[The damage control surgery]. / Damage control surgery: orientamenti attuali.

AIM OF THE STUDY: To evaluate our experience in the treatment of complex abdominal injuries with the principles of Damage Control Surgery (DCS). METHOD: A retrospective review was conducted of 55 patients with multiple abdominal injuries and severe haemorrhage induced hypothermia and acidosis admitted to the "Ospedale Maggiore Trauma Center" in Bologna from 1989 to June 2005. RESULTS: All the patients but one had major blunt trauma. Mean age was 40.1; mean ISS 42; mean RTS 4.11; extimated loss of blood was greater than 4000 ml. Packing provide definitive control of bleeding in 44 patients but 10 had recurrent bleeding or bleeding from different injuries such as bone fractures and required further surgery (2) or arterial embolization (8). Twenty eights patients (50.9%) died. 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 severe abdominal injuries is not appropiate. In this situation, alternative and aggressive treatment such as the Damage Control Surgery has been recommended as the procedure of choice.

[The education of the trauma surgeon: the "trauma surgery course" as advanced didactic tool]. / Modelli educazionali in chirurgia del trauma: il "Corso Teorico-Pratico di Chirurgia del Politrauma" come proposta di didattica avanzata.

BACKGROUND: The consequences of low incidence of penetrating injuries in Europe and of the increasing in nonoperative management of blunt trauma are a decrease in surgeons' confidence for managing traumatic injuries. The Corso Teorico Pratico di Chirurgia del Politrauma was developed as model for teaching operative trauma techniques. The aim of this retrospective study is to evaluate the effectiveness of the course and compare it with other similar courses. METHOD: The Corso Teorico Pratico di Chirurgia del Politrauma is a two day course and consists of lecture on trauma topics and porcine operative experience. Data on the first 124 participants were collected and analyzed. RESULTS: One hundred twenty general surgeons and 2 pediatric surgeons had participated at the course. All the participants judged the course an efficient model to improve knowledge on surgical treatment of trauma. CONCLUSION: A two days course, focused on trauma, with didactic lectures and operative life-like situations, can be a model for simulated education and useful to improve surgeons' confidence in trauma patients.

[Diagnosis and treatment of retroperitoneal traumatic injuries. Our experience on 221 patients]. / Le lesioni traumatiche del retroperitoneo: inquadramento diagnostico e terapeutico. Nostra esperienza su 221 pazienti.

BACKGROUND: The management of traumatic retroperitoneal injuries is still confusing to many surgeons. The presence of injuries of retroperitoneum generally worsens the prognosis in trauma patients and need more attention both the diagnosis and treatment and mortality is high comparated to abdominal traumati injuries. METHOD: A retrospective review was conducted of 221 patients with retroperitoneal injuries admitted to the Ospedale Maggiore Trauma Center in Bologna from 1989 to March 2005. RESULTS: Two hundred seven were blunt traumas and 14 penetrating. Mean age was 40.3; 25 patients died in operating room and 25 were treated with Damage Control Surgery for both abdominal and retroperitoenal injuries. The mortality rate was 15%. Data about surgical treatments, associate treatments for abdominal injuries, and need of reoperation are reported. CONCLUSION: Retroperitoneal traumatic injuries are challenging emergencies and need of attention and expertise by the suorgeon. Only with a careful judgement on the tactics and the procedure to carry on it is possible to gain valid results, which often means to safe the patients life.

Gabexate mesilate (FOY) inhibition of amylase and phospholipase A(2) activity in sow pancreatic juice.

We designed this study in sows to investigate the enzyme inhibitory action of gabexate mesylate (GM) directly in the pancreatic juice. We studied 16 sows, each weighing about 130 kg. The pancreatic duct was identified and cannulated to collect the pancreatic juice. Sows in the treated group received intravenous GM infusion at a dose of 1000 mg over 24 h. Control sows underwent the same sampling schedule while receiving physiological solution. GM inhibited the two pancreatic enzymes amylase and phospholipase A(2) (PA(2)) in pancreatic juice. Thus, the enzyme inhibition in the pancreatic gland itself and the central role of (PA(2)) inhibition in enzyme cascade responsible for activating other proteases confirm the therapeutic use of GM in acute pancreatitis.

Abdominal rectopexy for complete rectal prolapse: preliminary results of a new technique.

