappa values = 0.213 and 0,248, respectively and 95% CI = 0.106 to 0.319 and 95% CI = 0.142 to 0.355, respectively). When overall morbidity, mortality and the need of a terminal colostomy were considered as main endpoints no concordance was observed between surgical and radiological findings and the CDD (P=NS). CONCLUSIONS: The need for a more accurate classification of ACD, able to better stage this emergency, and to provide surgeons with reliable information for the best treatment is advocated.

Clinico-pathological Features of Colon Cancer Patients Undergoing Emergency Surgery: A Comparison Between Elderly and Non-elderly Patients.

BACKGROUND: Colorectal cancer (CRC) is one of the most common cancers in patients older than 65 years. Emergency presentation represents about 30% of cases, with increased morbidity and mortality rates. The aim of this study is to compare the perioperative outcome between elderly and non-elderly patients undergoing emergency surgery. METHOD: We retrospectively analysed CRC patients that underwent emergency surgery at the Departments of Surgery of the Sapienza University Sant'Andrea Hospital in Rome, and at San Donato Hospital in Arezzo, between June 2012 and June 2017. Patients were divided into two groups: non-elderly (< 65 years) and elderly (≥ 65 years). Variables analysed were sex, onset symptoms, associated disease, ASA score, tumor site and TNM stage, surgical procedures and approach, and morbidity and mortality. RESULTS: Of a total of 123 patients, 29 patients were non-elderly and 94 patients were elderly. No significant differences were observed in sex, onset symptoms and tumor site between the two groups. Comorbidities were significantly higher in elderly patients (73.4% vs 41.4%, p<0.001). No significant differences were observed between the two groups in surgical approach and the rate of one-stage procedures. Elderly patients were more frequently treated by Hartmann's procedure compared to non-elderly patients (20.2% vs 6.9%). Left colorectal resection with protective ileostomy was most frequent in the non-elderly group (27.6% vs 11.7%). No significant differences were found in the pT and pN categories of the TNM system between the two groups. However, a higher number of T3 in non-elderly patients was observed. A consistent number of non-oncologically adequate resections were observed in the elderly (21.3% vs 3.5%; p<0.03). The morbidity rate was significantly higher in the elderly group (31.9 % vs 3.4%, p<0.001). No significant difference was found in the mortality rate between the two groups, being 13.8% in the elderly and 6.9% in the non-elderly. CONCLUSIONS: Emergency colorectal surgery for cancer still presents significant morbidity and mortality rates, especially in elderly patients. More aggressive tumors and advanced stages were more frequent in the non-elderly group and as a matter it should be taken into account when treating such patients in the emergency setting in order to perform a radical procedure as much as possible.

Management of Complications of First Instance of Hepatic Trauma in a Liver Surgery Unit: Portal Vein Ligation as a Conservative Therapeutic Strategy.

BACKGROUND: According to the National Trauma Data Bank, the liver, after the spleen, is the first most injured organ in closed abdominal trauma. METHODS: From June 2010 to December 2015 we observed in our department of Hepato-biliary Surgery and Liver Transplant Unit of the A.O.R.N. A. Cardarelli of Naples 40 patients affected by hepatic trauma. In our retrospective study, we review our experience and propose portal vein ligation (PVL) as a first - line strategy for damage control surgery (DCS) in liver trauma. RESULTS: 26/40 patients (65%) which received gauze-packing represented our study group. In 10 cases out of 26 patients (38,4%) the abdominal packing was enough to control the damage. In 7 cases (18,4%) we performed a liver resection. In 7 cases, after de-packing, we adopted PVL to achieve DCS. Trans Arterial Embolization was chosen in 6 patients. 2 of them were discharged 14 days later without performing any other procedure.In 3 cases we had to perform a right epatectomy in second instance. Two hepatectomies were due to hemoperitoneum, and the other for coleperitoneum. Two patients were treated in first instance by only doing hemostasis on the bleeding site. We observed 6 patients in first instance. Five of them underwent surgery with hepatic resection and surgical hemostasis of the bleeding site. The other one underwent to conservative management. In summary we performed 15 hepatic resections, 8 of them were right hepatectomies, 1 left hepatectomy, 2 trisegmentectomies V-VI-VII. So in second instance we operated on 10 patients out of 34 (30%). CONCLUSIONS: The improved knowledge of clinical physio-pathology and the improvement of diagnostic and instrumental techniques had a great impact on the prognosis of liver trauma. We think that a rigid diagnostic protocol should be applied as this allows timely pathological finding, and consists of three successive but perfectly integrated steps: 1) patient reception, in close collaboration with the resuscitator; 2) accurate but quick diagnostic framing 3) therapeutic decisional making. Selective portal vein ligation is a well-tolerated and safe manoeuvre, which could be effective, even if not definitive, in treating these subjects. That is why we believe that it can be a choice to keep in mind especially in post-depacking bleeding.

