"Falling down": a retroperitoneal catastropheC.

Hemoperitoneum due to ruptured retroperitoneal varices is an extremely rare condition and a poor prognostic sign with a catastrophic and life-threatening situation. Early recognition affords appropriate management and urgent surgical intervention in order to favor the survival rate. In this case report we accurately describe the complex clinical course of a 56-year old woman with retroperitoneal varices, who few months earlier had a chest trauma with multiple left lower rib fractures and 10 years earlier she underwent to ovarian hyperstimulation for an ovulation induction. She was taken to the emergency room for a fainting episode with signs of a clear hemodinamic shock without a present history of trauma. The intricacy of this case was mostly due to the choice of the correct management, where the damage control resuscitation turned out to have an important role.

Clinical outcomes of primary arterial embolization in severe hepatic trauma: A systematic review.

PURPOSE: This purpose of this systematic review was to determine the safety and efficacy of arterial embolization as the primary treatment for grade III-V liver trauma, excluding the postoperative use of arterial embolization. MATERIAL AND METHODS: A total of 24 studies published between January 2000 and June 2018 qualified for inclusion in this study. Four of them were prospective studies and 20 were retrospective. A total of 3855 patients (mean age, 33.5 years; range: 22-52.5 years) were treated non-operatively and 659 patients (659/3855; 17.09%) with hepatic hemorrhage underwent primary arterial embolization from 2000 to 2017. Indication for arterial embolization was a contrast blush visible on computed tomography in hemodynamically stable patient in all studies. RESULTS: The arterial embolization success rate ranged from 80% to 97%. The most commonly reported complication was bile leak, with an incidence of 5.7%. Nineteen bilomas (2.8%) were reported in five studies with a range between 4% and 45%. Hepatic ischemia was reported in eight studies, with a mean incidence of 8.6%. CONCLUSION: Primary arterial embolization has a high success rate in patients with hepatic trauma. Complications, including biloma and hepatic ischemia, have acceptable rates in the context of a minimally-invasive procedure that allows stabilization of life-threatening, complex liver injuries.

Pancreas-sparing, ampulla-preserving duodenectomy for major duodenal (D1-D2) perforations.

BACKGROUND: Ideal surgical treatment for acute duodenal injuries should offer a definitive treatment, with low morbidity and mortality. It should be simple and easily reproducible by acute care surgeons in an emergency. Duodenal injury, due to major perforated or bleeding peptic ulcers or iatrogenic/traumatic perforation, represents a surgical challenge, with high morbidity and mortality. The aim was to review definitive surgery with pancreas-sparing, ampulla-preserving duodenectomy for these patients. METHODS: Pancreas-sparing, ampulla-preserving D1-D2 duodenectomy was used for patients presenting with major duodenal injuries over a 5-year interval. The ampulla was identified and preserved using a transcystic/transpapillary tube. The outcomes were recorded. RESULTS: Ten patients were treated with this technique; seven had perforated or bleeding peptic ulcers, two had iatrogenic perforations and one blunt abdominal trauma. Their mean age was 78 (range 65-84) years. Four patients were haemodynamically unstable. The location of the duodenal injury was always D1 and/or D2, above or in close proximity to the ampulla of Vater. The surgical approach was open in nine patients and laparoscopic in one. The mean duration of surgery was 264 (range 170-377) min. All patients were transferred to the ICU after surgery (mean ICU stay 4·4 (range 1-11) days), and the overall mean hospital stay was 17·8 (range 10-32) days. Six patients developed major postoperative complications: cardiorespiratory failure in five and gastrointestinal complications in four. Surgical reoperation was needed in one patient for postoperative necrotizing and bleeding pancreatitis. Two patients died from their complications. CONCLUSION: Pancreas-sparing, ampulla-preserving D1-D2 duodenectomy for emergency treatment of major duodenal perforations is feasible and associated with satisfactory outcomes.

Non-surgical Management of Blunt Splenic Trauma: A Comparative Analysis of Non-operative Management and Splenic Artery Embolization-Experience from a European Trauma Center.

PURPOSE: The objective of our study was to retrospectively compare the outcomes of non-operative management (NOM) and splenic artery embolization (SAE) in the management of hemodynamically stable patients with splenic injuries. MATERIALS AND METHODS: In a 5-year period, 109 patients were recorded; 60/109 were treated with NOM and 49/109 with SAE. For each patient, the following parameters were assessed: Glasgow coma scale, injury severity score, American Association for the Surgery of Trauma splenic injury grade, transfusion requirements, hemoglobin level, presence of a splenic vascular lesion (SVL) and amount of hemoperitoneum (Bessoud scale). Different SAE techniques (proximal, distal, combined) with different materials were employed. Clinical success was defined as spleen conservation at 30 days; failure was defined as spleen re-bleeding within 30 days, requiring splenectomy. Student's t test or Chi-square analysis and the Kaplan-Mayer curve were used to analyse each group's results and compare them with those of the other group. RESULTS: In the SAE group, AAST splenic injury grade was higher and serum hemoglobin levels were lower. The SAE group had significantly more SVL and hemoperitoneum compared to the NOM group. The clinical success rate was not significantly different between groups (NOM = 95%, SAE = 87.8%; p = 0.16). Sixty-six percent of NOM failures were related to inadequate patient selection, while 67% of SAE failures were due to technical/procedural issues. CONCLUSION: Our study observed a high splenic salvage rate with the use of SAE as an adjunct to NOM, and suggests that it may be further improved with appropriate patient selection and an improved embolization technique.