PURPOSE: Although the technique for the surgical repair of rectal prolapse has advanced over the years, no ideal procedure has been found. We aim to test a new surgical procedure for abdominal rectopexy that uses the greater omentum to support the rectum below the rectopexy, to reconstruct the anorectal angle and dispense with the need for synthetic mesh, thus reducing the risk of infection. METHODS: A series of ten patients, all young and medically fit, underwent repair surgery for rectal prolapse with the new rectopexy technique. Some patients had concomitant sigmoidectomy. Preoperative and postoperative assessment included a clinical examination, anal manometry and defecography. RESULTS: Follow-up lasted a mean of 56.4 months. None of the patients had recurrent rectal prolapse or infection. Postoperative assessment at 24 months disclosed significant improvements in all the bowel and sphincter variables assessed. The 8 patients who had severe incontinence preoperatively had notably improved and 4 were fully continent, 3 moderately incontinent, and only 1 patient had persistently high levels of incontinence. In only 1 patient who initially had severe incontinence, continence completely regressed and severe constipation developed. Maximal basal pressure values increased significantly after surgery (p=0.0025), although they increased slightly less evidently in patients in whom marked incontinence persisted at postoperative follow-up. Maximal voluntary contraction pressure also increased significantly after surgery (p=0.0054), although the values changed less than those for basal pressure. During rest, squeeze and straining, and in all the patients who regained continence, even those who recovered it only partly, surgery substantially reduced the anorectal angle. The reduction during rest was statistically significant (p=0.0062). CONCLUSIONS: The rectopexy technique we tested in patients with rectal prolapse avoids the need for synthetic mesh, and provides good results in terms of bowel and sphincter function, without infection or recurrence.

Multislice spiral CT colonography in the evaluation of colorectal neoplasms.

PURPOSE: The purpose of our study was to evaluate the efficacy of multislice spiral CT colonography: 1) in the diagnosis and staging of colorectal carcinoma; 2) in the evaluation of the proximal colon in patients with stenosing neoplasms. MATERIALS AND METHODS: There were 33 patients (21 males and 12 females) with known colorectal carcinoma diagnosed by conventional colonoscopy. All patients enrolled in the study underwent both conventional colonoscopy followed by CT colonography on the same day. CT examination was performed using a multislice spiral CT scanner (Somatom Plus 4 Volume Zoom; Siemens, Erlangen, Germany). Imaging parameters were: slice collimation, 1 mm; slice thickness, 1 mm; table speed, 8 mm/sec; reconstruction interval, 1 mm; mAs, 80; kVp, 120; acquisition time, 25-32 sec. Image analysis was performed using a software package with volume-rendering capabilities (Vitrea 2.6; Vital Images, Minneapolis, USA). Image analysis consisted in the evaluation of: 1) number, size, and location of the lesions; 2) primary tumor staging. For the purposes of tumor staging, we utilized the TNM staging system. For the evaluation of parameters T and N, histologic examination on resected surgical specimens and lymph nodes served as the standard of reference. The presence of hepatic metastases was confirmed by means of partial surgical resection in patients with single metastasis or by means of intraoperative ultrasonography in patients with multiple metastases. RESULTS: Conventional colonoscopy detected 33 carcinomas and 4 polyps and was incomplete in 9 cases (27.2% of all examinations) due to stenosing lesions. CT colonography provided adequate visualization of the whole colon in all patients with identification of 35 carcinomas (33 primary and 2 synchronous) and 10 polyps. Therefore, CT colonography correctly detected all lesions seen at conventional colonoscopy and yielded the additional identification of 2 synchronous tumors and 6 polyps located in the colon proximal to the primary stenosing neoplasm. Primary tumor staging with CT colonography was correct in 32 of 33 patients (accuracy, 96.9%) CONCLUSIONS: Multislice spiral CT colonography detected all primary neoplasms, provided correct staging of 96.9% of tumors and visualized the whole colon even in patients with stenosing lesions. Considering the current limitations of the other procedures and the possibility of assessing both the colon and the extracolonic structures, multislice spiral CT colonography can be proposed as the initial diagnostic modality for pre-operative evaluation of patients with colorectal carcinoma.

Computed tomographic colonography without cathartic preparation for the detection of colorectal polyps.

BACKGROUND AND AIMS: We prospectively compared the performance of low-dose multidetector computed tomographic colonography (CTC) without cathartic preparation with that of colonoscopy for the detection of colorectal polyps. METHODS: A total of 203 patients underwent low-dose CTC without cathartic preparation followed by colonoscopy. Before CTC, fecal tagging was achieved by adding diatrizoate meglumine and diatrizoate sodium to regular meals. No subtraction of tagged feces was performed. Colonoscopy was performed 3-7 days after CTC. Three readers interpreted the CTC examinations separately and independently using a primary 2-dimensional approach using multiplanar reconstructions and 3-dimensional images for further characterization. Colonoscopy with segmental unblinding was used as reference standard. The sensitivity of CTC was calculated both on a per-polyp and a per-patient basis. For the latter, specificity, positive predictive values, and negative predictive values were also calculated. RESULTS: CTC had an average sensitivity of 95.5% (95% confidence interval [CI], 92.1%-99%) for the identification of colorectal polyps > or =8 mm. With regard to per-patient analysis, CTC yielded an average sensitivity of 89.9% (95% CI, 86%-93.7%), an average specificity of 92.2% (95% CI, 89.5%-94.9%), an average positive predictive value of 88% (95% CI, 83.3%-91.5%), and an average negative predictive value of 93.5% (95% CI, 90.9%-96%). Interobserver agreement was high on a per-polyp basis (kappa statistic range, .61-.74) and high to excellent on a per-patient basis (kappa statistic range, .79-.91). CONCLUSIONS: Low-dose multidetector CTC without cathartic preparation compares favorably with colonoscopy for the detection of colorectal polyps.