Non-operative management of blunt splenic injury: is it really so extensively feasible? a critical appraisal of a single-center experience.

INTRODUCTION: The spleen is one of the most commonly injured organ following blunt abdominal trauma. Splenic injuries may occur in isolation or in association with other intra-and extra-abdominal injury. Nonoperative management of blunt injury to the spleen has become routine in children. In adult most minor splenic injuries are readily treated nonoperatively but controversy exists regarding the role of nonoperative management for higher grade injuries above all in multi-trauma patients. The aim of this study is the assessment of splenic trauma treatment, with particular attention to conservative treatment, its limits, its efficiency, and its safety in multi-trauma patient or in a severe trauma patient. METHODS: The present research focused on a retrospective review of patients with splenic injury. The research was performed by analyzing data of the trauma registry of St. Andrea University Hospital in Rome. The St. Andrea University Hospital trauma registry includes 1859. The variables taken into account were spleen injury and general injuries, age, sex, cause and dynamic of trauma, hemoglobin, hematocrit, white blood cells count, INR, number and time blood transfusion, hemodynamic stability, type of treatment provided, hospitalization period, morbidity and mortality. Assessment of splenic injuries was evaluated according to Abbreviated Injury Scale (AIS). RESULTS: The analysis among the general population of spleen trauma patients identified 68 patients with a splenic injury representing the 41.2% of all abdomen injury. The Average age was of 37.01 ± 17.18 years. The Average ISS value was of 22.88 ± 12.85; mediana of 24.50 (range 4-66). The average Spleen AIS value was of 3.13 ± 0.88; mediana 3.00 (range 2-5). The overall mortality ratio was of 19.1% (13 patients). The average ISS value in patients who died was of 41.92 ± 12.48, whereas in patients who survided was of 23.33 ± 10.15. The difference was considered to be statistically significant (p <0.001). The relashionship between the ISS and AIS values in patients who died was considered directly proportional but not statistically significant (Pearson test AIS/ISS = 0.132, p = n.s.). The initial management was a conservative treatment in 27 patients (39.7%) of them 4 patients (15%) failed, in the other 41 cases urgent splenectomies were performed. The average spleen AIS in all the patients who underwent splenectomy was 3.61 ± 0.63 whereas in the patients who were not treated surgically was 2.42 ± 0.69. The difference was deemed statistically significant (p <0.001). CONCLUSION: Splenic injury, as reported in our statistic as well as in literature, is the most common injury in closed abdominal trauma. Nonoperative management of blunt injury to the spleen in adults has been applied with increasing frequency. However, the criteria for nonoperative management are controversial. The preference of a conservative treatment must be based on the hemodynamic stability indices as well as on the spleen lesion severity and on the general trauma severity. The conservative treatment represent a feasible and safe therapeutic alternative even in case of severe lesions in politrauma patients, but the choice of the treatment form requires an assessment for each singular case.

Hollow viscus injuries: predictors of outcome and role of diagnostic delay.

