REsiDENT 1 (Re-assessment of Appendicitis Evaluation during laparoscopic appendectomy: Do we End a Non-standardized Treatment approach and habit?): Peritoneal irrigation during laparoscopic appendectomy - Does the grade of contamination matter? A prospective multicenter resident-based evaluation of a new classification system

Background: Laparoscopic appendectomy has progressively gained acceptance as the standard of care for acute appendicitis. Focusing on the incidence of postoperative intra-abdominal abscess after a laparoscopic appendectomy, discordant data have been reported ranging from 1.5 to 20%. Besides, evidence advocating advantages from peritoneal irrigation over suction only are lacking. Most studies are burdened by a high level of heterogeneity regarding the severity of the appendicitis and modalities of peritoneal irrigation. One of the main drawbacks is the lack of an accepted classification for different degrees of appendicitis and peritoneal contamination. The aim of the study is to introduce a classification to clarify the relationship between grade of appendicitis, contamination, and postoperative incidence of IAA considering the surgeon's attitude toward irrigation or suction alone. Preoperative, intra-operative, and postoperative predictive factors for infectious complication will also be assessed. This study is meant to be the first Italian multicenter resident-based observational study. Methods: Patients suffering from acute appendicitis will be enrolled during a 1-year period, according to inclusion and exclusion criteria. Participants will fill an online form reporting all clinical and intra-operative data of each patient undergoing a laparoscopic appendectomy. General surgery residents will be responsible for data collection. Our proposal of classification is based on the histological grade of appendicitis and intra-operative degree of peritoneal contamination. For each grade, a progressively increasing score is assigned. Discussion: The observational nature of this study is mandatory to examine surgeons' attitude toward peritoneal contamination during laparoscopic appendectomy for appendicitis. Identification of different severity grades of acute appendicitis and their relationship with the development of postoperative abscesses is necessary. The resulting classification and score, even considering peritoneal lavage or suction alone, will define risk classes of peri-appendiceal contamination each one related to a specific incidence rate of postoperative IAA. Nowadays, maximum effort should be made to reach the best procedural standardization and surgical decision-making should be supported by solid evidence, especially in an emergency surgery setting

Trauma, alcohol and drugs misuse in car and motorcycle drivers: a prevalence study in a level one trauma center

Alcohol and drugs misuse represents an important social problem. There is no agreement about influence of ethanol and drugs on trauma severity and clinical course. The aim of this study was to investigate the impact of alcohol and drugs abuse on road related trauma managed to our Level I Trauma Center. Data of 1067 car or motorcycle drivers consecutively admitted in a 5 years period were retrospectively analyzed. The sample was divided into two groups: patients with alcohol and/or drugs misuse and patients without detectable plasmatic levels or not screened because no clinical suspicion of these substance. Demographic data, mechanism of trauma, severity of injury, daily and season time of trauma distribution, alcohol and drugs levels and outcomes were retrieved. Alcohol or drugs misuse were detected in 242 patients. Heavy alcohols levels were the 62.3%. Among drugs cannabis was the most detected substance. These patients were significantly younger than the overall study population (p = 0.011), with a higher ISS (p = 0.012) a lower RTS (p = 0.047), a lower GCS (p = 0.005) and an higher head injuries severity (p = 0.030). Regarding time distribution, Saturday was the day with the highest percentage of trauma associated with substance misuse (21%). Alcohol/drugs misuse plays a very important role in the epidemiology of road related trauma. Despite the higher severity of trauma scores and the higher incidence of severe head injuries in patients with alcohol or drugs consumption, there were no effects of this substances on mortality of injured patients involved in road crashes

A prospective study comparing two methods of pre-hospital triage for trauma

We conducted a prospective study comparing two different pre-hospital triage tools for trauma: the American College of Surgeons Committee on Trauma (ACS-COT) field triage decision scheme and the TRENAU score. The main objective was to evaluate which triage tool was more appropriate in the setting of Lombardy's trauma system. Data were collected from the population of trauma patients admitted to Niguarda hospital in Milan from January to June 2021. RStudio and Excel were used for data analysis. For each triage tool performance measures, Receiver Operating Characteristics (ROC) curves, and overtriage and undertriage rates were obtained. A total of 1439 injured patients admitted through 118 pre-hospital Emergency Medical Services (EMS) were included in the study. The ACS-COT triage tool showed a good accuracy but an excessive overtriage rate (59%). The TRENAU triage tool had a moderately good accuracy and a low overtriage rate (23%) while maintaining an acceptable undertriage rate (3.9%). The TRENAU triage tool proved to be efficient in optimizing the use of resources dedicated to trauma care while resulting safe for the injured patient. In a modern trauma system such as Lombardy's it would be more appropriate to adopt the TRENAU score over the ACS-COT field triage decision scheme

Epidemiology of trauma admissions in a level 1 trauma center in Northern Italy: a nine-year study

The aim of this study was to analyze the results of 9 years of trauma care and data collection in a level 1 urban trauma center in Northern Italy. Overall, 6065 patients have been included in the study; the number of patients managed yearly has doubled between 2011 and 2019. This rise mostly involved patients with injury severity score (ISS) < 16. Most injuries (94%) were blunt. Road traffic accidents, especially involving motorcycles, were the most common cause of injury. Self-inflicted injuries were responsible for less than 5% of trauma but they were severe in 56% of cases. The median age was 38 and it remained constant over the years; 43% of patients had 14–39 years of age. Different characteristics and patterns of injury were observed for each age group and gender. Males were more likely to be injured in the central years of life while females presented a trimodal pattern in the age distribution. Young adults (14–39 years old) were overall at higher risk of self-harm. Overall mortality was equal to 5.2%. Most deceased were male and ≥ 65 years of age

