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Growing evidence supports the role of the intestinal microbiome in the development of different intestinal and extraintestinal diseases. Diverticular disease (DD) is one of the most common disorders in western countries. In the last years, different articles have suggested a possible role of the intestinal microbiome in DD pathogenesis and in the development of acute diverticulitis (AD). This systematic review aimed to clarify the current knowledge on the role of the intestinal microbiome in colonic diverticulitis in different stages according to the 2009 PRISMA guidelines.Two independent reviewers searched the literature in a systematic manner through online databases, including Medline, Scopus, Embase, Cochrane Oral Health Group Specialized Register, ProQuest Dissertations and Theses Database, and Google Scholar. Patients with any stage of disease were included. The Newcastle-Ottawa scale for case-control and cohort studies was used for the quality assessment of the selected articles.Overall, nine studies were included in the review. Only one article was focused on patients with AD, while all other articles only considered patients with DD without acute inflammation signs. Enterobacteriaceae seems to be the microbiota most associated with the disease, followed by Bifidobacteria.All the included studies showed great heterogeneity in population characteristics and sampling methods. Therefore, given the high prevalence of colonic diverticulitis in the general population, further studies are needed to clarify the role of the intestinal microbiome, paving the way to new target therapies with important social implications.

Trauma is the leading cause of death in young people with a considerable socio-economic impact worldwide. A trimodal distribution of trauma mortality was described in the past, but recently different studies underlined a progressive change in trauma mortality distribution linked to improvement in trauma care. This study aimed to analyze the mortality trends in a Level-One Trauma Center in Italy. Data on 6065 patients consecutively admitted to the Trauma Center between 2011 and 2020 were selected and retrospectively analyzed. Causes of Death (CODs) and time of death were stratified in four main groups and the patient sample was further divided into five age groups. Multivariate regression models were then performed to identify independent predictors of mortality. The most common COD in all age groups was Central Nervous System injuries. Immediate deaths (in ED) affected mostly patients over 75 years of age (34.3%). Deaths caused by massive hemorrhage occurred soon upon arrival in the ED, whereas deaths due to other causes (e.g. sepsis, MOF) after the first week. Patients’ characteristics, the need for emergency procedures and high trauma severity scores were independent predictors of deaths. This study represented the first analysis on trauma mortality distribution in Italy over a nine-year period. The trimodal distribution described in the past seems to be no longer present in Italy, due to improvements in trauma systems and critical care. However, the high number of immediate and acute deaths underlies a persisting need for efforts in injury prevention and control .

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.

Background: Trauma is the leading cause of morbidity and mortality in the pediatric population. During the Covid-19 pandemic (C-19), different trends for Pediatric Trauma (PT) were described. This study aims to explore the trend over time of PT in our center, also considering the effects of C-19, focusing on trauma mechanisms, violence-related trauma (VRT) and intentionality, especially suicide attempts (SA).Methods: All PT patients accepted at Niguarda Trauma Center (NTC) in Milan from January 2015 to December 2020 were retrospectively analyzed. We considered demographics and clinical variables and performed descriptive and year comparison analyzes. Results: 684 PT were accepted at NTC: 84 in 2015, 98 in 2016, 125 in 2017, 119 in 2018, 114 in 2019 and 144 in 2020 (pConclusions: NTC is the adult level I referral trauma center for the Milan urban area, with pediatric commitment. During C-19, every traumatic emergency was centralized to NCT. In 2020 we observed an increasing trend of SA and VRT among PTs. The psychological impact of the C-19 restriction could explain this evidence. The long-term effects of C-19 on the mental health of the pediatric population should not be underestimated. Focused interventions on psychological support and prevention of SA and VRT should be implemented, especially during socio-demographic storms like the last pandemic.