INTRODUCTION: Hollow viscus injuries (HVIs) are uncommon but potentially catastrophic conditions with high mortality and morbidity rates. The aim of this study was to analyze our 16-year experience with patients undergoing surgery for blunt or penetrating bowel trauma to identify prognostic factors with particular attention to the influence of diagnostic delay on outcome. METHODS: From our multicenter trauma registry, we selected 169 consecutive patients with an HVI, enrolled from 2000 to 2016. Preoperative, intraoperative, and postoperative data were analyzed to assess determinants of mortality, morbidity, and length of stay by univariate and multivariate analysis models. RESULTS: Overall mortality and morbidity rates were 15.9% and 36.1%, respectively. The mean length of hospital stay was 23±7 days. Morbidity was independently related to an increase of white blood cells (P=0.01), and to delay of treatment >6 hours (P=0.033), while Injury Severity Score (ISS) (P=0.01), presence of shock (P=0.01), and a low diastolic arterial pressure registered at emergency room admission (P=0.02) significantly affected postoperative mortality. CONCLUSION: There is evidence that patients with clinical signs of shock, low diastolic pressure at admission, and high ISS are at increased risk of postoperative mortality. Leukocytosis and delayed treatment (>6 hours) were independent predictors of postoperative morbidity. More effort should be made to increase the preoperative detection rate of HVI and reduce the delay of treatment.

Emergency surgery for colorectal cancer does not affect nodal harvest comparing elective procedures: a propensity score-matched analysis.

PURPOSE: About 30% of colorectal cancers (CRCs) present with acute symptoms. The adequacy of oncologic resections is a matter of concern since few authors reported that emergency surgery in these patients results in a lower lymph node harvest (LNH). In addition, emergency resections have been reported with a longer hospital stay and higher morbidity rate. We thus conducted a propensity score-matched analysis with the aim of investigating LNH in emergency specimens comparing with elective ones. Secondary aim was the comparison of morbidity and hospital stay. METHODS: Eighty-seven consecutive R0 emergency surgical procedures were matched with elective CRCs using the propensity score method and the following covariates: age, sex, stage, and localization. Groups were compared using univariate and multivariate analyses. Outcome measures were LNH, nodal ratio, Clavien's morbidity grades, and hospital stay. RESULTS: Emergency patients presented more metastatic nodes compared with elective ones (p 0.017); however, both presented a comparable mean LNH. Multivariate analysis documented that a T stage ≥3 was the only variable correlated with a nodal positivity (OR 6.3). On univariate analysis, emergency CRCs had a longer mean hospital stay compared with elective resections (p 0.006) and a higher rate of Clavien ≥4 events (p 0.0173). Finally, emergency resection and an age >66 years were variables independently correlated with a mean hospital stay >10 days (OR, respectively, 3.7 and 3.5). CONCLUSIONS: Emergency CRC resections were equivalent to the elective procedures with respect to LNH. However, emergency surgery correlated with a longer mean hospital stay. Graphical abstract Emergency and Elective resections for CRC provide similar LNH.

The impact of frailty syndrome and risk scores on emergency cholecystectomy patients.

PURPOSE: Cholecystectomy, which is one of the most common surgical procedures, is also performed in the emergency setting. A number of risk scores have been introduced in recent studies; moreover, over the last few years literature has focused on surgical patients with frailty syndrome. The aim of the present study is to evaluate whether frailty syndrome and the risk scores are correlated with morbidity, post-operative hospital stay and the ICU admission rate following emergency cholecystectomy. METHODS: Eighty-five consecutive patients of >65 years of age who underwent cholecystectomy were selected from 2306 emergency procedures for inclusion in the present study. The patients were assessed for frailty syndrome and their scores were calculated on the basis of chart review. Univariate analyses were performed to compare severe frailty patients to intermediate frailty and robust patients. ROC and logistic regression analyses were performed with the end-points of morbidity, hospital stay and ICU admission. RESULTS: In addition to having worse ASA, inflammatory and risk values than robust patients, frailty syndrome patients also had higher rates of morbidity and ICU admission and longer hospitalization periods. A logistic regression analysis showed that the P-Possum was independently correlated with morbidity. Frailty and open surgery were independently correlated with longer hospitalization, whereas ICU admission was correlated with worse ASA and P-Possum values. CONCLUSIONS: Frailty syndrome significantly impacts the length of hospitalization in patients undergoing emergency cholecystectomy. Although the ORs were limited, the P-Possum value was independently associated with the outcome.

Robot-assisted surgery in elderly and very elderly population: our experience in oncologic and general surgery with literature review.

