Franco Baldoni

Prognosis and treatment of pancreaticoduodenal traumatic injuries: which factors are predictors of outcome?

Background/purposeAbdominal trauma rarely causes injuries involving the duodenum and pancreas. Associated injuries occur in 46% of all pancreatic injuries. The morbidity and mortality of pancreaticoduodenal injuries remain high.MethodsThe present study is a retrospective review of our experience from 1989 to 2008 in the surgical treatment of traumatic pancreaticoduodenal injuries. Mortality, morbidity, prognostic factors, and the value of surgical techniques were analyzed.ResultsIn our level I Trauma Center, between 1989 and 2008, 55 patients had a pancreaticoduodenal injury. In 68.5% of cases pancreatic injuries were found, 20.4% had duodenal injury, and 11.1% suffered combined pancreaticoduodenal injuries; 85.3% of the patients had blunt abdominal trauma, while 14.9% had penetrating injuries. We treated 78.1% of the patients with external drainage and/or simple suture; distal pancreatectomy was performed in 9% of cases and duodenal resection with anastomosis (3.7%) and diversion procedures (3.7%) were performed in an equal number of patients. Age, American Association for the Surgery of Trauma (AAST) grade, organ involved, hemodynamic status, intraoperative cardiac arrest, and operative time remained strongly predictive of mortality on multivariate analysis. The AAST grade represented, on multivariate analysis, the only independent prognostic factor predictive of overall morbidity. In the past decade we have used feeding jejunostomy more frequently, with a reduction of mortality and operating time, due also to a better approach from a dedicated trauma team.ConclusionsOptimal management and better outcome of pancreaticoduodenal injuries seem to be associated with shorter operative time, and with simple and fast damage control surgery (DCS), in contrast to definitive surgical procedures.

Stressful Events and Psychological Symptoms in Patients with Functional Urinary Disorders

The relationship between micturition, stressful events, and psychological symptoms was studied in 58 female patients with functional micturition disorders (urethral syndrome) and 21 control patients. All received three questionnaires (Symptom Questionnaire, Illness Behavior Questionnaire, and the Biographic Questionnaire). Analysis highlighted the appearance of the urethral syndrome in highly stressful situations and the increase in the patients anxiety, depression, dysphoria, hostility, and irritability. A tendency to complain of other psychophysiologic symptoms was also noted.

Refinement in the technique of perihepatic packing: a safe and effective surgical hemostasis and multidisciplinary approach can improve the outcome in severe liver trauma

BACKGROUND since 2005, we refined the technique of perihepatic packing including complete mobilization of the right lobe and packing around the posterior paracaval surface, lateral right side, and anterior and posteroinferior surfaces. METHODS two groups of patients with grade IV/V liver trauma underwent perihepatic packing before and after 2005. The study group included 12 patients treated with the new technique. The control group included 23 patients treated with the old technique. RESULTS all 13 patients except one who died within 24 hours were treated with the old technique. The overall survival rate was 75% in the patients treated with the new technique (vs 30.4%, P < .02); the liver-related mortality was 8.3% versus 34.8% (P = not significant). The mean survival time in the intensive care unit was longer in the latest group (39.4 vs 22.3 days, P = not significant). The incidence of rebleeding requiring repacking was 16.7% in the patients who underwent new packing versus 45.5% in the patient who were treated with the old technique (P = not significant). The overall (81.8% vs 100%, P = not significant) and liver-related morbidity rate (18.2% vs 41.7%, P = not significant) and the incidence of abdominal sepsis (9.1% vs 41.7%, P = not significant) decreased. CONCLUSIONS our refined technique of perihepatic packing seems to be safe and effective.

A 73-Year-Old Man with Long-Term Immobility Presenting with Abdominal Pain

Salomone Di Saverio and colleagues discuss the diagnosis and management of a man presenting with symptoms of partial intestinal obstruction.

Gastroesophageal reflux disease (GERD) and inflammatory bowel disease (IBD): attachment styles and parental bonding.