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)

Purpose: To identify preoperative predictive factors for technically challenging laparoscopic appendectomy (LA) and the need for external help to laparoscopically complete the procedure. Methods: We analysed data from a two-year data lock on the Resident-1 multicentre registry. The operator classified each procedure following a five-grade Likert scale to define technical difficulty. We performed univariate analysis comparing Grade 1–3 versus 4–5 procedures and then built a logistic regression model to identify independent predictors of Grade 4–5 procedures defined as needing external help to complete a LA. Results: 561 patients were recruited from 2019 to 2021, and 485 patients were included in the final analysis due to missing data. A BMI > 30 kg/m2, preoperative CT scan, and the AIR score were independent preoperative predictors of complex LA with the need for external help to be completed. Patients undergoing such procedures were more affected by CA, had longer operative times, and had the worst postoperative outcomes. Conclusion: The preoperative identification of technically demanding LA could be helpful in optimising the preoperative planning, maximise surgeons’ preparedness, and include expert surgeons in the procedure earlier. Creating a scoring system for the technical difficulty of LA is desirable.

Background: During the COVID-19 pandemic, the centralization of patients allowed trauma and transplants referral centers to continue their routine activity, ensuring the best access to health care. This study aims to analyze how the centralization of trauma is linked with liver allocation in Northern Italy. Methods: Cluster analysis was performed to generate patient phenotype according to trauma-related variables. Comparison between clusters was performed to evaluate differences in damage control strategy procedures (DCS) performed and the 30-day graft dysfunction. Results: During the pandemic period, the centralization of major trauma has deeply impaired the liver procurement and allocation between the transplant centers in the metropolitan area of Milan (Niguarda: 22 liver procurement; other transplant centers: 2 organ procurement). Two clusters were identified the in Niguarda’s series: cluster 1 is represented by 17 (27.4%) trauma donors, of which 13 (76.5%) were treated with DCS procedures, and 4 (23.5%) did not; cluster 2 is represented by 45 trauma donors (72.6%), of which 22 (48.8%) underwent DCS procedures. A significant difference was found in the number of DCS procedures performed between clusters (3.18 ± 2.255 vs. 1.11 ± 1.05, p = 0.0001). Comparative analysis did not significantly differ in the number of transplanted livers (cluster1/cluster2 94.1%/95.6% p = 0.84) and the 30-day graft dysfunction rate (cluster1/cluster2 0.0%/4.8% p = 0.34). Conclusions: The high level of care guaranteed by first-level trauma centers could reduce the loss of organs suitable for donation, maintaining the good outcomes of transplanted ones, even in case of multiple organ injuries. The pandemic period underlined that the centralization of major trauma impairs the liver allocation between transplant centers.

Purpose The Extra-Peritoneal Pelvic Packing (EPP) is a procedure used in emergency conditions to control pelvic hemorrhage. This procedure can be performed in Emergency Room (ER) if the patient is too unstable to be transported into the operating room (OR), with a possible increased risk of infections linked to a less sterile environment. Methods All patients who underwent EPP from 2009 to 2018 were selected from the trauma registry. The patients were divided into two groups according to where EPP was performed (ER or OR). A Propensity Score Matching was realized. EPP was removed in all patients in the OR after obtaining hemodynamic stabilization within 24–48 h and surgical pads were sent to the laboratory for microbiological analysis. Results Eighty-four patients underwent EPP during the period of the study. After PSM, 26 couples of patients were selected. No differences were observed between the two groups in the development of pelvic infection. Patients managed in OR showed a higher rate of associated abdominal injuries (p = 0.027) and an increasing need for external fixation (p = 0,005) as well as an increased proportion of laparotomies (p = 0.023), orthopedic interventions (p = 0.005) and a higher systolic blood pressure on admission (p = 0.003). Conclusions The EPP is a safe procedure, even when performed out of OR. The EPP in ER allows an earlier control of bleeding in patients in extremis. To minimize the risk of infection, EPP should be removed early, as soon as hemodynamics have been stabilized.