BACKGROUND: Although there is no agreement on a definition of elderly, commonly an age cutoff of ≥65 or 75 years is used. Nowadays most of malignancies requiring surgical treatment are diagnosed in old population. Comorbidities and frailty represent well-known problems during and after surgery in elderly patients. Minimally invasive surgery offers earlier postoperative mobilization, less blood loss, lower morbidity as well as reduction in hospital stay and as such represents an interesting and validated option for elderly population. Robot-assisted surgery is a recent improvement of conventional minimally invasive surgery. AIMS: We provided a complete review of old and very old patients undergoing robot-assisted surgery for oncologic and general surgery interventions. PATIENTS AND METHODS: A retrospective review of all patients undergoing robot-assisted surgery in our General Surgery Unit from September 2012 to June 2016 was conducted. Analysis was performed for the entire cohort and in particular for three of the most performed surgeries (gastric resections, right colectomy, and liver resections) classifying patients into three age groups: ≤64, 65-79, and ≥80. Data from these three different age groups were compared and examined in respect of different outcomes: ASA score, comorbidities, oncologic outcomes, conversion rate, estimated blood loss, hospital stay, geriatric events, mortality, etc. RESULTS: Using our in-patient robotic surgery database, we retrospectively examined 363 patients, who underwent robot-assisted surgery for different diseases (402 different robotic procedures): colorectal surgery, upper GI, HPB, etc.; the oncologic procedures were 81%. Male were 56%. The mean age was 65.63 years (18-89). Patients aged ≥65 years represented 61% and ≥80 years 13%. Overall conversion rate was of 6%, most in the group 65-79 years (59% of all conversions). The more frequent diseases treated were colorectal surgery 43%, followed by hepatobilopancreatic surgery 23.4%, upper gastro-intestinal 23.2%, and others 10.4%. DISCUSSION: Robot-assisted surgery is a safe and effective technique in aging patient population too. There was no increased risk of death or morbidity compared to younger patients in the three groups examined. A higher conversion rate was observed in our experience for patients aged 65-79. Prolonged operative time and in any cases steep positions (Trendelenburg) have not represented a problem for the majority of patients. CONCLUSIONS: In any case, considering the high direct costs, minimally invasive robot-assisted surgery should be performed on a case-by-case basis, tailored to each patient with their specific histories and comorbidities.

Hollow viscus injury due to blunt trauma. Epidemiology and outcome in a large urban area.

INTRODUCTION: Hollows viscus injury (HVI) is a rare occurrence and represents a clinical challenge because of its subtle and nonspecific clinical findings. The specific aims of this study were to determine the overall frequency of HVI in blunt trauma patients occurring in large urban area, the relative frequency of various hollow organ injuries, and the outcomes of such injuries. MATERIALS AND METHODS: A retrospective trauma registry review was performed by analysing data from the University Hospital Sant' Andrea in Rome and data from the Emergency Surgery and Trauma Care Unit of S. Filippo Neri Hospital in Rome The clinical records of all blunt abdominal trauma observed between January 2006 and December 2014 were blind analysed. Variables considered for analysis were: sex, age, time/type of trauma, associated injuries, timing/characteristics of operative treatment, ISS, AIS, length of hospital stay, morbidity and mortality. RESULTS: Seventy-one, 7.5% of all abdominal trauma recorded, were coded having 89 HVI. The overall morbidity and mortality rates were 29.6% (n=21/71) and 19.7% (n=14/71) respectively. Multivariate analysis indicated that only WBC (p=0.007) was significant independent predictor of morbidity whereas preoperative transfusion (p=0.010) and ISS (p<0.001) were significant risk factors for mortality. DISCUSSION: HVI is rarely found in patients with blunt abdominal trauma and it can be fatal and life-threatening, particularly in patients for whom a pertinent diagnosis is delayed. CONCLUSION: It appears clearly that during an ER evaluation of a blunt abdominal trauma an HIV has nowadays always to be considered to reach a quick diagnosis and prompt surgical intervention. KEY WORDS: Emergency, Hollow Viscus Injury, Surgery, Trauma.

