Emanuele Migliori

Istituto Oncologico Veneto

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Andrea Mingoli

Sapienza University of Rome

Giovanni Mariotta

Policlinico Umberto I

Gioia Brachini

Sapienza University of Rome

Paolo Sapienza

Sapienza University of Rome

C Modini

Policlinico Umberto I

Marco La Torre

Sapienza University of Rome

Andrea Saracino

Royal United Hospital

Martina Zambon

University of Birmingham

Marco Tonello

Istituto Oncologico Veneto

Bruno Cirillo

Sapienza University of Rome

Cooperative Institutions

Sapienza University of Rome

Policlinico Umberto I

Istituto Oncologico Veneto

Istituti di Ricovero e Cura a Carattere Scientifico

University of Padua

Sir Charles Gairdner Hospital

Carlo Forlanini Hospital

University of Birmingham

Institut de Virologie

AstraZeneca (Brazil)

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Nonoperative management for major blunt hepatic trauma. A case report.

PubMed (2015)

Andrea Mingoli Andrea Saracino Gioia Brachini Giovanni Mariotta Emanuele Migliori

Over the past 20 years the management of blunt liver trauma has evolved from a primary operative approach to a nonoperative one, for both low and high grade injuries, only on the basis of hemodynamic stability. However, in spite of a high success rate of non operative management, it is frequently observed, also in our country, an old fashioned way to approach these patients, based on habit more than observation and evidence based medicine.We present a case of successful nonoperative treatment of a grade IV blunt liver trauma (lacero-contusive injury of V, VI and VII segments) in a 34-year-old woman.Nowadays more than 85% of liver injuries are managed without operative intervention, irrespective of the injury grade. Success rate of the conservative approach ranges from 82% to 100% and almost all complications (14% in high grade injuries) can be managed with interventional radiology procedures, still avoiding major surgery.Today, in the absence of other abdominal injuries requiring surgical exploration, hemodynamic instability from ongoing hemorrhage after primary evaluation and resuscitative treatment, is the only indication to an operative management of traumatic liver injuries.Negli ultimi 20 anni il trattamento del trauma epatico chiuso si è modificato radicalmente passando da una gestione quasi costantemente chirurgica ad una non operativa in tutti i casi in cui non vi siano le condizioni di instabilità emodinamica o di variazione nella clinica del paziente traumatizzato. A tutt’oggi però non è raro osservare un approccio a tale condizione clinica seguendo criteri che la Medicina Basata sull’Evidenza dimostra essere superati. Presentiamo in questo lavoro il caso clinico di una donna di 34 anni che subiva un trauma diretto della regione postero-laterale dell’emitorace destro cadendo accidentalmente da una scala. Nonostante la gravità della lesione evidenziata dalla TC (IV grado secondo AAST Liver Injury Scale), si è optato per un trattamento non operativo data la condizione di stabilità emodinamica ottenuta con un primo bolo di cristalloidi. Una complicanza di tipo respiratorio ha complicato il quadro in terza giornata dal trauma richiedendo una toracentesi e dei cicli di ventilazione non invasiva. A 4 anni di distanza dal trauma la paziente sta bene e non lamenta disturbi. La letteratura mostra che il trattamento conservativo viene impiegato oggi in oltre l’85% dei traumi epatici, indipendentemente dall’entità della lesione. Il successo del trattamento conservativo varia nelle diverse casistiche dall’82% al 100% dei casi, e le sue complicanze, quando si verificano (14% dei traumi maggiori) possono spesso essere trattate con procedure di radiologia interventistica, evitando ancora l’intervento chirurgico. Oggi, in assenza di altre lesioni addominali che richiedano l’esplorazione chirurgica, l’indicazione al trattamento operativo è solo l’instabilità emodinamica del paziente che persiste o si ripresenta subito dopo un corretto trattamento rianimatorio iniziale.

Trauma centre

Blunt trauma

Conservative Management

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Operative and nonoperative management for renal trauma: comparison of outcomes. A systematic review and meta-analysis

Therapeutics and Clinical Risk Management (2017)

Andrea Mingoli Marco La Torre Emanuele Migliori Bruno Cirillo Martina Zambon

Introduction: Preservation of kidney and renal function is the goal of nonoperative management (NOM) of renal trauma (RT). The advantages of NOM for minor blunt RT have already been clearly described, but its value for major blunt and penetrating RT is still under debate. We present a systematic review and meta-analysis on NOM for RT, which was compared with the operative management (OM) with respect to mortality, morbidity, and length of hospital stay (LOS). Methods: The Preferred Reporting Items for Systematic Reviews and Meta-analyses statement was followed for this study. A systematic search was performed on Embase, Medline, Cochrane, and PubMed for studies published up to December 2015, without language restrictions, which compared NOM versus OM for renal injuries. Results: Twenty nonrandomized retrospective cohort studies comprising 13,824 patients with blunt (2,998) or penetrating (10,826) RT were identified. When all RT were considered (American Association for the Surgery of Trauma grades 1–5), NOM was associated with lower mortality and morbidity rates compared to OM (8.3% vs 17.1%, odds ratio [OR] 0.471; 95% confidence interval [CI] 0.404–0.548; P <0.001 and 2% vs 53.3%, OR 0.0484; 95% CI 0.0279–0.0839, P <0.001). Likewise, NOM represented the gold standard treatment resulting in a lower mortality rate compared to OM even when only high-grade RT was considered (9.1% vs 17.9%, OR 0.332; 95% CI 0.155–0.708; P =0.004), be they blunt (4.1% vs 8.1%, OR 0.275; 95% CI 0.0957–0.788; P =0.016) or penetrating (9.1% vs 18.1%, OR 0.468; 95% CI 0.398–0.0552; P <0.001). Conclusion: Our meta-analysis demonstrated that NOM for RT is the treatment of choice not only for AAST grades 1 and 2, but also for higher grade blunt and penetrating RT. Keywords: renal trauma, blunt trauma, penetrating trauma, operative management, nonoperative management, systematic review, meta-analysis

Blunt trauma

10.2147/tcrm.s139194

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Citations (57)

["Complete" prune belly syndrome: necroscopic study. Presentation of 2 cases].

PubMed (1986)

C Spinelli Achille Marconi Emanuele Migliori P Giannotti

Prune belly syndrome

Presentation (obstetrics)

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