Background: Bicycle-related trauma has increased during the last decades, mainly thanks to the antipollution environmental policies and the diffusion of bike-sharing companies. This study investigates the outcome of bicycle-related trauma in our level one trauma center over a period of eight years.Methods: Data of 446 consecutive bicycle-related trauma admitted to our trauma center from 2011 to 2019 were selected and retrospectively analysed. The sample was divided into 3 age groups: ≤ 17 years, 18–54 years, and ≥ 55 years. Mortality rates were obtained for the overall population and patients with Injury Severity Score (ISS) ≥ 25. Month and seasonal patients’ distribution was described to provide an epidemiological overview of bike-related trauma over the years.Results: Patients ³ 55 years showed a lower pre-hospital and in-hospital GCS (p≤ 0.001), higher levels of lactates (p< 0.019) and higher ISS (p≤ 0.001), probability of death (p≤ 0.001), and overall mortality (p≤ 0.001). The head and chest Abbreviated Injury Scale (AIS) ≥3 injuries were predictors of mortality, especially in patients over 55 years (pConclusions: Age over 55 years old, head and chest injuries, and an ISS > 25 were independent predictors of mortality. Multiple factors probably contributed to mortality rates in these patients.

Background: Trauma is the leading cause of morbidity and mortality in the pediatric population. During the COVID-19 pandemic (COVID-19), different trends for pediatric trauma (PT) were described. This study aims to explore the trend over time of PT in our center, also considering the effects of COVID-19, focusing on trauma mechanisms, violence-related trauma (VRT) and intentionality, especially suicide attempts (SAs). Methods: All PT patients accepted at Niguarda Trauma Center (NTC) in Milan from January 2015 to December 2020 were retrospectively analyzed. We considered demographics and clinical variables and performed descriptive and year comparison analyses. Results: There were 684 cases of PT accepted at NTC: 84 in 2015, 98 in 2016, 125 in 2017, 119 in 2018, 114 in 2019 and 144 in 2020 (p < 0.001), 66.2% male, mean age 9.88 (±5.17). We observed a higher number of traffic-related, fall-related injuries and an increasing trend for VRT and SAs, peaking in 2020. We report an increasing trend over time for head trauma (p = 0.002). The Injury Severity Score did not significantly change. During COVID-19 we recorded a higher number of self-presenting patients with low priority codes. Conclusions: NTC is the adult level I referral trauma center for the Milan urban area with pediatric commitment. During COVID-19, every traumatic emergency was centralized to NCT. In 2020, we observed an increasing trend in SAs and VRT among PT patients. The psychological impact of the COVID-19 restriction could explain this evidence. The long-term effects of COVID-19 on the mental health of the pediatric population should not be underestimated. Focused interventions on psychological support and prevention of SAs and VRT should be implemented, especially during socio-demographic storms such as the last pandemic.

This study aims to define possible predictors of the need of invasive and non-invasive ventilatory support, in addition to predictors of mortality in patients with severe thoracic trauma. Data from 832 patients admitted to our trauma center were collected from 2010 to 2017 and retrospectively analyzed. Demographic data, type of respiratory assistance, chest injuries, trauma scores and outcome were considered. Univariate analysis was performed, and binary logistic regression was applied to significant data. The injury severity score (ISS) and the revised trauma score (RTS) were both found to be predictive factors for invasive ventilation. Multivariate analysis of the anatomical injuries revealed that the association of high-severity thoracic injuries with trauma in other districts is an indicator of the need for orotracheal intubation. From the analysis of physiological parameters, values of systolic blood pressure, lactate, and Glasgow coma scale (GCS) score indicate the need for invasive ventilatory support. Predictive factors for non-invasive ventilation include: RTS, ISS, number of rib fractures and presence of hemothorax. Risk factors for death were: age over 65, the presence of bilateral rib fractures, pulmonary contusion, hemothorax and associated head trauma. In conclusion, the need for invasive ventilatory support in thoracic trauma is associated to the patient’s systemic severity. Non-invasive ventilation is a supportive treatment indicated in physiologically stable patients regardless of the severity of thoracic injury.