Clinical strategies for the management of intestinal obstruction and pseudo-obstruction. A Delphi Consensus study of SICUT (Società Italiana di Chirurgia d'Urgenza e del Trauma).

BACKGROUND: Intestinal obstructions/pseudo-obstruction of the small/large bowel are frequent conditions but their management could be challenging. Moreover, a general agreement in this field is currently lacking, thus SICUT Society designed a consensus study aimed to define their optimal workout. METHODS: The Delphi methodology was used to reach consensus among 47 Italian surgical experts in two study rounds. Consensus was defined as an agreement of 75.0% or greater. Four main topic areas included nosology, diagnosis, management and treatment. RESULTS: A bowel obstruction was defined as an obstacle to the progression of intestinal contents and fluids generally beginning with a sudden onset. The panel identified four major criteria of diagnosis including absence of flatus, presence of >3.5 cm ileal levels or >6 cm colon dilatation and abdominal distension. Panel also recommended a surgical admission, a multidisciplinary approach, and a gastrografin swallow for patients presenting occlusions. Criteria for immediate surgery included: presence of strangulated hernia, a >10 cm cecal dilatation, signs of vascular pedicles obstructions and persistence of metabolic acidosis. Moreover, rules for non-operative management (to be conducted for maximum 72 hours) included a naso-gastric drainage placement and clinical and laboratory controls each 12 hours. Non-operative treatment should be suspended if any suspects of intra-abdominal complications, high level of lactates, leukocytosis (>18.000/mm3 or Neutrophils >85%) or a doubling of creatinine level comparing admission. Conversely, consensus was not reached regarding the exact timing of CT scan and the appropriateness of colonic stenting. CONCLUSIONS: This consensus is in line with current international strategies and guidelines, and it could be a useful tool in the safe basic daily management of these common and peculiar diseases. KEY WORDS: Delphi study, Intestinal obstruction, Large bowel obstruction, Pseudo-obstruction, Small bowel.

Pseudoachalasia: A peculiar case report and review of the literature.

Pseudoachalasia is a rare secondary achalasia, which accounts for only a small subgroup of patients. We describe a 77-year-old woman with recent onset of dysphagia and typical esophageal manometric findings of achalasia. Moreover, esophageal manometric findings of vascular compression at 36 cm from the nose were associated with dysphagia. An upper endoscopy showed the absence of lesions both in the esophagus and gastro-esophageal junction, whilst a 15-mm ulcer on the gastric angulus was detected. The gastric ulcer resulted in being a diffuse signet ring cell carcinoma at histology, suggesting pseudoachalasia. An abdominal computed tomography scan showed an irregular concentric thickening of the gastro-esophageal junction wall extending for 7 cm and a dilated ascending thoracic aorta with no presence of the inferior vena cava, with an enlarged azygos as the source of vascular compression of esophagus. Moreover, cardia involvement from diffuse signet ring cell carcinoma of the gastric angulus was also recognized as the cause of dysphagia. The cancer was not suitable for a surgical approach in an old patient with cardiovascular comorbidities and support therapy was started. In our ambulatory series, pseudoachalasia was eventually diagnosed in 4.7% of 234 consecutive patients with esophageal manometric finding suggestive of achalasia. We also reviewed cases in the literature and aimed to evaluate the reported causes of pseudoachalasia.

The usefulness of a Trauma Registry and the role of the general surgeon in the multidisciplinary approach to trauma patients: 3-year experience at Sant'Andrea University Hospital in Rome.