Erratum to: 2016 WSES guidelines on acute calculous cholecystitis.

[This corrects the article DOI: 10.1186/s13017-016-0082-5.].

2016 WSES guidelines on acute calculous cholecystitis.

Acute calculus cholecystitis is a very common disease with several area of uncertainty. The World Society of Emergency Surgery developed extensive guidelines in order to cover grey areas. The diagnostic criteria, the antimicrobial therapy, the evaluation of associated common bile duct stones, the identification of "high risk" patients, the surgical timing, the type of surgery, and the alternatives to surgery are discussed. Moreover the algorithm is proposed: as soon as diagnosis is made and after the evaluation of choledocholitiasis risk, laparoscopic cholecystectomy should be offered to all patients exception of those with high risk of morbidity or mortality. These Guidelines must be considered as an adjunctive tool for decision but they are not substitute of the clinical judgement for the individual patient.

Emergency laparoscopic ileo-colic resection and primary intracorporeal anastomosis for Crohn's acute ileitis with free perforation and faecal peritonitis: first ever reported laparoscopic treatment.

INTRODUCTION: Laparoscopy for abdominal surgical emergencies is gaining increasing acceptance given the spreading of advanced laparoscopic skills among modern surgeons, as it may allow at the same time an accurate diagnosis and appropriate treatment of acute abdomen. The use of the laparoscopic approach also in case of diffuse peritonitis is now becoming accepted provided hemodynamic stability, despite the common belief in the past decades that such severe condition represented an indication for conversion to open surgery or an immediate contraindication to continue laparoscopy. Crohn's Disease (CD) is a rare cause of acute abdomen and peritonitis, only a few cases of CD acute perforations are reported in the published literature; these cases have always been approached and treated by open laparotomy. CASE DESCRIPTION: We report on a case of a faecal peritonitis due to an acute perforation caused by a terminal ileitis in an undiagnosed CD. The patient underwent diagnostic laparoscopy followed by a laparoscopic ileo-colic resection and primary intracorporeal anastomosis, with a successful postoperative outcome. CONCLUSIONS: Complicated CD has to be considered within the possible causes of small bowel non-traumatic perforation. Emergency laparoscopy with resection and primary intra-corporeal anastomosis can be feasible and may be a safe and effective minimally invasive alternative to open surgery even in case of faecal peritonitis, in selected stable patients and in presence of appropriate laparoscopic colorectal surgical skills and experience. To the best of our knowledge the present experience is the first ever reported case managed with a totally laparoscopic extended ileocecal resection with intracorporeal anastomosis in case of acutely perforated CD and diffuse peritonitis.

A proposed algorithm for multimodal liver trauma management from a surgical trauma audit in a western European trauma center.

Management of liver trauma is challenging and may vary widely given the heterogeneity of liver injuries' anatomical configuration, the hemodynamic status, the settings and resources available. Perhaps the use of non-operative management (NOM) may have potential drawbacks and the role of damage control surgery (DCS) and angioembolization represents a major evolving concept.1 Most severe liver trauma in polytrauma patients accounts for a significant morbidity and mortality. Major liver trauma with extensive parenchymal injury and uncontrollable bleeding is therefore a challenge for the trauma team. However a safe and effective surgical hemostasis and a carefully planned multidisciplinary approach can improve the outcome of severe liver trauma. The technique of perihepatic packing, according to DCS approach, is often required to achieve fast, early and effective control of hemorrhage in the highest grades of liver trauma and in unstable patients. A systematic and standardized technique of perihepatic packing may contribute to improve hemostatic efficacy and overall outcomes if wisely combined in a stepwise "sandwich" multimodal approach. DCS philosophy evolved alongside with damage control resuscitation (DCR) in the management of trauma patients, requiring close interaction between surgery and resuscitation. Therefore, as a result of a combined surgical and critical care clinical audit activity in our western European trauma center, a practical algorithm for multimodal sequential management of liver trauma has been developed based on a historical cohort of 253 liver trauma patients and subsequently validated on a prospective cohort of 135 patients in the period 2010-2013.

[Trauma and emergency surgery. Organization and surgeons experience]. / Chirurgia del trauma e chirurgia d'urgenza. Organizzazione ed attività chirurgica.