Patient: Male, 48 Final Diagnosis: Gallstone ileus in biliointestinal bypass Symptoms: Abdominal pain • jaundice • vomiting Medication: — Clinical Procedure: — Specialty: Surgery Objective: Unusual clinical course Background: Biliointestinal bypass is a malabsorptive procedure for surgical treatment of morbid obesity. It is the evolution of jejunoileal bypass, and it is characterized by a cholecysto-jejunostomy on the proximal end of the excluded jejunum, therefore, allowing bile flow through the excluded bowel loop reducing the risk of postoperative diarrhea and malabsorption syndrome. Obesity is a well-known risk factor for cholelithiasis; moreover, bariatric surgery has been showed to increases the risk of gallstones formation. Case Report: A 48-years-old male (body mass index 42 kg/m2) received a laparoscopic biliointestinal bypass. Nine years later, the patient received a cholecystotomy for removal of biliary stones. No surgical procedures were performed on the cholecysto-jejunostomy. Fourteen years after the bariatric treatment, the patient underwent enterolithotomy after a diagnosis of gallstone ileus. The impacted biliary stone was documented in the excluded loop proximal to the anti-reflux valvular system. The postoperative course and 1-year follow-up were uneventful. Conclusions: Few cases of gallstone ileus following biliointestinal bypass have been described in the literature. We report a new case and also propose few tips and tricks for cholelithiasis and gallstone ileus prevention after biliointestinal bypass.

Fournier’s gangrene (FG) is a Necrotizing Soft Tissue Infection (NSTI) of the perineal region characterized by high morbidity and mortality even if appropriately treated. The main treatment strategies are surgical debridement, broad-spectrum antibiotics, hyperbaric oxygen therapy, NPWT (Negative Pressure Wound Therapy), and plastic surgery reconstruction. We present the case of a 50-year-old woman with an NSTI of the abdomen, pelvis, and perineal region associated with a rectal fistula referred to our department. After surgical debridement and a diverting blow-out colostomy, an NPWT system composed of two sponges connected by a bridge through a rectal fistula was performed. Our target was to obtain healing in a lateral-to-medial direction instead of depth-to-surface to prevent the enlargement of the rectal fistula, promoting granulation tissue growth towards the rectum. This eso-endo-NPWT technique allowed for the primary suture of the perineal wounds bilaterally, simultaneously treating the rectal fistula and the perineum lesions. A systematic review of the literature underlines the spreading of NPWT and its effects.

Gastrointestinal (GI) cancers often require a multidisciplinary approach involving surgeons, endoscopists, oncologists, and interventional radiologists to diagnose and treat primitive cancers, metastases, and related complications. In this context, interventional radiology (IR) represents a useful minimally-invasive tool allowing to reach lesions that are not easily approachable with other techniques. In the last years, through the development of new devices, IR has become increasingly relevant in the context of a more comprehensive management of the oncologic patient. Arterial embolization, ablative techniques, and gene therapy represent useful and innovative IR tools in GI cancer treatment. Moreover, IR can be useful for the management of GI cancer-related complications, such as bleeding, abscesses, GI obstructions, and neurological pain. The aim of this study is to show the principal IR techniques for the diagnosis and treatment of GI cancers and related complications, as well as to describe the future perspectives of IR in this oncologic field.