Combined totally mini-invasive approach in necrotizing pancreatitis: A case report and systematic literature review

Background: Currently, both the step-up approach, combining percutaneous drainage (PD) and video-assisted retroperitoneal debridement (VARD), and endoscopic transgastric necrosectomy (ETN) are mini-invasive techniques for infected necrosis in severe acute pancreatitis. A combination of these approaches could maximize the management of necrotizing pancreatitis, conjugating the benefits from both the experiences. However, reporting of this combined strategy is anecdotal. This is the first reported case of severe necrotizing pancreatitis complicated by biliary fistula treated by a combination of ETN, PD, VARD, and endoscopic biliary stenting. Moreover, a systematic literature review of comparative studies on minimally invasive techniques in necrotizing pancreatitis has been provided. Case presentation: A 59-year-old patient was referred to our center for acute necrotizing pancreatitis associated with multi-organ failure. No invasive procedures were attempted in the first month from the onset: enteral feeding by a naso-duodenal tube was started, and antibiotics were administered to control sepsis. After 4 weeks, CT scans showed a central walled-off pancreatic necrosis (WOPN) of pancreatic head communicating bilateral retroperitoneal collections. ETN was performed, and bile leakage was found at the right margin of the WOPN. Endoscopic retrograde cholangiopancreatography confirmed the presence of a choledocal fistula within the WOPN, and a biliary stent was placed. An ultrasound-guided PD was performed on the left retroperitoneal collection. Due to the subsequent repeated onset of septic shocks and the evidence of size increase of the right retroperitoneal collection, a VARD was decided. The CT scans documented the resolution of all the collections, and the patient promptly recovered from sepsis. After 6 months, the patient is in good clinical condition. Conclusions: No mini-invasive technique has demonstrated significantly better outcomes over the others, and each technique has specific indications, advantages, and pitfalls. Indeed, ETN could be suitable for central WOPNs, while VARD or PD could be suggested for lateral collections. A combination of different approaches is feasible and could significantly optimize the clinical management in critically ill patients affected by complicated necrotizing pancreatitis

Evaluation of capillary leakage after vasopressin resuscitation in a hemorrhagic shock model

Background: Hemorrhagic shock (HS) is a major threat to patients with trauma and spontaneous bleeding. The aim of the study was to investigate early effects of vasopressin on metabolic and hemodynamic parameters and endothelium permeability by measuring capillary leakage compared to those of other resuscitation strategies in a HS model. Methods: Forty-five Sprague-Dawley rats were randomized into five groups: S group (n = 5), sham-operated rats without shock or resuscitation; HS group (n = 10), HS and no resuscitation; RL group (n = 10), HS and resuscitation with Ringer's lactate (RL); RLB group (n = 10), HS and resuscitation with two-third shed blood plus RL; and vasopressin group (n = 10), HS and resuscitation with RL, followed by continuous infusion of 0.04 U/kg/min vasopressin. The effects of resuscitation on hemodynamic parameters [mean arterial pressure (MAP), superior mesenteric artery blood flow (MBF), and mesenteric vascular resistances (MVR)], arterial blood gases, bicarbonate, base deficit, and lactate levels as well as on capillary leakage in the lung, ileum, and kidney were investigated. Capillary leakage was evaluated with Evans blue dye extravasation. Results: In the vasopressin group, the MAP was higher than in the RL and RLB groups (p < 0.001), while MBF was decreased (p < 0.001). MVR were increased only in the vasopressin group (p < 0.001). Capillary leakage was increased in the lungs of the animals in the vasopressin group compared to that in the lungs of animals in the RLB group (p < 0.05); this increase was associated with the lowest partial pressure of oxygen (p < 0.05). Conversely, decreased capillary leakage was observed with vasopressin in the ileum (p < 0.05). Increased capillary leakage was observed in the kidney in the RLB and vasopressin groups (p < 0.05). Lastly, vasopressin use was associated with higher base deficit and lactate levels when compared to the RL and RLB groups (p < 0.001). Conclusion: Although vasopressin was proposed as a vasoactive drug for provisional hemodynamic optimization in the early phase of HS resuscitation, the overall findings of this experimental study focus on the possible critical side effects of vasopressin on metabolic parameters and endothelium permeability

The open abdomen, indications, management and definitive closure

The indications for Open Abdomen (OA) are generally all those situations in which is ongoing the development an intra-abdominal hypertension condition (IAH), in order to prevent the development of abdominal compartmental syndrome (ACS). In fact all those involved in care of a critically ill patient should in the first instance think how to prevent IAH and ACS. In case of ACS goal directed therapy to achieve early opening and early closure is the key: paradigm of closure shifts to combination of therapies including negative pressure wound therapy and dynamic closure, in order to reduce complications and avoid incisional hernia. There have been huge studies and progress in survival of critically ill trauma and septic surgical patients: this in part has been through the great work of pioneers, scientific societies and their guidelines; however future studies and continued innovation are needed to better understand optimal treatment strategies and to define more clearly the indications, because OA by itself is still a morbid procedure