BACKGROUND: To evaluate if combining operative treatment of patients with trauma and general surgery emergencies offers a good operative experience and can be a model for a Trauma Center organization, we compare our surgical experience with that of our general surgeons. METHODS: We reviewed records to determine number of operation, need of intensive care unit care for patients treated, the after hours practice by the trauma and emergency surgeons and general surgeons over a 1-year period at Ospedale Maggiore of Bologna. RESULTS: Emergency and trauma surgeons performed more operations per surgeons (133.7 vs 102.6) and managed more patients in intensive care unit than general surgeons. 51.8% of emergency and trauma operations were after hours. CONCLUSION: The care of trauma and emergency patients resulted in a breadth and scope of practice for trauma and emergency surgeons compared well with that of general surgeons but in a worse lifestyle.

[Emergency surgery in elderly: experience gained in 198 cases over 80]. / La chirurgia d'urgenza nell'anziano: nostra esperienza su 198 casi di ultraottantenni.

PURPOSE: To evaluate our 2-year experience in the emergency surgical treatment of elderly people (aged > or = 80). METHOD: A retrospective review was conducted of 198 elderly patients admitted to Emergency Surgery Unit of the Ospedale Maggiore in Bologna from 01.07.2001 to 30.06.2003. RESULTS: All the Patients were submitted to emergency operations. Mean age was 84.8 (range 80-96); Female were 152, male 73. Preexisting condition, ASA scores and surgical procedures were recorded. The postoperative mortality was 17.1%. The mean length of stay in our Unit was 9.7 days; 93 patients needed rehabilitation facility at discharge. CONCLUSION: The Authors concluded that emergency surgery entails a high risk to the patients, high cost in hospital resources and rehabilitation facility.

[The treatment of splenic injuries from splenectomy to non-operative management: our experience on 429 cases]. / Il trattamento delle lesioni spleniche: dalla splenectomia alla gestione non operatoria. Nostra esperienza su 429 casi.

BACKGROUND: From the first successful splenectomy performed in 1893 the trend, in the management of splenic injuries has been increasingly toward avoiding splenectomy in favor of splenic preservation, either operatively or nonoperatively. The aim of this study is to evaluate our experience in the management of splenic injuries. METHOD: 429 Patients who suffered splenic injuries from 1989 to 2001, were examinated retrospectively. RESULTS: 120 Patients were treated non operatively; 270 were treated with splenectomy and 39 with operative preservation. The mortality rate was 6.8% but no Patient treated nonoperatively or with surgical preservation died. CONCLUSION: The splenic preservation either operatively or nonoperatively is the treatment of choice of splenic injuries in all Patients irrespective of the grade of injury or the age of the Patient.

[The "damage control" in severe hepatic injuries: our experience]. / Il "damage control" nel trattamento di gravi lesioni epatiche: nostra esperienza.

PURPOSE: To evaluate our 12-year experience in the treatment of complex hepatic injuries with periepatic packing and damage control priciples. METHOD: A retrospective review was conducted of 21 Patients with grade IV-V injuries of the liver and severe haemorrage induced hypothermia and acidosis admitted to the Ospedale Maggiore Trauma Center in Bologna from 1989 to 2001 RESULTS: All the Patients had major blunt trauma. Mean age was 39.6; mean ISS 41.5; mean RTS 4.13; extimated loss of blood was greater than 5300 ml. Packing provide definitive control of bleeding in 16 Patients but 10 had recurrent bleeding or bleeding from different injuries such as bone fractures and required further surgery or arterial embolization. 12 Patients died (57.2%). Survival was strongly associated with the ISS, GCS, the loss of blood and acidosis. CONCLUSION: The authors concluded that in selected circumstances the traditional approach to hepatic injuries is not appropiate. In this situation, alternative and aggressive treatment--damage control--has been recommended as the procedure of choice.

[Hernioplasty compared: Shouldice-Trabucco-Lichtenstein]. / Ernioplastiche a confronto: Shouldice-Trabucco-Lichtenstein.

The authors report their experience with the mostly used technique of hernioplasty. They compare the Shouldice hernioplasty, development of the traditional Bassini, with the Trabucco and Lichtenstein techniques in which synthetic prosthesis are used. The two surgical departments participating to this study present 234 patients who underwent hernioplasty with the above mentioned techniques. The authors consider local and general complications during the postoperative time and after a 6-month follow-up. Results indicate that the surgical techniques used are efficient in terms of low complication rates and reduced hospitalization.

[Appendectomy without inversion of the stump. A valid alternative. Our experience in 690 cases]. / L'appendicectomia senza affondamento del moncone. Una valida alternativa. Nostra esperienza su 690 casi.

The paper reports the Authors' ten year experience on simple ligation in appendicectomy. After having reviewed the various surgical procedures, the Authors report their clinical experience and, considering the good postoperative results with this method, regard this procedure as an alternative to the technique of ligation with inversion of the stump in appendicectomy.

[Acute cecal diverticulitis. Presentation of 2 cases]. / Diverticolite acuta del cieco. Presentazione di due casi.

Two cases of acute caecal diverticulitis are reported. The Authors describe the clinical aspects, diagnostic procedures, histological pictures and surgical treatment. Particular emphasis is also placed on problem of a correct preoperative diagnosis.