Background To prepare for surgery, surgeons often recur to surgical videos, with YouTube being reported as the preferred source. This study aimed to compare the evaluation of three surgical trainees and three senior surgeons of the 25 most viewed laparoscopic appendectomy videos listed on YouTube. Additionally, we assessed the video conformity to the published guidelines on how to report laparoscopic surgery videos (LAP-VEGaS). Methods Based on the number of visualization, the 25 most viewed videos on laparoscopic appendectomy uploaded on YouTube between 2010 and 2018 were selected. Videos were evaluated on the surgical technical performance (GOALS score), critical view of safety (CVS), and overall video quality and utility. Results Video image quality was poor for nine (36%) videos, good for nine (36%), and in high definition for seven (28%). Educational content (e.g., audio or written commentary) was rarely present. With the exception of the overall level of difficulty, poor consistency was observed for the GOALS domains between senior surgeons and trainees. Fifteen videos (60%) demonstrated a satisfactory CVS score (≥ 5). Concerning the overall video quality, agreement among senior surgeons was higher (Cronbach’s alpha 0.897) than among trainees (Cronbach’s alpha 0.731). The mean overall videos utility (Likert scale, 1 to 5) was 1.92 (SD 0.88) for senior examiners, and 3.24 (SD 1.02) for trainee examiners. The conformity to the LAP-VEGaS guidelines was weak, with a median value of 8.1% (range 5.4–18.9%). Conclusion Laparoscopic videos represent a useful and appropriate educational tool but they are not sufficiently reviewed to obtained standard quality. A global effort should be made to improve the educational value of the uploaded surgical videos, starting from the application of the nowadays-available LAP-VEGaS guidelines. Electronic supplementary material The online version of this article (10.1186/s13017-019-0241-6) contains supplementary material, which is available to authorized users.

Background Laparoscopic cholecystectomy is one of the most performed surgeries worldwide but its learning curve is still unclear. Methods A systematic review was conducted according to the 2009 Preferred Reporting Items for Systematic Reviews and Meta‐analyses guidelines. Two independent reviewers searched the literature in a systematic manner through online databases, including Medline, Scopus, Embase, and Google Scholar. Human studies investigating the learning curve of laparoscopic cholecystectomy were included. The Newcastle–Ottawa scale for cohort studies and the GRADE scale were used for the quality assessment of the selected articles. Results Nine cohort studies published between 1991 and 2020 were included. All studies showed a great heterogeneity among the considered variables. Seven articles (77.7%) assessed intraoperative variables only, without considering patient's characteristics, operator's experience, and grade of gallbladder inflammation. Only five articles (55%) provided a precise cut‐off value to see proficiency in the learning curve, ranging from 13 to 200 laparoscopic cholecystectomies. Conclusions The lack of clear guidelines when evaluating the learning curve in surgery, probably contributed to the divergent data and heterogeneous results among the studies. The development of guidelines for the investigation and reporting of a surgical learning curve would be helpful to obtain more objective and reliable data especially for common operation such as laparoscopic cholecystectomy., (1) Laparoscopic cholecystectomy is one of the most performed surgeries worldwide but its learning curve is still unclear. (2) A systematic review was conducted according to the 2009 Preferred Reporting Items for Systematic Reviews and Meta‐analyses guidelines. (3)The lack of clear guidelines when evaluating learning curve in surgery, probably contributed to the divergent data and heterogeneous results among the studies.

Traumatic limb wound management represents a common and challenging health problem. Conservative treatment can be a good option when surgery fails or surgical reconstruction is planned. Wound healing is a complex process that involves several factors and can be delayed if wound details are not noticed. So, expert healthcare professionals should take care of these delicate patients to obtain satisfactory outcomes in terms of cosmesis and functionality of the residual scar. Thanks to the description of three patients with traumatic limb injuries, this article emphasizes the importance of respecting what we call the three golden rules of wound management: correct cleaning of the wound, its accurate inspection and choose the appropriate dressing according to the wound aspect.