The attachment styles and parental bonding by 64 patients (M age = 43.2 yr., SD = 13.3) with Gastroesophageal Reflux Disease (GERD) were compared with those of 64 patients (M age = 42.2 yr., SD = 13.5) with Inflammatory Bowel Disease (IBD) and 126 Healthy participants (M age = 42.2 yr., SD = 12.1). Analysis of scores on the Attachment Style Questionnaire indicated insecure attachment in both the patient and control groups. The Parental Bonding scores indicated perceptions of Affectionless Control by parents in both patient groups. In particular, the mean Father-Protection subscale scores were significantly higher for in the GERD group than in the Healthy and IBD groups.

Urethral Syndrome: A Study in Psychosomatic Urology

The authors studied a sampling of 50 female patients diagnosed with urethral syndrome (urinary symptoms and pain without infection or organic lesion) on purpose to explore some psychological aspects. The evaluation procedure began with a complete urodynamic examination followed by a clinical interview. After this all patients were given three questionnaires: Symptom Questionnaire, Illness Behaviour Questionnaire and a Biographic Questionnaire prepared specifically for this study. Statistical analysis of the data showed higher levels of hostility, irritability, anxiety, dysphoria and depression in the group of patients than in the control group. There was also a marked tendency to suffer from psychophysiological symptoms.

Preterm infant development, maternal distress and sensitivity: The influence of severity of birth weight

OBJECTIVE To evaluate the influence of the severity of prematurity based on birth weight on maternal distress and sensitivity and on infant development. METHODS Sixty-eight mothers and their preterm babies (30 babies classified into Extremely-Low-Birth Weight-ELBW and 38 into Very-Low-Birth Weight-VLBW) were assessed at 9months of infant corrected age, using: Griffiths Scales for infant development, CARE-Index for maternal sensitivity during 5-minute of mother-infant interaction, and Parenting Stress Index-Short Form (PSI-SF) for maternal distress. Sixty-six healthy full-term infants (FT) and their mothers were assessed with the same procedure. RESULTS ELBW, VLBW and FT groups showed similar levels at CARE-Index and PSI-SF. Nevertheless, considering infant development as outcome, a significant interaction between birth weight and maternal distress emerged, with higher Hearing & Language mean quotients in association with Non-Distressed mothers, but only in VLBW infants, compared to FT ones. Also the interaction between birth weight and maternal sensitivity influenced infant development: higher quotients (Eye-hand coordination, Hearing & Language, Locomotor) were significantly associated with sensitive mothers but only in ELBW infants. CONCLUSION The severity of prematurity, in interaction with the degree of maternal distress and sensitivity, influenced the level of infant development. PRACTICAL IMPLICATIONS Taken together, these results suggest the relevance of considering severity of prematurity and maternal variables in order to implement appropriate interventions for supporting parenting role after a preterm birth and promoting an adequate infant development.

The NOTA study: non-operative treatment for acute appendicitis: prospective study on the efficacy and safety of antibiotic treatment (amoxicillin and clavulanic acid) in patients with right sided lower abdominal pain.

Background Case control studies that randomly assign patients with diagnosis of acute appendicitis to either surgical or non-surgical treatment yield a relapse rate of approximately 14% at one year. It would be useful to know the relapse rate of patients who have, instead, been selected for a given treatment based on a thorough clinical evaluation, including physical examination and laboratory results (Alvarado Score) as well as radiological exams if needed or deemed helpful. If this clinical evaluation is useful, the investigators would expect patient selection to be better than chance, and relapse rate to be lower than 14%. Once the investigators have established the utility of this evaluation, the investigators can begin to identify those components that have predictive value (such as blood analysis, or US/CT findings). This is the first step toward developing an accurate diagnostic-therapeutic algorithm which will avoid risks and costs of needless surgery. Methods/design This will be a single-cohort prospective observational study. It will not interfere with the usual pathway, consisting of clinical examination in the Emergency Department (ED) and execution of the following exams at the physicians discretion: full blood count with differential, C reactive protein, abdominal ultrasound, abdominal CT. Patients admitted to an ED with lower abdominal pain and suspicion of acute appendicitis and not needing immediate surgery, are requested by informed consent to undergo observation and non operative treatment with antibiotic therapy (Amoxicillin and Clavulanic Acid). The patients by protocol should not have received any previous antibiotic treatment during the same clinical episode. Patients not undergoing surgery will be physically examined 5 days later. Further follow-up will be conducted at 7, 15 days, 6 months and 12 months. The study will conform to clinical practice guidelines and will follow the recommendations of the Declaration of Helsinki. The protocol was approved on November 2009 by Maggiore Hospital Ethical Review Board (ID CE09079). Trial Registration ClinicalTrials.gov identifier: NCT01096927.