The purpose of this study is to verify the usefulness of a multidisciplinary Trauma Registry in the evaluation of trauma, particularly in relation to the number of specialists involved, and to analyze the effective role of the general trauma surgeon in an integrated trauma care system. The present study was performed by analyzing data from the Trauma Registry of the University Hospital Sant'Andrea in Rome, which was set up in March 2006. Data recorded between March 2006 and March 2009 was considered for the present study. The severity of trauma was categorized by dividing patients into 4 subgroups based on the value of ISS: minor injuries (ISS 1-8), moderate (ISS 9-15), severe (ISS 16-24) and very severe (ISS> 24). Patients who had an ISS greater than 9 were taken into account for further analysis and comparison. To evaluate the significance of the multidisciplinarity the patients were stratified in subgroups considering the number of specialists involved in relation to the anatomic location of injuries. In the 1386 trauma patients entered in the registry, the mean and median ISS value were 10.7 ± 8.4 and 9 respectively. The overall mortality and morbidity were 4.1% and 7.4% respectively. There was a statistically significant linear relationship between the number of specialists involved and the ISS (multidisciplinarity / ISS r = 0.493, p <0.001). Patients with ISS greater than 9 were 358, 25.8% of all cases. The mean ISS was 21.4 ± 10.3. Mortality and morbidity rates were 9.8% (35 patients) and 22.1% (79 patients) respectively. The average number of specialists involved was 2.4 ± 1.1, median 2 (range 1- 6). Results confirmed the significance of the multidisciplinary treatment for patients with trauma and the central role played by the general surgeon.

Emergency presentation of intestinal lymphoma.

PURPOSE: The aim of the present study was to evaluate the clinical features, management and outcome of patients submitted to emergency surgery because of intestinal lymphoma. METHODS: A consecutive series of fourteen patients with gastrointestinal tract lymphoma referred for emergency surgery between March 2006 and May 2010 was retrospectively analyzed. RESULTS: Patients including 9 males (64.2%) and 5 females (35.7%). The mean age of male and female was 55.4 + 21.2 and 78.4 + 9.0 respectively. The difference was statistically significant (p <0.04). Ileum was the most common location (13 cases, 86.6%) and a small bowel resection was the commonest surgical procedure performed. Presence of etiological risk factor for developing intestinal lymphoma was detected in 6 patients (40%). The overall morbidity rate was 40.0% (6 patients) and the mortality rate was 53,3% (8 patients). The estimated 12, 24, and 36-months overall survival rate was 56%, 33%, and 22% respectively. DISCUSSION: Our study reports an elevated overall mortality accounting for 8 patients which were all but two of advanced stage; 6 patients died in the postoperative course. Univariate and multivariate analysis failed to show significant differences maybe because the total number of subjects was too small to reach statistical significance. However the Odds Ratio was significantly high for the presence of etiological risk factor (OR 7.50) and perforation as presenting symptom (OR 6.67). CONCLUSION: An aggressive surgical attitude comprising an ample ileum resection is needed in almost all cases because an acute presentation is closely related with an advanced stage of the disease and with a high risk for anastomotic disruption, both conditions leading to a poor short and long-term survival.

The prognostic significance of thoracic and abdominal trauma in severe trauma patients (Injury severity score > 15).

The aim of the present study was to assess the prognostic significance of thoracic and abdominal trauma in severely injured patients. A retrospective analysis was performed based on data from the period from March 1 2006 to December 31 2007, taken from the Trauma Registry of the University Hospital "SantAndrea" in Rome. A total of 844 trauma patients were entered in a database created for this purpose, and only patients with an Injury Severity Score (ISS) > 15, (163 patients, 19.3%), were selected for the present study. These patients were divided into 2 groups: Group A (103 patients, 63.2%), consisting of patients with at least one thoracic injury, and Group B (46 patients, 28.2%) consisting of patients with concomitant thoracic and abdominal injuries. The impact of thoracic and abdominal trauma was studied by analyzing mortality and morbidity, in relation to patient age, cause and dynamics of trauma, length of hospital stay, and both ISS and New ISS (NISS). In a vast majority of cases, the cause of trauma was a road accident (126 patients, 77.3%). The mean age of patients with ISS > 15 was 45.2 +/- 19.3 years. The mean ISS and NISS were 25.7 +/- 10.5 and of 31.4 +/- 13.1 respectively. The overall morbidity and mortality rates were 18.4% (30 patients) and 28.8% (47 patients) respectively. In Group A the mortality rate was 23.3% (24 patients) and the morbidity rate was 33.9% (35 patients). In Group B mortality and morbidity rates were 369% (17 patients) and 43.5% (20 patients) respectively. It was shown that the presence of both thoracic and abdominal injuries significantly increases the risk of mortality and morbidity. In patients with predominantly thoracic injuries, NISS proved to be the more reliable score, while ISS appeared to be more accurate in evaluating patients with injuries affecting more than one region of the body.