Falls from height (FFH) represent a distinct form of blunt trauma in urban areas. This study aimed to identify independent predictors of in-hospital mortality after accidental or intentional falls in different age groups. We conducted a retrospective study of all patients consecutively admitted after a fall in eight years, recording mechanism, intentionality, height of fall, age, site, classification of injuries, and outcome. We built multivariate regression models to identify independent predictors of mortality. A total of 948 patients with 82 deaths were observed. Among the accidental falls, mortality was 5.2%, whereas intentional jumpers showed a mortality of 20.4%. The death rate was higher for increasing heights, age &gt, 65, suicidal attempts, and injuries with AIS &ge, 3 (Abbreviated Injury Scale). Older patients reported a higher in-hospital mortality rate. Multivariate analysis identified height of fall, dynamic and severe head and chest injuries as independent predictors of mortality in the young adults&rsquo, group (18&ndash, 65 years). For patients aged more than 65 years, the only risk factor independently related to death was severe head injuries. Our data demonstrate that in people older than 65, the height of fall may not represent a predictor of death.

Patient: Male, 51 Final Diagnosis: Oxidised cellulose retain Symptoms: Abdominal pain • nausea • vomiting Medication: — Clinical Procedure: Laparoscopic abdominal exploration and drainage Specialty: Surgery Objective: Challenging differential diagnosis Background: Bleeding is a major intraoperative complication during surgical procedures. When conventional methods such as ligature and diathermocoagulation are ineffective for bleeding management, hemostatic agents should be used. Oxidized cellulose is one of the major hemostatic agents used worldwide. Oxidized cellulose is often left in situ after hemostasis because of its high level of reabsorption that lasts up to 8 weeks. However, 38 cases of retaining-associated complications are reported in the literature. Case Report: A 51-year-old male patient presented in our emergency department with acute abdominal pain, nausea, and vomiting. The patient had been admitted in our department for laparoscopic cholecystectomy for acute cholecystitis 25 months previously. Abdominal ultrasound and CT scan showed the presence of a cystic circular mass, with homogeneous fluid content, close to the surgical clips of the previous surgery, resembling a “neo-gallbladder”. Laparoscopic abdominal exploration and drainage were performed. Histological examination reported protein-based amorphous material with rare lymphocytes and macrophages. Culturing was negative for bacterial growth. The patient was discharged uneventfully on the 4th postoperative day. The primary surgical report was evaluated with evidence of application of Gelita-Cel® Standard for hemostatic purposes. Results of 12-month follow-up were normal. Conclusions: Herein, we report the first case of a complication associated with the use of Gelita-Cel® Standard. We reviewed the literature to better define the purpose and limits of oxidized cellulose use as a hemostatic agent. Despite the fundamental role of oxidized cellulose as a hemostatic agent, we provide some practical suggestions to prevent the reported severe complications and surgical overtreatments.

BackgroundMotorcyclists are often victims of road traffic incidents. Though elderly patients seem to have worse survival outcomes and sustain more severe injuries than younger patients, concordance in the literature for this does not exist. The aim of the study is to evaluate the impact of age and injury severity on the mortality of patients undergoing motorcycle trauma. MethodsData of 1725 patients consecutively admitted to our Trauma Center were selected from 2002 to 2016 and retrospectively analyzed. The sample was divided into three age groups: ≤ 17 years, 18-54 years and ≥ 55 years. Mortality rates were analyzed for the overall population and patients with Injury Severity Score (ISS) ≥ 25. Differences in survival among age groups were evaluated with Log-Rank test and multivariate logistic regression models were created to identify independent predictors of mortality.ResultsA lower survival rate was detected in patients older than 55 years (83,6% vs 94,7%; p = 0.049) and in those sustaining critical injuries (ISS ≥ 25, 61% vs 83% p = 0.021). Age (p =0,027; OR: 1,03), ISS (p p p p p p =0,014; OR: 1,26) injuries as independent risk factors related to mortality as well. Compared to the theoretical probability of survival, patients of all age groups showed a survival advantage when managed at a level I Trauma Center.ConclusionsWe detected anatomical injury distributions and mortality rates among three age groups. Patients aging more than 55 years had an increased risk of death, with a prevalence of severe chest injuries, while younger patients sustained more severe head trauma. Age represented an independent predictor of death. Management of these patients at a Level I Trauma Center may lead to improved outcomes.