Concomitant intestinal obstruction: a misleading diagnostic pitfall

A 78-year-old man presented to the casualty department, complaining of recurrent and worsening constipation for the previous 2 months. This was associated with central, colicky abdominal pain and melena. In the last days, the symptoms worsened and the patient became partially obstructed, with nausea, vomiting and passing flatus but not stools for 72 h. The past medical history was unremarkable. The radiological findings of the plain abdominal film were consistent with mechanical small-bowel obstruction. CT scan revealed an intraluminal mass in the small bowel, which drew attention away from gross thickening of the caecal wall that was also present. A careful review of the images should not be omitted. One must be aware of a polymorphous appearance and the multiple causes of intestinal obstruction and avoid underestimating even the minor and less evident radiological findings.

Houdini's last deception (or, Aristotle's bowel)

In October, 2005, the abdomen of a 30-year-old, previously healthy builder was crushed between a wooden board, which fell on his back, and a workbench. He was taken by ambulance to the emergency department at a local hospital. He had back pain. However, the attending doctors found no other symptoms or signs of illness. Notably, examination and ultrasonography of his abdomen showed no abnormality, and vital signs were stable. They therefore discharged him after a few hours of clinical observation. 1 month later, the patient came to our emergency department, with pain in the right lower quadrant of his abdomen. He said that the pain had begun 10 days earlier, and had worsened in the 24 h before his return. He had rebound tenderness in the light lower quadrant; blood tests showed leucocytosis. Suspecting appendicitis, we took the patient to the operating theatre. We found severe infl ammation of 38 cm of the ileum and appendix, with several areas of necrosis. The intestinal wall was thick and oedematous, and coated in white membranes, creating what might be described as an infl ammatory mass—which adhered to the caecum, sigmoid colon, omentum, and bladder. We removed the infl amed tissue. Histopathological analysis of the resected ileum showed acute and chronic infl ammation, fi brosis, and diff use necrosis of the full thickness of the intestinal wall, and serosal connective tissue. We noted haemorrhagic infi ltration of the omentum and mesentery, and diff use erosions of the mucosa, but no pathological features of infl am matory bowel disease. Most of the infl ammatory cells were neutrophils; lymphocytes and histiocytes were distributed irregularly in the intestinal wall. We deduced that the damage had been caused by the earlier crush injury. Postoperative recovery was straightforward. When last seen, in May, 2008, the patient was well. Houdini was struck repeatedly in the abdomen by a fi rst-year university student, while demonstrating his abdominal musculature. He developed worsening abdominal pain, nevertheless continuing his scheduled performances. A few days after being struck, he underwent surgery, which revealed a ruptured appendix and diff use peritonitis. Although the appendix was removed and the peritoneum cleaned, his condition worsened (no appropriate antibiotics were then available), and the renowned magician passed away on Oct 31, 1926. As early as 350 BC, Aristotle stated, “a slight blow [to the abdomen] will cause rupture without injury to the skin.” It is now thought that small-bowel injury occurs in around 1% of cases of blunt abdominal trauma. The extent of damage ranges from mild bruising, with oedema, to full-thickness necrosis. Small-bowel injury usually presents as an acute abdomen, caused by perforation; sometimes, appendicitis has been reported. Ischaemia that is localised or transient, and hence does not induce necrosis, can cause residual chronic infl ammation with fi brosis, leading to bowel obstruction or perforation. Delayed bowel perforation can present several days after trauma; stenosis and obstruction can develop in several weeks or months.