The epidemiology and clinical evaluation of abdominal trauma. An analysis of a multidisciplinary trauma registry.

Abdominal trauma is present in 7-10% of all trauma victims, and in cases of severe trauma is often found together with orthopedic, thoracic or central nervous system (CNS) injuries. The aim of the present study was to perform a comparative analysis of abdominal trauma and trauma involving other body regions, evaluating the prognostic significance of abdominal injuries in patients with severe trauma, based on data from a multidisciplinary trauma registry. Data from the period from March 1 2006 to December 31 2007 was collected from the trauma registry of the University Hospital Sant'Andrea in Rome, Italy. There were 25.875 patients (31.4%) with the diagnosis of trauma out of a total of 82.293 patients admitted to the emergency department. Eight hundred forty-four patients were selected according to specific inclusion criteria and patients with abdominal injuries were further selected. The following data were investigated: patient age, the trauma mechanism, duration of recovery, Abbreviated Injury Scale (AIS), Injury Severity Score (ISS), type and the incidence of abdominal and extra-abdominal injuries. Morbidity and mortality, especially in patients with spleen and liver injuries, were analyzed. There were 79 patients (9.3%) with abdominal trauma. Their mean ISS was 25.7 +/- 14.3. Sixty-one (77.2%) of these patients had sustained severe trauma (ISS > 15). Forty-one patients (51.8%) underwent surgery. The overall mortality rate was 24.1%, 19 patients all with ISS > 15, so that the mortality rate for patients with severe trauma was 31.2%. Splenic trauma was the most frequent, and was found in 36 patients (45.6%) whose mean ISS was 31.1 +/- 144. Twenty-two patients (61.6%) were treated surgically; a total of 21 splenectomies and one laparoscopic procedure to control bleeding were performed. Overall mortality among patients with splenic trauma was 30.5% (11 patients), with an average spleen AIS of 3.3 +/- 0.8 (died vs. survived p = n.s.). Liver injuries were found in 33 patients (41.7%). The mean ISS was 28.4 +/- 11.6. Sixty-five percent of the patients were given nonsurgical treatment. Overall mortality among liver trauma patients was 24.2% (8 patients) with an average liver AIS of 3.2 +/- 0.3 (died vs. survived p < 0.05). In multivariate analysis, among the general population of trauma patients, the ISS (p < 0.001), patient age (p < 0.003), and an orthopedic (p < 0.002) or CNS injury (p < 0.006) proved to be significant independent predictors of the presence of an abdominal injury. Multivariate analysis showed that in patients with abdominal trauma, only the ISS (p < 0.001) was a significant independent predictor of mortality.

[Emergency colonic surgery: analysis of risk factors predicting morbidity and mortality]. / Chirurgia del colon in urgenza: analisi dei fattori di rischio di morbilità e mortalità.

The aim of the present study was to identify risk factors for morbidity and mortality in patients submitted to emergency colonic surgery. Between 1997 and 2008 157 patients, 106 of whom affected by colon cancer (67.5%) and 51 by benign disease (32.5%), were treated. The risk factors for morbidity and mortality were evaluated by univariate and multivariate analysis considering clinical and demographic data. The overall 30-day morbidity and mortality rates were 19.1% (30 patients) and 12.7% (20 patients), respectively. Among patients affected by cancer the mortality rate was 15% (16 patients) and the morbidity rate 23.6% (25 patients), while among the patients with benign disease the mortality rate was 7.8% (4 patients) and the morbidity rate 9.8% (5 patients). No postoperative surgical complications were noted. The strongest risk factors for early death were postoperative medical complications such as cardiopulmonary, renal, thrombo-embolic and infectious complications. The results of the univariate analysis showed that advanced age, neoplastic disease, advanced stage of cancer and associated medical disease prior to surgery play a role as risk factors for morbidity and mortality. In the multivariate analysis only the presence of associated medical disease proved to be a significant independent predictor of outcome. Emergency surgery for both neoplastic and benign colonic disease is still associated with an increased risk of death. Although restorative colectomy should be regarded as the first choice procedure in the emergency setting, Hartmann's procedure is still widely used in high-risk patients.